Citation Nr: 0002214 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 93-11 861 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to an evaluation in excess of 60 percent for residuals of a fracture of the right femur and tibia with impairment of the femoral artery and sciatic nerve and degenerative joint disease of the right knee. 2. Entitlement to an evaluation in excess of 40 percent for residuals of a fracture of the left femur with sciatic nerve involvement, due to a shell fragment wound. 3. Entitlement to an evaluation in excess of 10 percent prior to November 21, 1997, for degenerative joint disease of the left ankle, and to a rating in excess of 20 percent thereafter. 4. Entitlement to special monthly compensation based upon the loss of use of both lower extremities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Ralph G. Stiehm, Associate Counsel INTRODUCTION The veteran had active service from February 1967 to November 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 1992 and an October 1995 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine. In March 1995, the Board remanded this case for further development. Thereafter, in December 1997 the Board again remanded this case to the RO for development. This case is now once again before the Board for review. During the course of this appeal the rating for the veteran's residuals of a fracture of the right femur and tibia with impairment of the femoral artery and sciatic nerve and the degenerative joint disease of the right knee was increased from 60 to 100 percent, due to a total knee replacement, effective from February 19, 1999, which is to remain in effect until April 1, 2000; the 60 percent rating will be in effect thereafter. The record shows that the veteran was in receipt of a total (100 percent) compensation rating based on individual unemployability from January 15, 1971 to March 18, 1992, and to a 100 percent schedular combined service-connected rating since March 19, 1992. He is also in receipt of special monthly compensation under 38 U.S.C.A. § 1114 (s) and 38 C.F.R. § 3.350 (I). FINDINGS OF FACT 1. The veteran's service-connected residuals of a fracture of the right femur and tibia with impairment of the femoral artery and sciatic nerve and degenerative joint disease of the right knee do not result in complete paralysis of the sciatic nerve. 2. The veteran's residuals of a fracture of the right femur also include a right hip disability, which is productive of some pain and limitation of motion of the hip, to include limitation of rotation of the thigh with an inability to toe out more than 15 degrees. 3. The veteran's service-connected residuals of a fracture of the left femur with sciatic nerve involvement, due to a shell fragment wound, do not result in severe paralysis of the sciatic nerve. 4. The veteran's service-connected degenerative joint disease of the left ankle was not productive of more than moderate disability prior to November 21, 1997, and has been productive of marked disability, but not ankylosis, since that time. 5. Prior to a right knee replacement in February 1999, the veteran's service-connected disabilities did not result in loss of effective function of either foot other than that which would be equally well served by an amputation stump at the site of election below the knee with use of a suitable prosthetic appliance; there was no loss of balance, propulsion, etc., to a degree that could be accomplished equally well by an amputation stump with prosthesis; there was no unfavorable complete ankylosis of either knee, or complete ankylosis of two major joints of either lower extremity, or shortening of either lower extremity of 3 and one half inches or more, nor was there complete paralysis of either external popliteal nerve and consequent foot drop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve; the veteran had indicated that he does not wish to undergo a current examination and, therefore, a determination as to his current status cannot be made at this time. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 60 percent for residuals of a fracture of the right femur and tibia with impairment of the femoral artery and sciatic nerve and degenerative joint disease of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.55, 4.71a, Diagnostic Code 5055, 4.124a, Diagnostic Code 8520 (1999). 2. The criteria for a separate 10 percent rating for a right hip disability associated with the fracture of the right femur have been met. 38 U.S.C.A. § 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.71a, Diagnostic Code 5253 (1999). 3. The criteria for an evaluation in excess of 40 percent for residuals of a fracture of the left femur with sciatic nerve involvement, due to a shell fragment wound, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.124a, Diagnostic Code 8520 (1999). 4. The criteria for a rating in excess of 20 percent evaluation for degenerative joint disease of the left ankle, prior to November 21, 1997, and to a rating in excess of 20 percent thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1-4.14, 4.71a, Diagnostic Code 5271 (1999). 