Citation Nr: 0002144 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 96-05 339 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for sinus bradycardia. 2. Entitlement to service connection for hyperlipidemia. 3. Entitlement to service connection for a disability manifested by elevated liver function test results. 4. Entitlement to an increased (compensable) rating for right knee patellofemoral syndrome. 5. Entitlement to an increased (compensable) rating for left knee patellofemoral syndrome. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD John M. Clarkson, III, Counsel INTRODUCTION The veteran had active service from July 1978 to April 1981, and from May 1986 to September 1994. He also had a period of active duty for training from January 1984 to June 1984. This appeal arises from a May 1995 rating decision which, among other things, denied service connection for a cardiac disorder, hyperlipidemia, and a disability manifested by abnormal liver function test results. The rating decision awarded service connection and assigned a noncompensable rating for right knee patellofemoral syndrome, and awarded service connection and assigned a separate, noncompensable rating for left knee patellofemoral syndrome. However, a 10 percent rating was assigned pursuant to the provisions of 38 C.F.R. § 3.324 based on multiple noncompensable service connected disorders. In November 1998, the Board of Veterans' Appeals (Board) remanded this case to the RO to accord the veteran a hearing before a member of the Board at the RO. The undersigned Board member conducted that hearing in November 1999. A transcript of the hearing is included in the claims folder. FINDINGS OF FACT 1. There is no competent evidence that the veteran currently has sinus bradycardia. 2. The veteran's right knee patellofemoral syndrome is manifested by complaints of pain and clinical findings of no more than slight limitation of motion; ankylosis, subluxation or lateral instability are not shown. 3. The veteran's left knee patellofemoral syndrome is manifested by complaints of pain and clinical findings of no more than slight limitation of motion; ankylosis, subluxation or lateral instability are not shown. CONCLUSIONS OF LAW 1. The claim for service connection for sinus bradycardia is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. A 10 percent rating for the veteran's right knee patellofemoral syndrome is warranted. 38 U.S.C.A. §§ 1155 and 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, and 4.71(a), Codes 5257, 5260, and 5261 (1999). 3. A 10 percent rating for the veteran's left knee patellofemoral syndrome is warranted. 38 U.S.C.A. §§ 1155 and 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, and 4.71(a), Codes 5257, 5260, and 5261 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service clinical records prior to August 1989 reveal no clinical documentation of cardiac pathology. The service medical records include an August 1989 medical note, in which the veteran reported that he had spit out light red-colored blood 4 or 5 times after taking part in heavy, strenuous, physical activity with his unit. He denied dizziness, trauma, nausea, or vomiting. He complained of muscle pain in his chest, at the center of the sternum, along with nasal congestion, following a strenuous workout. The assessment was possible muscle strain with sinusitis following an obstacle course run. In a followup report in August 1989, the examiner noted that the veteran had had no complaints or blood in his sputum since his previous evaluation. He denied chest wall tenderness, and the assessment was that the previous condition had resolved. An x-ray evaluation of the veteran's chest in September 1993 was negative for abnormalities. However, electrocardiograms (EKGs) in September 1993 were abnormal, and showed marked sinus bradycardia with first degree atrioventricular block. On separation examination in October 1993, the veteran denied a history of pain or pressure in the chest, palpitation or pounding heart, and heart trouble. In November 1993, he complained of congestion in his chest and sinuses. The assessment was sinusitis. A December 1993 medical board report indicated that the veteran had been assigned light duty on four occasions, each lasting four months, in connection with bilateral patellofemoral syndrome. In a June 1994 report, a military physical evaluation board concluded that the veteran was unfit for duty due to chronic bilateral patellofemoral syndrome. On VA orthopedic examination in March 1995, the veteran complained that he had bilateral knee pain after sitting or running. His knees swelled after exertion, it was difficult for him to climb stairs, and prolonged standing was painful. His knees sometimes buckle and give out, but he does not fall to the ground. On clinical evaluation, his knees were not tender or swollen. Both knees showed extension to 180 degrees and flexion to 100 degrees. (It appears that the examiner referred to the fully extended position of the knee as 180 degrees instead of the zero degree position.) There was no knee laxity in either knee, but the veteran's gait was weakened due to knee pain. The diagnoses were bilateral knee strain, chronic patellofemoral syndrome, and weakened gait due to pain. On a separate VA examination in March 1995, the examiner noted that the veteran had no reported symptoms of heart disease. A recent EKG was normal and his pulse was 72 at