Citation Nr: 0004659 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 98-02 311 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut THE ISSUES 1. Entitlement to an increased evaluation for a right knee disability, currently rated 30 percent disabling. 2. Entitlement to an increased evaluation for a left knee disability, currently rated 10 percent disabling. 3. Entitlement to an increased evaluation for residuals of a right radius fracture, currently rated 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Cooper, Associate Counsel INTRODUCTION The veteran served on active duty from October 1965 to October 1968 and from February 1971 to January 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 1997 RO decision which denied an increase in a 10 percent rating for chondromalacia of the right knee, increased the rating for chondromalacia of the left knee from 0 percent to 10 percent, and denied a compensable rating for residuals of a fractured right radius. The veteran appealed for higher ratings for all three conditions. In an April 1998 decision, the RO hearing officer granted an increased 30 percent rating for chondromalacia of the right knee, and granted an increased 20 percent rating for residuals of a fracture of the right radius. The veteran has not indicated he is satisfied with these ratings; thus the claims for higher ratings are still on appeal. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. The veteran's service-connected right knee disability produces no subluxation or instability, and range of motion is from 25 to 80 degrees. 2. The veteran's service-connected left knee disability produces no subluxation or instability, and range of motion is from 5 to 98 degrees. 3. The veteran's service-connected residuals of a right radius fracture (major upper extremity) are manifested by limitation of forearm pronation to 65 degrees with motion lost beyond the last quarter of the arc. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent for a right knee disability have not been met. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (1999). 2. The criteria for an evaluation in excess of 10 percent for a left knee disability have not been met. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (1999). 3. The criteria for a rating in excess of 20 percent for residuals of a right radius fracture have not been met. 38 U.S.C.A. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. § 4.71a, Diagnostic Code 5213 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty in the Army from October 1965 to October 1968 and from February 1971 to January 1984. A review of his service medical records reveals that the veteran was seen on numerous occasions for bilateral chondromalacia patella with degenerative joint disease. He underwent a lateral release and debridement of the right patella in 1979. An arthroscopy, arthrotomy, and lateral release were performed on the left knee in 1980. In 1980 he was treated for a distal right radius fracture. In 1982 he underwent a right knee arthrotomy with a Maquet procedure due to chondromalacia. In 1983, following medical and physical evaluation board proceedings, the veteran was medically retired from service due to a bilateral knee condition and residuals of a right radius fracture. On VA examination in February 1984, a bilateral knee condition and residuals of a right distal radius fracture were diagnosed. In an April 1984 decision, the RO granted service connection for chondromalacia of the right knee with a 10 percent rating. Service connection for chondromalacia of the left knee and for residuals of a right radius fracture was also established, both rated noncompensable. On VA examination in May 1994, the veteran reported his history of injury to both knees and subsequent surgeries during service. He said that in March 1993 he had a carpal tunnel release and shoulder surgery on the right side. He indicated that his right median nerve was transected during surgery for the carpal tunnel syndrome. The veteran complained of pain in both knees, which was getting progressively worse. He indicated that since the surgery in 1993, he had very little pain in the right wrist; however, he still had paresthesia of the right wrist. The examiner noted no swelling on the right knee. Slight swelling of the right wrist was observed. It was noted that the left knee had marked swelling with probable effusion in the suprapatellar bursa. The examiner indicated that the veteran demonstrated severely restricted range of motion of the right wrist in any direction. Wasting of the thenar eminence of the right side and absent sensation over the distribution of the right median nerve was also noted. Limitation of flexion of both knees was observed. The diagnoses were chondromalacia of both knees, postoperative; right carpal tunnel syndrome, status post carpal tunnel release; right median nerve transection; degenerative joint disease of the right wrist; and status post right wrist fracture in July 1980. Private treatment records dated from November 1993 to May 1995 show that the veteran sustained a work-related injury to his right shoulder in 1992. It was noted that during his recovery a diagnosis of right carpal tunnel syndrome was made and he underwent right carpal tunnel release in 1993. Subsequent records show two surgeries for a right median nerve injury with a poor recovery. VA treatment records from 1996 and 1997 show that the veteran was seen for complaints of bilateral knee pain. On VA examination in January 1997, the veteran related that he had