5. The criteria for entitlement to special monthly compensation for loss of use of the lower extremities have not been met. 38 U.S.C.A. § 1114(k) (West 1991); 38 C.F.R. § 3.350, 3.655 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In February 1968, while in service, the veteran sustained multiple fragment wounds, described as penetrating, to both lower extremities. The veteran's injuries included a severely comminuted fracture of the distal shaft of the right femur, a spiral fragment of the distal shaft of the left femur, and perforation of the right femoral artery. In November 1968, the veteran was placed on a temporary disability retired list and separated from the service. In December 1968, the RO assigned a temporary total convalescent rating for residuals of multiple fragment wounds to both lower extremities. The veteran underwent a VA examination in April 1969. X-ray examination at that time revealed multiple small irregular shrapnel fragments in the soft tissue of both buttocks and both thighs, a comminuted fracture of the lower third of the shaft of the right femur, a healed oblique fracture of the left femur at the junction of the middle and distal third, a fracture of the left foot, multiple small shrapnel fragments in the soft tissues of the right leg and foot and in both femora. In June 1970, the RO assigned a 60 percent evaluation for a fracture of the right femur and right tibia with involvement of the right femoral artery and right sciatic neuropathy, residual shrapnel wound, with degenerative joint disease of the knee, and a 40 percent evaluation for a fracture of the left femur with sciatic neuropathy, residuals shrapnel wound, both of which previously had been covered by the veteran's convalescent rating. The evaluation of those disabilities has since remained largely unchanged, excepting a number of periods of temporary total ratings associated with surgery performed on the veteran's right knee. In July 1992, the RO granted service connection for disabilities that included degenerative joint disease of the left ankle, evaluated as 10 percent disabling, left knee instability, and bilateral varicose veins, effective March 1992. The 10 percent evaluation for the degenerative joint disease of the left ankle remained unchanged until the RO, in the course of this appeal, increased the evaluation of the veteran's disability to 20 percent, effective November 21, 1997. The grant of benefits was made subsequent not only to the date of the veteran's claim, but to the October 1995 notice of disagreement that gave rise to this appeal. At issue, therefore, is not only whether the veteran is entitled to an evaluation in excess of the 20 percent evaluation currently in effect, but whether the veteran is entitled to an evaluation in excess of 10 percent prior to November 21, 1997. The RO assigned to the veteran's right extremity disability a temporary total evaluation from November 1995 to January 1996 and then again from February 1996 to April 1996. More recently, in February 1999, the veteran was admitted for an elective right total knee arthroscopy in connection with which the RO assigned a total rating for a period of slightly more than one year, that is still in effect. Treatment records since 1992 document complaints that include right knee and left ankle pain and right knee instability. A January 1992 entry notes slight stiffness of the left ankle and documents range of motion in the ankle from 0 to 85 degrees. The veteran reportedly had range of motion in the right knee from 0 to 30 degrees, and although there were slight findings of the right knee there was otherwise no laxity. During a VA examination in June 1992, the veteran complained that his symptoms had worsened. He complained of leg swelling, muscle cramps, and knee instability. Examination revealed multiple scars of the legs, including several large scars associated with muscle loss. The veteran exhibited 0 to 90 degrees range of motion in the right knee and 0 to 110 degrees range of motion in the left knee. The left knee was characterized as stable. The right knee reportedly exhibited mild instability with varus and valgus. Range of motion in the left ankle reportedly was 0 to 15 degrees. The veteran had several points of tenderness and walked with an awkward gait with "a lot of" limping. The impression was bilateral fractured femurs, and a fracture of the right tibia with multiple shell fragment wounds requiring skin grafting. The examiner observed that the veteran had nerve damage, muscle loss and left ankle arthritis. A December 1994 report references a history of a traumatic fracture of the right femur, reflects the presence of full range of motion in the left knee and full extension in the right knee, with flexion in the right knee limited to 105 degrees. Examination at that time revealed significant fullness of the right knee not present on the left, tenderness above the popliteal area, and decreased plantar and dorsiflexion in the left ankle. A December 1994 discharge summary, which includes, among other diagnoses, right-sided deep venous thrombosis, popliteal and femoral veins, reflects that the veteran was quite functional and only experiences pain if on his feet for long periods of time. A May 1995 letter associated with the claims file references multiple scars of the right thigh and skin grafts. That letter characterizes range of motion in the hip and knee as excellent. In June 1995, the veteran underwent an examination of the muscles that revealed chronic edema of the right lower extremity and saphenous vein; it was noted that there were no trophic changes that one might expect with a 25 years history of injuries. It was further observed that the veteran was a "good candidate" for developing ulcers in the future, and that he had not yet "had trouble." In July 1995 the veteran underwent another VA examination, during which he complained of pain and crackling of the right knee and left ankle, as well as low back pain. Examination revealed the thighs to be equal in circumference. Examination also