rest. At an RO hearing in March 1996, the veteran testified that he first learned of his sinus bradycardia following an EKG performed in service, but he had not received medical treatment for sinus bradycardia since service. He indicated that his knees were swollen, and he could not perform certain physical activities. He had lost three days from work when knee pain prevented him from driving. He indicated that, when he feels his knee pain becoming more severe at work, he attempts to relax until the pain subsides. He was issued knee braces at Bayley Seton Hospital, and he wears them once every three to four months. He stated that he can only walk approximately two blocks before knee pain begins to bother him. On VA examination of the veteran's knees in April 1997, both knees were globally tender, and there was no evidence of swelling. Patellar motion was decreased in both knees, extension was zero degrees bilaterally, and flexion was limited, due to pain, to 95 degrees. There was no evidence of ligamentous laxity in the knees. The examiner's impression was bilateral patellofemoral syndrome of both knees, with mild decreased range of motion. X-ray study of the knees revealed some hypertrophy of the tibial spines bilaterally. Otherwise, the knee joints were well maintained, without significant degenerative change. The soft tissues were unremarkable. The impression was mild tibial spine hypertrophy bilaterally. The veteran was accorded a hearing at the RO before the undersigned member of the Board in November 1999. At the time of the hearing, the veteran submitted additional records of private medical treatment with a signed waiver of initial review of the additional evidence by the RO. The records submitted included a discharge summary from Rancocas Hospital, dated in April 1997. During the veteran's hospitalization at Rancocas Hospital for a disorder not at issue in this appeal, his heart rhythm was regular, and there was an ejection murmur at the left sternal border. Records of medical treatment of the veteran by Michael L. Levinson, M.D., dating from September 1998 to June 1999, include September 1998, January 1999, and June 1999 progress reports indicating that the veteran's chest was clear, and that cardiac examination revealed no murmurs, gallops, or rubs. A June 1999 medical note reported that the veteran complained of aches in his left chest. He had had an x-ray study performed several months earlier, and he reported that he was going to have another x-ray study performed to ensure that everything was all right. (However, no report of a subsequent chest x-ray study has been associated with the claims folder.) At the hearing at the RO in November 1999 before the undersigned member of the Board, the veteran testified that he was unable to complete an obstacle course in 1986 because of an episode of dizziness and spitting up blood. After a medical examination, he was placed on light duty for 45 days. He was admitted to the hospital in 1997 and 1998 after experiencing a blackout while driving to work. He indicated that he was unable to breathe, and he was told by a physician that one of his lungs had collapsed and that he had asthma. He acknowledged that he was not told that he had a cardiac disability during his post-service hospitalizations. However, he testified that sinus bradycardia was diagnosed on his military separation examination. He stated that damp, cold weather increases the severity of his bilateral knee pain. Sometimes he can walk no more than one block. He explained that he has difficulty climbing steps. The pain in his knees does not radiate to other parts of his body. He indicated that he had not been treated for problems relating to his knees since his VA examination in April 1997. He tried to walk regularly and attempted to avoid over-exertion. Analysis Service Connection for Sinus Bradycardia Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110 and 1131 (West 1991); 38 C.F.R. § 3.303(d) (1999). If a veteran had 90 days or more of wartime service or following peacetime service on or after January 1, 1947 and cardiovascular-renal disease is manifested to a compensable degree within one year following discharge from service, it will be considered to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, and 1137 (West 1991); 38 C.F.R. §§ 3.307 and 3.309 (1999). A person who submits a claim for benefits under a law administered by VA shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial tribunal that the claim is well-grounded. VA shall assist such a claimant in developing facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991). If he has not presented evidence of a well-grounded claim, his appeal must fail as to that claim, and there is no duty to assist him further in the development of his claim because such development would be futile. