BVA9502856 DOCKET NO. 91-48 694 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a back disability as secondary to service-connected postoperative residuals of a meniscectomy of the right knee with arthritis. 2. Entitlement to service connection for shortening of the right lower extremity as secondary to service-connected postoperative residuals of a meniscectomy of the right knee with arthritis. 3. Entitlement to an increased evaluation for postoperative residuals of a meniscectomy of the right knee with arthritis, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. W. Loeb, Counsel INTRODUCTION The veteran served on active duty from February 1941 to October 1945. The Board of Veterans Appeals (Board) remanded this case to the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, in February 1994 for additional development. The requested development has been completed, and the case has been returned to the Board for further appellate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his back disability and right leg shortening are due to his service-connected right knee disability and that his right knee disability involves sufficient symptomatology, including pain and limitation of motion, to warrant an increased evaluation. The veteran maintains that there are many things that he cannot do because of his right knee disability, such as prolonged standing, walking, or driving, and that he must use a cane to help him walk. 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 preponderance of the evidence is against the veteran's claims for secondary service connection for a back disability and shortening of the right leg and that the preponderance of the evidence supports his claim for an increased evaluation for right knee disability. FINDINGS OF FACT 1. All relevant evidence necessary to an equitable determination of the veteran's appeal has been obtained. 2. A back disability is not causally related to the veteran's service-connected right knee disability. 3. A shortened right leg is not causally related to the veteran's service-connected right knee disability. 4. The veteran's right knee disability is productive of moderate impairment. 5. The veteran's right knee disability does not involve an unusual disability picture with such factors as marked interference with employment or frequent periods of hospitalization. CONCLUSIONS OF LAW 1. A back disability is not proximately due to or the result of the veteran's service-connected right knee disability. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310(a) (1993). 2. Shortening of the right lower extremity is not proximately due to or the result of the veteran's service-connected right knee disability. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.310(a) (1993). 3. The criteria for an evaluation of 20 percent, but not more, for the veteran's service-connected right knee disability have been met. 38 U.S.C.A. §§ 1155, 5107(a); 38 C.F.R. §§ 3.321(b)(1), 4.71a, Diagnostic Codes 5010, 5257, 5259, 5260, 5261 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claims are well-grounded within the meaning of 38 U.S.C.A. § 5107(a). Additionally, the facts relevant to the issues on appeal have been properly developed and the statutory obligation of VA to assist the veteran in the development of his claim has been satisfied. 38 U.S.C.A. § 5107(a). Although service medical records show that the veteran complained of low back pain while hospitalized in March and April 1945, musculoskeletal examination at that time did not find any abnormality and no back disorder was noted on hospital discharge in April 1945 or on service discharge examination in October 1945. Medical evidence on file from R. A. Moyers, D.C., reveals that he treated the veteran in 1978 and 1979 for low back and right knee pain. According to an October 1981 report from George S. Kerr, M.D., the veteran had been given a 1/8 inch lift for his right shoe because of a leg length discrepancy. According to a June 1992 VA orthopedic examination report, the veteran complained that his right knee pain caused an abnormal gait, which resulted in strain and pain in the lower back. The examiner diagnosed chronic low back pain syndrome and concluded that the veteran's low back pain might be related to his abnormal gait secondary to his post-traumatic arthritis. According to a July 1992 VA orthopedic examination report, the veteran had post-traumatic and post-meniscectomy degenerative arthritis of the right knee, which the same examiner as on examination in June 1992 said might, in causing an abnormal gait, exacerbate the veteran's low back symptoms. It was noted by a different examiner on VA orthopedic examination in September 1992 that the veteran's left leg was 1 cm. longer than his right when measured from the anterosuperior iliac spine to the medial malleolus. The examiner's impression was that the mild leg length discrepancy of 1 cm. was not likely related to the veteran's knee pathology. The examiner thought that the leg length discrepancy was most likely a normal variant or possibly due to an additional injury. According to an April 1994 VA orthopedic examination report by another examiner, the veteran's complaints included a 10 to 15 year history of back pain, recently progressive, which occasionally radiated to his buttock and posterior right thigh. The examiner found the veteran's leg lengths to be within normal limits and expressed his opinion that the veteran's gait abnormalities might exacerbate his low back symptoms, but the major underlying cause of his back pain was probably more likely related to a degenerative etiology. The above evidence shows that the VA examiner noted in June 1992 that the veteran's low back pain might be related to his abnormal gait secondary to post-traumatic arthritis, and the same examiner said on examination in July 1992 that the veteran's right knee disorder, in causing an abnormal gait, exacerbated his low back symptoms. He did not on either occasion state that it was his opinion that the veteran's low back pathology was etiologically related to his right knee disability. Moreover, another VA examiner noted on back examination in April 1994 that the major underlying cause of the veteran's back pain was probably more likely related to the degenerative changes seen on x-ray studies. Service connection is not warranted, as in this case, when a service-connected disability merely exacerbates a nonservice- connected disorder, rather than being a proximate cause of the nonservice-connected disorder. Leopoldo v. Brown, 4 Vet.App. 216, 218 (1993). Therefore, service connection for a back disorder as secondary to the veteran's service-connected right knee disorder is denied. 