revealed a mild difference in calf circumference, the right calf being slightly larger than the left. This was characterized as representing possible minimal atrophy on the left because the veteran was left side dominant. The veteran was able to flex the right hip to 95 degrees and the left hip to 100 degrees. He was able to extend both hips fully. The right hip rotated externally to 20 degrees and internally to 7 degrees; the left hip rotated externally to 18 degrees and internally to 18 degrees. Both hips abducted to 30 degrees. The right knee was bulbous in appearance compared to the left, which was characterized as normal. The examiner noted that minimal right knee effusion might be present. The right knee flexed from 0 degrees to 95 degrees; the left knee flexed from 0 degrees to 113 degrees. Both knees reportedly were reasonably stable. The right ankle, which was "somewhat" swollen, demonstrated plantar flexion from 0 to 50 degrees and extension to the neutral position (0 degrees). This compared to 12 degrees beyond neutral on the left. Lower extremity strength, estimated as at least 3/5 bilaterally, overall, was reportedly "quite good." Strength about the ankles in terms of extension and flexion was likewise good. A report of a July 1995 neurological examination makes reference to mild to moderate impairment of physical activities. The veteran reported during that examination that he was able to climb stairs, walk a reasonable distance, and that he tolerated activities around the house well provided that they did not require lifting. Examination of the lower extremities revealed numerous large and significant scars, including three or four scars on the left thigh with small entry wounds and large exit wounds. Examination also revealed moderate weakness in left ankle extension and poor function of the extensor hallucis longus on the left. There was good function of the ankle and toe extension on the right side. The veteran was unable to stand or walk on the ball of his foot because of weakness. Ankle reflexes were essentially absent. However, gait and stance were normal. Impressions included sciatic nerve injury, probably in the lower thigh or calves, and secondary back pain. A November 1995 letter from a private physician reflects that physician's opinion that the veteran ambulated with a genus valgus deformity and that his only option was a knee replacement. That month, the veteran underwent a right knee arthroscopy with partial medial and lateral meniscectomies, in connection with which the veteran later was assigned a convalescent rating until January 1, 1996. A January 1996 letter from a private physician shows that that the veteran had a small foreign body in the right thigh which was believed to be most likely a piece of shrapnel; removal was recommended. In January 1996, the veteran underwent excision of a foreign body from the right posterior thigh, after which the veteran was assigned a second convalescent period from February 27, 1996 until April 1, 1996. During a March 1996 VA examination of the veins the veteran indicated that he could not stand and that he could not walk more than one half of a mile. Examination revealed bilateral varicose veins, most extensive on the right side, and moderate swelling of the right ankle, as well as mild skin changes. During an examination of the spine in May 1996, an examiner observed that the veteran was not walking with a cane or crutches. The veteran indicated that he used Motrin for back and knee problems and occasional Oxychodone. Examination in October 1997 by a private physician revealed complaints of increasing pain in the veteran's knees and ankle. The veteran indicated that he had been doing a fair amount of work at home over the previous several weeks, particularly standing on ladders, and had markedly increased discomfort in his knees. Examination revealed significant crepitus through motion in the left knee and limitation of motion in the right knee. Although the veteran demonstrated full extension in the right knee, flexion was limited to 95 degrees. The ankle reportedly was significantly limited in dorsiflexion. A November 1997 examination by a private physician revealed that the veteran, who suffered from a valgus deformity of the right leg and an arthritic right knee and left ankle, as well as anterior left knee pain, worked as an EMT in the Bridgton area. Examination revealed 100 degrees flexion on the right and 110 degrees flexion on the left, as well as 5+ quad strength. There were soft tissues wounds throughout and moderate anterior knee crepitus on the left, characterized as the more symptomatic knee. Left ankle motion was stiff with mild effusion. Hip motion was satisfactory and pain free. The impression was anterior knee pain and arthritic left ankle pain. Subsequent examination that month revealed continued complaints of right knee pain. The veteran reportedly demonstrated marked decreased motion of the left ankle, although he still had motion present, and the right knee had a considerable amount of valgus. In February 1999, the veteran underwent a total right knee arthroplasty. A report of hospitalization reflects that until that time the veteran had been able to ambulate without the need for any device, but that this had become gradually more difficult as a result of the progressive nature of the veteran's pain. At the time of hospitalization the veteran was able to ambulate only short distances using bilateral axillary crutches. The RO has assigned a total rating, effective February 19, 1999, which is still in effect at this time and which is scheduled