BVA9501788 DOCKET NO. 91-34 902 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for a circulatory disorder of the left lower extremity as secondary to service-connected traumatic arthritis of the left knee with total left knee arthroplasty. 2. Entitlement to service connection for a right lower extremity disorder including the right knee as secondary to service- connected traumatic arthritis of the left knee with total left knee arthroplasty. 3. Entitlement to an increased evaluation for traumatic arthritis of the left knee with total left knee arthroplasty, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Ronald R Bosch, Counsel INTRODUCTION The veteran served on active duty from March 1952 to January 1956. This appeal arose from March 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The RO denied entitlement to an increased evaluation for traumatic arthritis of the left knee with total left knee arthroplasty. In a September 1990 rating decision, the RO affirmed the determination previously entered, and denied entitlement to service connection for traumatic arthritis of the right knee with total right knee arthroplasty as secondary to service-connected disability of the left lower extremity. The Board of Veterans' Appeals (Board) remanded the case to the RO for further development in November 1991. In a March 1992 rating decision, the RO granted an increased evaluation of 60 percent for traumatic arthritis of the left knee with total left knee arthroplasty effective November 13, 1989; assigned a temporary total evaluation effective from December 4, 1991 through February 28, 1993; and reinstated the previous evaluation of 30 percent for disability of the left knee effective March 1, 1993. The RO denied entitlement to service connection for a circulatory disorder of the left lower extremity as secondary to service-connected disability of the left knee when it issued a rating decision in June 1993. The Board administratively remanded the case to the RO in October 1993. In a November 1993 rating decision, the RO affirmed the denial of entitlement to service connection for a circulatory disorder of the left lower extremity as secondary to service-connected disability of the left knee, and denied entitlement to service connection for a circulatory disorder of the right lower extremity as secondary to service-connected disability of the left knee. The RO affirmed all previously entered determinations when it issued rating decisions in 1994. The case has been returned to the Board for further appellate review. The issues of entitlement to service connection for bilateral lower extremity disorders as secondary to service-connected traumatic arthritis of the left knee with total left knee arthroplasty will be addressed in the REMAND part of this decision.. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he traumatic arthritis of the left knee with total left knee arthroplasty is more disabling than currently evaluated, thereby warranting entitlement to an increased evaluation. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence supports a grant of an increased evaluation of 60 percent for traumatic arthritis of the left knee with total left knee arthroplasty. FINDING OF FACT Traumatic arthritis of the left knee with total left knee arthroplasty is productive of chronic residuals consisting of severe painful motion or weakness. CONCLUSION OF LAW The schedular criteria for an increased evaluation of 60 percent for traumatic arthritis of the left knee with total left knee arthroplasty have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. 3.321(b)(1), 4.7, 4.40, 4.71(a), Diagnostic Codes 5010- 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board finds that the veteran's claim of entitlement to an increased evaluation for traumatic arthritis of the left knee with total left knee arthroplasty is well grounded within the meaning of 38 U.S.C.A. § 5107(a), in that he has presented a claim which is plausible. The Board is satisfied that all relevant facts have been properly developed, and that no further assistance to the veteran is required in order to comply with 38 U.S.C.A. § 5107(a). A review of the service medical records discloses the veteran sustained injury to his left knee on its lateral side when struck in 1952. He had moderate swelling after the injury, but no locking. He returned to duty in satisfactory condition; however, one month later, he was again injured in a football game. He had further swelling and a tendency to give way as a result of the injury. In November 1954 he reported with complaints of pain over the lateral aspect of the knee and a tendency of the knee to go into hyperextension. He felt some crepitation in the joint on motion but he never experienced any clicking or popping. A physical examination resulted in a diagnosis of probable torn lateral collateral ligament, with