difficulty walking due to constant knee pain. He stated that his left knee gave out on him when going downgrade. He indicated that he underwent a carpal tunnel release for his median nerve after a work-related injury. The veteran demonstrated right knee flexion to 45 degrees and then stopped due to pain. He had complete extension. Squatting was stopped halfway because of pain. The left knee revealed no deformity or lateral instability. Small nucleated effusion on the upper lateral side was noted. Flexion of the left knee was limited to 40 degrees and stopped due to pain. Light effusion and tenderness over the right wrist was noted. The veteran had decreased sensation in the lateral three fingers. No limitation of movements was revealed. The diagnoses were chondromalacia of both knees, postoperatively with limitations of movement; right carpal tunnel syndrome, medial nerve injuries with decreased sensation in the lateral three fingers; and status post right wrist fracture in July 1980. January 1997 X-ray studies of both knees showed large effusion in the right knee joint and status post right tibial tubercle elevation surgery with small effusion of the left knee joint. Bilateral degenerative changes of the medial femoral tibial compartments and of both patellofemoral joints were noted. In April 1997, the RO denied an increase in a 10 percent rating for the right knee disorder, granted an increased 10 percent rating for the left knee disorder, and denied a compensable rating for residuals of a right radius fracture. A June 1997 VA treatment record shows that the veteran continued to complain of bilateral knee pain. No effusions were noted on either knee. The left knee revealed medial joint line tenderness. Range of motion was 0 to 120 degrees. No leg laxity was noted. X-rays reflected degenerative joint disease in three compartments. The diagnostic impression was bilateral degenerative joint disease. An October 1997 VA medical record reflects that the veteran complained of right knee pain which was progressively worse over the previous three months. It was noted that the veteran had increased pain with flexion and over the medial joint line, medial collateral ligament, and over the patella. Radiographs were consistent with a medially narrowed joint space and osteophytes. The diagnostic assessment was degenerative joint disease. In November 1997, the veteran was admitted to a Naval hospital with a preoperative diagnosis of degenerative joint disease, right knee. It was noted that the veteran had multiple procedures on his right knee in the past and now developed pain and locking upon ambulating one block. Operations performed during the current admission included a right knee arthroscopy, debridement, and partial medial meniscectomy. [The veteran was later granted a temporary total convalescent rating based on right knee surgery during this admission.] Follow-up treatment records note degenerative joint disease with patella and medial pain. Examination revealed patellofemoral grinding. During the March 1998 RO hearing, the veteran testified that he experienced constant pain in both knees. He stated that his right knee "goes out" sometimes; however, instability of the left knee was not as severe. He related that he had significant limitation of motion of the right wrist and that the bone was out of alignment. The veteran noted that pain in his right wrist was due to carpal tunnel release surgery from a work-related injury. On VA examination in April 1998, the veteran related his history of bilateral knee and right wrist conditions. On examination of the right knee it was noted that he had active range of motion of 25-80 degrees. The examiner observed a prominent tibial tubercle. Atrophy of the medialis muscle was noted. The left knee demonstrated range of motion of 5- 98 degrees. The examiner noted tenderness on palpation throughout the left knee. Atrophy of the vastus medialis muscle of the left knee was noted. The veteran had 1+ effusion and a very positive patella test of both knees. Ligamentous structures of both knees tested out normally. Examination of the right wrist revealed no swelling. Range of motion showed 65 degrees of pronation and 85 degrees of supination. The veteran demonstrated upward motion of 28 degrees and palmar flexion of 47 degrees. Radial deviation was 35 degrees and ulnar deviation was 25 degrees. The diagnoses were severe degenerative joint disease, severe chondromalacia of the patella, and severe limitation of motion of both knees. Degenerative joint disease of the right wrist and limitation of motion due to the in-service fracture was also noted. The examiner indicated that neuropathy of the right median nerve was not related to his service-connected right wrist condition. It was noted that the veteran did not have a misalignment of the bone in his right wrist. In an April 1998 decision, the RO hearing officer granted an increased 30 percent rating for the right knee disorder, denied an increase in a 10 percent rating for the left knee disorder, and granted an increased 20 percent rating for residuals of a right radius fracture. II. Analysis The veteran's claims for increased ratings are well grounded, meaning plausible. The file shows that the RO has properly developed the evidence, and there is no further VA duty to assist the veteran with his claims. 