to remain in effect until April 1, 2000. The veteran indicated in a March 27, 1999 statement that he did not wish to undergo another VA compensation examination. I. Right Lower Extremity Residuals of a fracture of the right femur and tibia with impairment of the femoral artery and sciatic nerve and degenerative joint disease of the right knee is evaluated as 60 percent disabling under diagnostic codes 8520 and 5055, pertaining to paralysis of the sciatic nerve and knee replacement (prosthesis), respectively. Paralysis of the sciatic nerve warrants a 60 percent evaluation if incomplete, but severe, with marked muscular atrophy. An 80 percent evaluation contemplates compete paralysis with the foot dangling and dropping, no active movement possible of the muscles below the knee, and/or flexion of the knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. A knee replacement (prosthesis) warrants a 60 percent evaluation if it results in severe painful motion or weakness in the affected extremity and a total evaluation for one year following implantation. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Evidence associated with the claims file does not reflect the presence of complete paralysis of the sciatic nerve. Examination on various occasions has revealed relatively good strength in the lower extremity, and neurological examination in July 1995 revealed good function of the ankle and toe extension on the right side. Although the veteran has articulated various knee complaints, these apparently are largely orthopedic in nature. As such, a higher evaluation for paralysis of the sciatic nerve is not available. The veteran did not undergo a total knee replacement until February 1999, in connection with which a total evaluation has already been assigned. Criteria pertaining to the evaluation of limitation of motion the hips and knees do not provide for a higher evaluation, except in the case of intermediate ankylosis of the hip, which warrants a 70 percent evaluation, a 60 percent evaluation being available in the case of favorable ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Code 5250. The Board observes that the VA's regulations, under 38 C.F.R. § 4.40 and 4.45, recognize that functional loss of a joint may result from pain on motion or use, when supported by adequate pathology. See DeLuca v. Brown, 8 Vet. App. 202, 205-57 (1995); see also Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Further, 38 C.F.R. § 4.59, which addresses the evaluation of arthritis, recognizes that painful motion is an important factor of disability, entitled to at least the minimum applicable evaluation. However, while there is some limitation of motion, his disability clearly does not approach ankylosis or complete immobility of that joint. A higher evaluation, as such, is not available. The provisions of 38 C.F.R. 4.14 preclude the assignment of separate ratings for the same manifestations of a disability under different diagnoses. The critical element is that none of the symptomatology for any of the conditions is duplicative of or overlapping with symptomatology of the other conditions. Esteban v. Brown, 6 Vet. App. 259 (1995). The Board finds that, in reviewing the applicable rating criteria for residuals of injuries to the femur, knee, sciatic nerve, and tibia, and in considering the pertinent medical evidence, the veteran is entitled to a separate 10 percent rating for his pain and functional impairment of the right hip under 38 C.F.R. § 4.71a, Code 5253. That is, the medical evidence shows an old femur fracture with some pain and limitation of motion of the hip that, and when considering 38 C.F.R. §§ 4.40 or 4.45, and DeLuca v. Brown, 8 Vet. App. 202 (1995), the degree of limitation more closely approximates limitation of rotation of the thigh with an inability to toe out more than 15 degrees, which warrants a 10 percent rating under Code 5253. There is no medical evidence to show that pain, weakness, or any other symptoms or clinical finding results in additional limitation of function to a degree that would support a rating in excess of 10 percent for the hip. It is pertinent to note that there is no medical or X-ray evidence of nonunion or malunion of the right femur fracture. See 38 C.F.R. § 4.71a, Code 5255. As to whether the veteran is entitled to any other separate ratings under Esteban, the Board finds that some of the symptoms associated with his residuals of a sciatic nerve injury overlap with symptoms associated with his thigh (other than the hip), knee, and lower leg symptoms so as to essentially preclude any additional separate ratings under the cited legal authority. The Board has also considered rating the veteran's residuals of shell fragment wounds of the right lower extremity on the basis of the various muscle injuries. The severity of the injury to the right thigh, with a severely comminuted fracture of the femur, would result in a 40 percent rating under 38 C.F.R. § 4.73, Codes 5313-5316, but such a rating would preclude the grant of the separate 10 percent rating for the right hip, as each of these muscle codes include hip function. The extent of the muscle damage to the right leg would not result in a rating in excess of 20 percent, as there is no more than moderately severe injury to the affected muscle group. See 38 C.F.R. § 4.56. Several of the thigh and lower leg muscle codes also involve function of the knee. The Board further notes that a muscle injury rating cannot be combined with a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions. 38 C.F.R. § 4.55. The Board must also bear in mind the