a good possibility of a torn lateral meniscus. He underwent a left lateral meniscectomy in January 1955. He continued to experience painful and limiting symptomatology and an examination in later 1955 concluded in a diagnosis of chondromalacia of the patella, traumatic arthritis of the knee joint. At a June 1962 VA examination, the veteran was found to have a well-healed, almost angulated, crescent shaped left knee as a result of surgery for a meniscus cyst. On flexion the knee lacked 10 degrees of full flexion and there was considerable crepitus on active motion. An x-ray was interpreted as showing a loose body in the lateral joint space with evidence of slight margination of the lateral tibial plateau. The special orthopedic diagnosis was cyst of lateral meniscus, left knee, postoperative, with loose osseous body and traumatic arthritis. The RO granted entitlement to service connection for postoperative residuals of surgery for the left knee with loose osseous body and traumatic arthritis with assignment of a 10 percent evaluation when it issued a rating decision in June 1962. A January 1966 VA orthopedic examination concluded in a diagnosis of a postoperative cyst, lateral meniscus of the left knee; and internal derangement of the left knee, postoperative, times two. A May 1967 VA orthopedic examination resulted in a diagnosis of chondromalacia of the left knee with postoperative residuals. In a letter dated in January 1974, Frank B. Throop, M.D., reported that in June 1973, he had performed a total left knee arthroplasty replacing the articular surfaces of the lateral compartment of the knee, both the femoral and tibial. He provided a copy of the operative report. In a January 1974 rating decision, the RO assigned a temporary total convalescence rating for disability of the left knee effective from September 18 through December 31, 1973; and increased the evaluation to 30 percent effective January 1, 1974. Postoperative residuals of left knee surgery was diagnosed as the result of a VA orthopedic examination conducted in January 1975. The veteran complained of pain at a January 1990 VA orthopedic examination. A clinical inspection of the left knee disclosed that it was grossly deformed. There was tenderness on pressure over the area of the medial meniscus. Extension was to 0 degrees and flexion was to 90 degrees. X-rays of the left knee were interpreted as showing status post replacement of the lateral femoral condyle and lateral tibial plateau. There were degenerative changes at the femoral patellar joint with joint space narrowing and osteophyte formation. There was also narrowing and osteophyte formation at the femoral tibial joint space greater laterally than medially. It was noted that this may represent post-traumatic degenerative changes. There was calcification in the medial meniscus. There was a small amount of depression with underlying subchondral sclerosis of the lateral tibial plateau. Small joint effusion was present. The clinical diagnosis was residuals of trauma to the left knee, postoperative knee joint replacement. In a June 1990 medical report, Dr. Throop noted that the veteran had reported for treatment of pain. He was unable to run and could not make a lateral movement; more specifically, the veteran could not quickly step to the left or laterally. His walking tolerance was one block because of pain. His standing tolerance was only one minute. His knee swelled daily if he was up on it. Clinically he could not fully extend his knee without pain. Motion was from 0 to 90 degrees. The knee was swollen with fluid and had a boggy synovium. On x-ray evaluation Dr. Throop was amazed that the implants had not come apart. The femoral component was grooving the lateral facet of the patella. There was marked arthritis in all of the compartments of his knee. The clinical assessment was tri-compartmental arthritis with a hemiarthroplasty on the lateral side, Marmor type. Dr. Throop expressed the belief that the veteran needed to have this converted to a Duo condylar type of total knee replacement. At an August 1990 VA examination, the veteran reported that he was not working and complained of knee pain. He continued under medication. A physical examination of the left knee disclosed two surgical scars laterally. There was no crepitus, signs of inflammation, or tenderness on palpation. Flexion was to 90 degrees and extension was to 0 degrees. The relevant diagnosis was status post total knee arthroplasty for traumatic arthritis. The appellant testified as to the disabling manifestations of his left knee disability at an RO hearing held in March 1991. He stated that his knee disability was more severe than had been indicated on VA examinations. He could not sit in one position for too long because of numbness. He was unable to cross his legs. He stated that his reflexes were poor. The claimant