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). In order for a claim for service connection to be well- grounded, there must be competent medical evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). The United States Court of Appeals for Veterans Claims (Court) has also held that laypersons are not competent to provide medical opinions. Layno v. Brown, 6 Vet. App. 465 (1994). In this case, EKGs performed in September 1993, while the veteran was in service, were abnormal, and showed marked sinus bradycardia with first degree atrioventricular block. This satisfies the element of Caluza which requires lay or medical evidence of the presence of cardiac symptoms in service. However, what is missing is a current medical diagnosis of sinus bradycardia and medical evidence showing a nexus between current sinus bradycardia and service. The March 1995 examination indicated that the veteran had no reported symptoms of heart disease, and a normal EKG. As sinus bradycardia was reported in service in connection with an abnormal EKG, and a post-service EKG report was normal, with no report of sinus bradycardia, the Board concludes that there is no competent medical evidence that the veteran currently has sinus bradycardia. The veteran's complaint of aches in his left chest, which was reported in a June 1999 medical note, has been noted but, as a layperson he is not competent to provide medical opinions. Layno, 6 Vet. App. at 470. Absent evidence of current sinus bradycardia, the claim of service connection for sinus bradycardia is not well- grounded. Since the veteran has not presented a well- grounded claim of service connection for sinus bradycardia, the claim must be denied. An Increased (Compensable) Rating for Right Knee Patellofemoral Syndrome and an Increased (Compensable) Rating for Left Knee Patellofemoral Syndrome The Board finds that the veteran's claims for separate, increased (compensable) ratings for right knee patellofemoral syndrome and for left knee patellofemoral syndrome are "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a). The Court has held that, when a veteran claims a service-connected disability has increased in severity, the claim is well-grounded. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Court has also stated that, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The veteran's service connected right knee patellofemoral syndrome and left knee patellofemoral syndrome have been rated noncompensably disabling under Diagnostic Code 5257. Under Diagnostic Code 5257, when there is slight recurrent subluxation or lateral instability of the knee, a 10 percent rating is assigned. Moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling. 38 C.F.R. § 4.71(a), Diagnostic Code 5257 (1999). Limitation of flexion of the leg to 60 degrees warrants a noncompensable rating. A 10 percent rating requires that flexion be limited to 45 degrees. Flexion limited to 30 degrees is rated 20 percent disabling. When flexion is limited to 15 degrees, a 30 percent rating is assigned. 38 C.F.R. § 4.71(a), Diagnostic Code 5260 (1999). Limitation of extension of the leg to 5 degrees warrants a noncompensable rating. A 10 percent rating requires that extension be limited to 10 degrees. Extension limited to 15 degrees is rated 20 percent disabling. When extension is limited to 20 degrees, a 30 percent rating is assigned. 38 C.F.R. § 4.71(a), Diagnostic Code 5261 (1999). On VA examination in April 1997, the examiner specifically noted that there was no evidence of ligamentous laxity in the knees, and there is no reported clinical findings of recurrent subluxation or lateral instability to warrant a compensable rating for either knee under Diagnostic Code 5257. A full range of motion of the knee is zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (1999). Here, in both knees, extension was zero degrees and flexion was limited to 95 degrees bilaterally. There is global tenderness in both knees and the veteran complains of pain. The examiner characterized the degree of limitation of motion in the veteran's knees as mild. The Board concludes that the evidence supports the grant of separate 10 percent ratings for right knee patellofemoral syndrome and left knee patellofemoral syndrome. Consideration of the provisions of 38 C.F.R. §§ 4.40 and 4.45 and the Court's holding in DeLuca v. Brown, 8 Vet. App. 202 (1995), in conjunction with the evidence provides the basis for these 10 percent ratings. Tenderness, pain on motion, and mild limitation of motion, while meeting the requirements for 10 percent ratings, do not equate to moderate knee disability and do not equate to the degree of limitation of flexion or extension required for 20 percent ratings under Diagnostic Codes 5260 or 5261. As such, a 10 percent rating, but no more, is warranted for each knee disorder. ORDER Service connection for sinus bradycardia is denied. A 10 percent rating for right knee patellofemoral syndrome is granted, subject to the regulations governing the payment of monetary awards. A 10 percent rating for left knee patellofemoral syndrome is granted, subject to the regulations governing the payment of monetary awards. REMAND With regard to the claim of service connection for hyperlipidemia, the service medical records include a November 1991 medical note, which indicated that the veteran needed to be placed on a low cholesterol diet. The provisional diagnosis was mild hyperlipidemia. The veteran was discharged from service as unfit for duty due to chronic bilateral patellofemoral syndrome, and VA examinations of record do not include clinical findings as to the veteran's lipid levels. Therefore, it is unclear whether the single occasion in service when hyperlipidemia was provisionally diagnosed demonstrates that the veteran has hyperlipidemia as a chronic, current disability. Since hyperlipidemia was diagnosed in service and may be currently present, the Board concludes that the claim of service connection for hyperlipidemia may be well-grounded, and a remand is necessary to