amputation rule. That is, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. For example, the combined evaluations for disabilities above the knee to the lower third or mid thigh region shall not exceed the 60 percent evaluation, diagnostic code 5162. This 60 percent rating may be further combined with evaluation for disabilities above the knee but not to exceed the above the knee amputation elective level. Simply stated, in considering the totality of the veteran's residuals of injuries to his right lower extremity, his current 60 percent rating and, as the result of this decision, his now separate 10 percent rating for the hip, is the maximum level of compensation allowed under the rating schedule. II. Left Lower Extremity Residuals of a fracture of the left femur with sciatic nerve involvement, due to a shell fragment wound is evaluated as 40 percent disabling under diagnostic code 8520. A 40 percent evaluation is warranted under that diagnostic code is available for a disability that is moderately severe. Examination of the ankle during a July 1995 neurological examination revealed peripheral nerve injuries and weakness in the ankle extension that was characterized as moderate, as well as relatively poor function of the extensor hallucis on the left. Another July 1995 examination characterized strength in the area of the ankles as good, and more recent records, although they contain some references to stiffness of the ankle, do not suggest increased weakness or neurological impairment. The veteran's disability, therefore, does not result in severe impairment, and a higher evaluation under the criteria pertaining to diseases of the peripheral nerves is not available. The Board has considered the possibility of a higher evaluation under limitation of motion of the knee. Limitation of extension warrants a 50 percent evaluation if extension is limited to 50 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Ankylosis of the knee warrants a 50 percent evaluation, if the knee is ankylosed in a position of flexion between 20 and 45 degrees. Examination has not revealed significant limitation of motion of the left knee. The July 1995 VA examination, for instance, revealed flexion from 0 degrees to 113 degrees. A November 1997 entry similarly documents 110 degrees flexion on the left and makes no reference to limitation of extension. Although the veteran has articulated complaints of increasing pain in the area of the left knee, even considering the veteran's complaints of pain and the holding of DeLuca, the veteran, who until shortly prior to his most recent surgery was climbing ladders, does not experience limitation of motion of the left knee analogous to either limitation of extension to 50 degrees or ankylosis of the knee. The Board has also considered the possibility of a higher rating under the diagnostic codes pertaining to muscle injuries. However, muscle injuries of the foot and leg do not warrant an evaluation in excess of 30 percent. 38 C.F.R. § 4.73. Muscle injuries to the pelvic girdle and thigh do not warrant an evaluation in excess of 40 percent, except in the case of severe muscle injuries to Muscle Group XVII, which consists of the gluteus maximus, medius, and minimus. Such injuries warrant a 50 percent evaluation. 38 C.F.R. § 4.73, Diagnostic Code 5317. Although a VA examination shortly after the veteran's separation from service contains some evidence of shrapnel injuries in the area of the buttocks, these involve an anatomical area different from the site of the veteran's fracture. Further, service medical records make reference only to the lower extremities or the veteran's thighs. Later examinations have also documented significant scars on the veteran's thighs and contain no findings concerning the muscles of the buttocks. The evidence suggests, therefore, that any injury to that area was relatively minor compared to the veteran's overall injuries and would not warrant characterization as severe or even moderately severe. The function of the veteran's hip remains completely intact, and the rating criteria applicable to muscle injuries does not afford the veteran a possibly higher evaluation. See 38 C.F.R. §§ 4.56, 4.73, Diagnostic Code 5317 (1999); 38 C.F.R. §§ 4.56, 4.72, 4.73, Diagnostic Code 5317 (1997); see also Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991); 62 Fed. Reg. 30235 (1997). A higher evaluation, therefore, is not available for the injury to the veteran's left leg. III. Left Ankle Degenerative joint disease of the left ankle is evaluated as 20 percent disabling as of November 21, 1997, under diagnostic code 5271. Prior to that time the veteran's left ankle disability was evaluated as 10 percent disabling under the same diagnostic code. Limitation of motion of the ankle warrants a 10 percent evaluation if moderate and a 20 percent evaluation if marked. 