was privately hospitalized from December 1991 to January 1992. He underwent a total left knee replacement. At an April 1992 VA orthopedic examination, the appellant reported some tingling and numbness down the inside of his left calf when he struck the knee. He had some marked loss of motion, and pain on motion as well as with prolonged ambulation. He used a cane for ambulation. A physical examination of the left knee disclosed multiple anterior scars as well as maturing skin grafts with several areas of his anterior wound, demonstrating some wound scarring and continued evidence of healing. There was a long medical calf incision secondary to the medial gastrocnemius donor site as well as two proximal lateral thigh skin graft donor sites. Left knee range of motion was from 5 to 50 degrees. Tinel's sign was positive at the medial calf. There was tenderness along the medial joint. The clinical assessment reflected the above clinical findings. A May 1992 VA orthopedic examination report shows that motion of the left knee was 0 to 80 degrees. There was a healed split thickened skin graft over the gastrocnemius flap in the anterior knee, with the exception of a small area of scabbing on the anterior aspect. Joint stability was intact. X-rays were said to reveal a total knee component to be in good position. The bone implant interfaces appeared to be intact. The examiner noted that the veteran had a post-traumatic condition of the left knee which had required multiple surgeries, most recently a total knee replacement. At a July 1992 VA orthopedic examination, the veteran reported that he continued to have problems with his left knee. His postoperative course was complicated by non-healing of the wound and perhaps even infection. He complained of continued pain and occasional feeling of instability. On examination was seen complete healing of previous surgery. Left knee range of motion was 0 to 70 degrees. The knee was stable with medial and lateral stress. In his clinical assessment, the examiner noted that the veteran continued to have left knee pain, although radiographs had not revealed any abnormalities. On file are VA outpatient treatment reports dated during the early 1990's showing that the veteran has reported for treatment of left knee symptomatology including pain. The current 30 percent evaluation for the disability of the left knee is predicated on the basis of a minimum rating assignable under diagnostic code 5055 of the VA Schedule for Rating Disabilities. Diagnostic code 5010 is also utilized due to the presence of traumatic arthritis. The veteran has previously been rated as 100 percent disabled under diagnostic code 5055 due to his total left knee replacement surgery, an evaluation which remained in effect for one year in accordance with the criteria under this diagnostic code. A 60 percent may be assigned under diagnostic code 5055 with chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion may be rated by analogy to diagnostic codes 5256, 5261, or 5262. Under diagnostic code 5256, a 60 percent evaluation may be assigned for extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more. A 50 percent evaluation may be assigned for ankylosis in flexion between 20 degrees and 45 degrees, and 40 percent may be assigned for ankylosis in flexion between 10 degrees and 20 degrees. The veteran does not have ankylosis of his left knee; accordingly, an increased evaluation under diagnostic code 5256 is not warranted. He does not have limitation of extension of his left knee to 30 degrees, consequently an increased evaluation of 40 degrees under diagnostic code 5261 is not indicated. As nonunion of the left tibia and fibula with loose motion requiring a brace is not shown by the medical evidence of record, an increased evaluation of 40 percent under diagnostic code 5262 is not warranted. The RO has determined that residuals of the veteran's most recent surgery are reflective of minimal impairment warranting no more than the minimum 30 percent evaluation under diagnostic code 5055. The Board does not agree. In this regard, the Board observes that VA examinations and reports from non-VA health care professionals have consistently shown that the veteran continues to suffer from chronic residuals of his most recent surgery. Severe pain per se and on motion constitute only few of his many residual manifestations. He is severely limited in his left lower extremity activity, requires medication, and continues to seek treatment from VA as well as non-VA health care professionals. The appellant has quite graphically and satisfactorily described his ongoing symptomatology at the RO hearing and on the numerous occasions on which he has been examined by VA and non-VA medical personnel. The Board is of the opinion that the veteran's current postoperative residuals of left knee surgery more closely reflect the level of impairment contemplated in the next higher evaluation under diagnostic code 5055. 