determine whether he currently has hyperlipidemia. With regard to the claim of service connection for a disability manifested by elevated liver function test results, the veteran has testified that he became aware that he had a liver disability following blood tests in service which yielded abnormal results. The service medical records include a November 1988 medical report which noted that the veteran was being referred for laboratory tests in connection with abnormal test results after he donated blood. His blood was screened and the serum glutamic pyruvic transaminase (SGPT) level was 100. A subsequent evaluation was normal. In June 1990, he was referred to sick call due to abnormal alamine transaminase levels following a blood donation several weeks earlier. The examiner noted that the veteran was healthy, and there was no memory or record of hepatitis or other symptoms referable to his liver. On VA examination in March 1995, the examiner indicated that references in the record to "abnormal blood tests" referred to an unexplained mild elevation of the SGPT level. Serum glutamic oxalo-acetic transaminase (SGOT) and alkaline phosphatase levels were normal. The veteran had no history of liver disease and evaluation of the slightly raised SGPT level in service showed that hepatitis "B" and "A" serologies were negative for abnormalities. Hepatitis "C" antibody testing was negative. The SGPT level was slightly elevated. The examiner noted that the veteran's liver was normal in size, and concluded that chronic viral hepatitis was not found on examination. The diagnosis included an unexplained mild increase in the transaminase level. At the hearing at the RO in November 1999 before the undersigned member of the Board, the veteran testified that, after he attempted to donate blood in service, he was told that he had an abnormal liver, and should never donate blood. Given the foregoing, it is undisputed that the veteran was evaluated for liver disease both during and since service, clinical findings described as abnormal blood test results were noted in service, and findings described as unexplained mild elevations of the SGPT level were noted after service. However, it is unclear whether the veteran either currently has liver disease which began in service or whether the abnormal blood test results shown during service and unexplained elevation of the SGPT level shown since service are manifestations of another identifiable disability which began in service. Therefore, the Board concludes that the claim for service connection for a disability manifested by elevated liver function test results is potentially well- grounded, and a remand is required to establish the existence and etiology of any liver-related disability. Accordingly, the claims of service connection for hyperlipidemia and for a disability manifested by elevated liver function test results are REMANDED for the following: 1. The veteran should be contacted and requested to furnish the full names and addresses of all health care providers who have treated him for hyperlipidemia and for a disability manifested by elevated liver function test results since his VA examination in March 1995. Where necessary, the veteran should be requested to sign and submit the appropriate forms giving his consent for the release to VA of all records of any such treatment listed by the veteran. All records obtained must be associated with the claims folder. 2. After the above referenced development is completed, the veteran should be accorded a VA examination to determine the existence and etiology of hyperlipidemia and a disability manifested by abnormal liver function test results. All clinical findings should be reported in detail. The examiner must review the claims folder and a copy of this remand in connection with the examination and state in the examination report that the review has been accomplished. With regard to hyperlipidemia, the examiner should opine as to whether the veteran currently has hyperlipidemia and whether it is at least as likely as not that it is related to a provisional diagnosis of hyperlipidemia reported in service. With regard to a disability manifested by abnormal liver function test results, the examiner should opine as to the following questions: (a) Does the veteran currently have a liver disease or other identifiable disorder of the liver? (b) If a liver disease or other disorder of the liver is present, is it at least as likely as not that such disease or disorder had its onset during service and was manifested by the abnormal blood test results reported in service? (c) If the answers to both of the above questions are in the negative, the examiner should explain whether any abnormal liver function tests are merely laboratory findings and not diagnostic of any disease or disorder. 3. Following completion of the foregoing, the RO should review the claims folder and ensure that all of the aforementioned development action has been conducted and completed. 4. The RO should then review the claims for service connection for hyperlipidemia and for a disability manifested by elevated liver function test results to determine whether they may be granted. If either claim remains denied, the veteran and his representative should be furnished an appropriate supplemental statement of the case and given an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. BRUCE E. HYMAN Member, Board of Veterans' Appeals