38 C.F.R. § 4.71a, Diagnostic Code 5271. A November 21, 1997 entry reflects the first characterization of limitation of motion of the left ankle as moderate. Prior to that time, although treatment records documented slight stiffness of the ankle and complaints of pain, a July 1995 examination of the veteran's muscles demonstrated good range of motion of the left ankle when compared to the right. See 38 C.F.R. § 4.71, Plate II. Evidence associated with the claims file, therefore, suggests that the veteran's left ankle disability was no more than moderate prior to November 21, 1997. An evaluation in excess of 20 percent is not available for limitation of motion of the ankle. A higher evaluation requires ankylosis of the ankle in plantar flexion between 30 and 40 degrees or in dorsiflexion between 0 and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5270. The evidence associated with the claims file, even viewed in the light most favorable to the veteran, does not suggest the presence of ankylosis. Therefore, a higher evaluation is not warranted. IV. Special Monthly Compensation Special monthly compensation is payable for each anatomical loss or loss of use of one foot. Loss of use of a foot will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function, whether the acts of balance, propulsion, etc., could be accomplished equally well by an amputation stump with prosthesis. For example, extremely unfavorable complete ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3 and one half inches or more, will constitute loss of use of the foot involved. Complete paralysis of the external popliteal nerve and consequent foot drop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot. 38 C.F.R. § 3.350. The veteran does not have ankylosis of either knee or ankle, and examination in July 1995 revealed leg lengths to be equal. As discussed above, evidence associated with the claims file, including the July 1995 VA neurological examination, reveals that the veteran does not have complete paralysis in either extremity. In July 1995, the veteran's activities, which included climbing stairs and walking a reasonable distance, were only mildly to moderately impaired, and his gait was relatively normal. In October 1997, the veteran indicated that he had been doing a "fair" amount of work at home, including standing on ladders. Further, as noted above, shortly prior to his admission in February 1999 the veteran, who reportedly lives in a house with a flight of stairs, was able to ambulate without assistance. A report of a February 1999 hospitalization indicates that, following a total right knee arthroplasty, prior to that time, the veteran had been able to ambulate without the need of any device, but ambulation had become increasingly more difficult as a result of the progressive nature of the veteran's pain. At the time of this latter hospitalization, it was noted that he was only able to ambulate short distances using bilateral axillary crutches. However, this was shortly after the total right knee replacement, which was rated 100 percent at the time. (In fact, the 100 percent rating began in February 1999 and is to remain in effect until April 1, 2000. See 38 C.F.R. § 4.71a, Code 5055.) An examination is warranted to determine the veteran's current status, but he has indicated that he does not wish to undergo another compensation examination. (See veteran's March 27, 1999 statement.) While understandable, the Board must point out that it cannot make a determination as to whether there is current loss of use of the lower extremities without such an evaluation. VA regulations provide that: [W]hen entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) or (c) of this section as appropriate. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. For purposes of this section, the terms examination and reexamination include periods of hospital observation when required by VA. (b) Original or reopened claim, or claim for increase. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655(a)(b). While the veteran has obvious difficulties with ambulation, such is compensated by his current 60, 40, 20 and 10, 10 percent ratings for his right lower extremity, left lower extremity, right hip, left knee, and left ankle, respectively, along with the 20 and 10 percent ratings for his right and left leg varicose veins. The Board finds that there is no the medical evidence to show that the veteran's service-connected disabilities result in loss of effective function of either foot within the meaning of the cited legal authority, other than immediately after a total knee replacement, which was compensated (100 percent) at that time and for one year thereafter. There is otherwise no medical evidence of loss of balance, propulsion, etc., to a degree that could be accomplished equally well by an amputation stump with prosthesis; there is no unfavorable complete ankylosis of either knee, or complete ankylosis of two major joints of either lower extremity, or shortening of either lower extremity of 3 and one half inches or more, nor is there complete paralysis of either external popliteal nerve and consequent foot drop, accompanied by characteristic organic changes, including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve. In reaching its decisions, the Board has considered the doctrine of reasonable doubt, however, aside from the separate 10 percent rating for the veteran's right hip, as the preponderance of the evidence is against the appellant's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An evaluation in excess of 60 percent for residuals of a fracture of the right femur and tibia with impairment of the femoral artery and sciatic nerve and degenerative joint disease of the right knee, is denied. Entitlement to a separate 10 percent rating for a right hip disability due to a femur fracture is granted. An evaluation in excess of 40 percent for residuals of a fracture of the left femur with sciatic nerve involvement, due to a shell fragment wound, is denied. An evaluation in excess of 10 percent for degenerative joint disease of the left ankle, prior to November 21, 1997, and to a rating in excess of 20 percent thereafter, is denied. Entitlement to special monthly compensation for loss of use of the lower extremities is denied. R. F. WILLIAMS Member, Board of Veterans' Appeals