38 C.F.R. § 4.7. The claimant's left knee disability has not rendered his disability picture unusual or exceptional in nature and has not markedly interfered with his employment. It has not required frequent periods of inpatient care as to render impractical the application of regular schedular standards, thereby precluding assignment of an increased evaluation on an extraschedular basis. 38 C.F.R. § 3.321(b)(1). Undoubtedly, as the Board noted earlier, the veteran suffers from significant pain; however, such severe pain is contemplated in the 60 percent evaluation granted by the Board under diagnostic code 5055, thereby precluding a grant of an increased evaluation for functionally disabling pain under the criteria of 38 C.F.R. § 4.40. The Board finds that a 60 percent evaluation is warranted for traumatic arthritis of the left knee with total left knee arthroplasty. The prior 100 evaluation for the appellant's most recent surgery was in effect for one year in accordance with the criteria under the subject code and such 100 evaluation is no longer warranted. As the Board noted earlier, the minimum 30 percent rating assigned by the RO is not sufficient to adequately compensate the veteran for the current degree of left knee impairment shown by the evidence of record. The Board concludes that the record supports a grant of a 60 percent evaluation for traumatic arthritis of the left knee with total left knee arthroplasty. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.40, 4.71(a), Diagnostic Codes 5010-5055. ORDER An increased evaluation of 60 percent for traumatic arthritis of the left knee with total left knee arthroplasty is granted, subject to pertinent criteria applicable to the payment of monetary awards. REMAND When the case was previously before the Board in November 1991, service connection for additional disability of the left leg was not in issue. The Board sought on REMAND an opinion from a physician whether a disorder of the right lower extremity was related to the service-connected left knee impairment. A VA physician rendered an opinion on November 1992. The opinion reads, in pertinent part, "I am unable to say that this is connected to his left knee, as it appears his left knee injury would have absolutely no bearing on his right knee degenerative condition." A rationale for the opinion was not given. Also, it is not entirely clear that the examiner reviewed the claims file. The current record, including the physician's opinion, does not adequately respond to 38 C.F.R. § 4.58, which is applicable to this veteran's case. Also, the provisions of 38 C.F.R. § 4.62 must be considered and the Board should be told whether it applies to the veteran's case, and if it does not, why not. A complete rationale must accompany the conclusion. Since the Board's REMAND, the issues have been expanded to include service connection for additional disability of the left lower extremity, namely peripheral vascular disease. It is important that a medical opinion now be given to cover peripheral vascular disease of both lower extremities as well as arthritis of the right knee. Accordingly, it is the determination of the Board that consideration of the remaining issues of the claimant's appeal be deferred pending a REMAND of his case to the RO for further development as follows: 1. The RO should schedule the veteran for a VA examination by a physician who has not previously examined him to determine the etiology of bilateral lower extremity peripheral vascular disease and arthritis of the right knee. The examination is to be conducted in accordance with the diagnostic procedures outlined in Chapter 2 of the VA Physician's Guide for Disability Evaluation Examinations. All indicated studies are to be accomplished. The RO must provide the examiner with the provisions of 38 C.F.R. §§ 4.58, 4.62. The examiner should be requested to provide an opinion as to whether it is at least as likely as not that bilateral lower extremity peripheral vascular disease and arthritis of the right knee are etiologically related to service-connected traumatic arthritis of the left knee with total left knee arthroplasty. Any opinions expressed must be accompanied by a complete rationale with application of 38 C.F.R. §§ 4.58, 4.62. The claims file must be made available to and reviewed by the examiner prior to the examination. 2. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issues of entitlement to service connection for bilateral lower extremity peripheral vascular disease and arthritis of the right knee as secondary to service-connected traumatic arthritis of the left knee with total left knee arthroplasty. If the benefits sought on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. BRUCE KANNEE Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).