38 U.S.C.A. § 5107(a). When rating the veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, it is the more recent evidence which is generally the most relevant in an increased rating claim, as the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A. Right and Left Knee Disabilities The veteran's left and right knee disabilities include arthritis. Degenerative or traumatic arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate code, a rating of 10 percent is warranted for each major joint affected by limitation of motion. 38 C.F.R. § 4.71a, Codes 5003, 5010. A 0 percent rating is warranted for limitation of leg flexion when it is limited to 60 degrees, a 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Code 5260. A 0 percent rating is warranted when leg extension is limited to 5 degrees, a 10 percent rating is warranted when it is limited to 10 degrees, a 20 percent rating is warranted when it is limited to 15 degrees, a 30 percent rating is warranted when it is limited to 20 degrees, and a 40 percent rating is warranted when it is limited to 30 degrees. 38 C.F.R. § 4.71a, Code 5261. Standard motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Of the recent medical records, the findings on the 1998 VA examination provide the basis for the highest possible ratings. At the 1998 VA examination, the veteran had 5 degrees of extension and 98 degrees of flexion in the left knee. Flexion of the right knee was 80 degrees with 25 degrees of extension. Both knees revealed a very positive patella test and 1+ effusion. Ligamentous structures were normal, bilaterally. The diagnoses were severe degenerative joint disease, chondromalacia and limitation of motion of the both knees. With regard to the left knee, the Board notes that if the veteran's left knee disorder were strictly rated under either Code 5260 or Code 5261, he would be assigned a noncompensable evaluation. However, the presence of arthritis with at least some limitation of motion supports a rating of 10 percent for the left knee under Codes 5003 and 5010. There is no objective evidence of additional limitation of motion of the knees due to pain on use, and certainly not additional limitation to the extent necessary for a 20 percent rating under limitation of motion codes. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Regarding the right knee, the most recent medical evidence shows limitation of flexion to 80 degrees, which corresponds to a noncompensable evaluation under Code 5260. Limitation of extension of the right knee was 25 degrees, which corresponds to a 30 percent rating under Code 5261. Even considering the effects of pain on use, limitation of motion is not shown to be more than 30 percent disabling. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, supra. Consequently, the Board finds that an increase in the current 30 percent rating for the right knee disability is not warranted. Knee impairment with recurrent subluxation and lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71a, Code 5257. Separate ratings for knee instability and for knee arthritis with limitation of motion are permissible. See VAOPGCPREC 9-98 and 23-97. Although the veteran has subjective complaints of giving way of the left and right knees, objective testing disclosed no instability. The evidence does not show even slight recurrent subluxation or lateral instability of the knees and thus, a separate 10 percent rating under Code 5257 is not in order. 38 C.F.R. § 4.31. As the preponderance of the evidence is against the veteran's claims, the benefit-of-the-doubt rule is inapplicable, and the claims for increased ratings for right and left knee disabilities must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App 49 (1990). B. Residuals of Right Radius Fracture Limitation of supination of either forearm is rated 10 percent when limited to 30 degrees or less. Limitation of pronation of either forearm is rated 20 percent when motion is lost beyond the last quarter of arc and the hand does not approach full pronation. Limitation of pronation which is lost beyond the middle of arc warrants a 30 percent rating for the major extremity. 38 C.F.R. § 4.71a, Code 5213. Standard forearm pronation is from 0 degrees to 80 degrees, and standard supination is from 0 degrees to 85 degrees. 38 C.F.R. § 4.71, Plate I. The veteran is right-handed and his service-connected residuals of a right radius fracture involve his major upper extremity. The medical evidence of record shows that the veteran suffered a right radial fracture during service. Many recent medical records relate to non-service-connected neuropathy of the right forearm, including multiple surgeries. Medical evidence from the 1998 VA examination shows pronation of the right forearm to 65 degrees and supination to 85 degrees. Even assuming that such limitation of motion is entirely due to the service-connected residuals of a right radius fracture (and not due to the non-service- connected right forearm neurological condition), such supports only the current 20 percent evaluation under Code 5213 for limitation of pronation with motion lost beyond the last quarter of arc. Pronation lost beyond the middle of arc, as required for a 30 percent rating has not been demonstrated. As the preponderance of the evidence is against the veteran's claim, the benefit-of-the-doubt rule is inapplicable, and the claim for a rating in excess of 20 percent for residuals of a right radius fracture must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER An increased rating for a right knee disability is denied. An increased rating for a left knee disability is denied. An increased rating for residuals of a right radius fracture is denied. L. W. TOBIN Member, Board of Veterans' Appeals