38 C.F.R. § 3.310(a). VA examination in September 1992 determined that the veteran's right lower extremity was 1 cm. shorter than his left lower extremity, and VA examination in April 1994 found that the right lower extremity was .5 cm. shorter. The VA examiner in September 1992 concluded that the mild leg length discrepancy of 1 cm. was more likely a normal variant, or due to a possible additional injury, rather than due to the veteran's service-connected right knee disability. The examiner in April 1994 determined that the veteran's leg length discrepancy was within normal limits. The only medical evidence supporting the claim is the X-ray evidence of narrowing of the right knee joint. The record contains no medical opinion specifically supporting the claimed causal relationship. In view of the equivocal evidence concerning the presence of right leg shortening and the September 1992 VA orthopedic opinion against the claim, the Board must conclude that service connection for shortening of the right lower extremity as secondary to the veteran's service-connected right knee disability is also not warranted. Id. Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1993). The veteran is currently assigned a 10 percent evaluation for his service-connected right knee disability under Diagnostic Codes 5010 and 5259. According to the VA Schedule for Rating Disabilities, arthritis due to trauma, which is substantiated by x-ray findings, is rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved; when limitation of motion is noncompensable, a rating of 10 percent is provided for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. A 10 percent evaluation is provided in the rating schedule for removal of semilunar cartilage, symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. According to Diagnostic Codes 5260 and 5261, an evaluation of 10 percent is provided when flexion of the leg is limited to 45 degrees or when extension is limited to 10 degrees; a 20 percent evaluation is provided when flexion is limited to 30 degrees or when extension is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Other knee impairment, including recurrent subluxation or lateral instability, warrants a 10 percent evaluation if it is slight, a 20 percent evaluation if it is moderate or a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (1993) and Schafrath v. Derwinski, 1 Vet.App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's right knee disability. The Board has found nothing in the historical record which would lead us to conclude that the current evidence of record is not adequate for rating purposes, nor have we found any of the historical evidence in this case to be of sufficient significance to warrant a specific discussion herein. On VA orthopedic examination in November 1990, the veteran complained of right knee pain and instability. Physical examination revealed that he walked with a normal gait, although he had a little difficulty getting up. He appeared to slightly favor his right side. Range of motion of the right knee was from 0 to 125 degrees. He had discomfort with full extension. Minimal osteophyte was palpated on the lateral side. There was 1+ Lachman's and anterior drawer signs with solid endpoints. X- ray studies of the right knee in November 1990 revealed mild narrowing of the knee joint, especially on the lateral compartment. The examiner's impression was degenerative arthritis of the lateral compartment of the right knee. A cane for walking and nonsteroidal anti-inflammatory medication were suggested. According to an August 1991 letter from Robert J. Brill, M.D., the veteran was developing arthritis in his right knee secondary to his previous lateral meniscectomy, which was noted to be a common occurrence after a subtotal or total lateral meniscectomy. On VA orthopedic examination in June 1992, the veteran complained of progressive pain in his right knee with activity and of occasional locking and giving way of the knee. Physical examination revealed that he used a cane to walk and had a right antalgic limp. Range of motion of the right knee was from 10 degrees of extension to 130 degrees of flexion. The mechanical axis of the right lower extremity fell medial to the knee joint because the knee was in 3 degrees of varus. Patella compression test was markedly positive for both pain and crepitus. It was noted that x-ray studies of the right knee had not changed since November 1990. The assessment was post-traumatic degenerative arthritis of the right knee. It was noted on VA orthopedic examination of the right knee in July 1992 that the veteran reported only one episode over the last few years prior to the examination where his knee possibly locked up, and he did not report any signs or symptoms of patellar instability. He was taking Motrin, which helped but did not completely eliminate his symptoms. The results on physical examination were similar to those found in June 1992, with range of motion from 10 to 125 degrees. Mild to moderate lateral joint line tenderness was noted. There was no effusion or ligamentous instability. Although no new x-ray studies of the right knee were taken, the examiner interpreted the June 1992 x-rays as showing mild to moderate changes of degenerative arthritis with involvement of the lateral compartment consistent with the previous history of meniscectomy. The assessment was essentially the same as in June 1992. VA orthopedic examination of the right knee in September 1992 revealed that the veteran walked with a cane and with a marked antalgic gait secondary to right knee pain. On physical examination, he had what was described as full range of motion from 0 to 120 degrees. There was 1+ Lachman's with a good endpoint and negative pivot shift. The veteran had severe lateral joint line tenderness, both to palpation and during range of motion. He was noted to be in 10 degrees of valgus. No new x-ray studies of the right knee were taken. The examiner's impression was moderate degenerative changes in the lateral compartment of the right knee. On VA orthopedic examination in April 1994, the veteran said that the lateral meniscectomy he underwent in 1963 resulted in marked relief of his right knee pain but did not completely relieve the underlying ache. It was noted that the veteran walked with a cane in his left hand and that his gait was fairly normal. Physical examination of the right knee revealed range of motion from 5 to 130 degrees. Anterior drawer, posterior drawer, pivot shift, and Lachman's signs were negative. Collateral ligaments were stable with firm end points, although there was slight opening to varus stress. The veteran had pain in the right knee on squatting. He was able to walk on his toes and heels without difficulty. Patellar deep tendon reflexes were 2+ and symmetrical. X-ray studies of the right knee were noted to reveal degenerative arthritis, especially of the lateral compartment, with osteophytes laterally off of the tibia. The examiner's impression was status-post lateral meniscectomy of the right knee with degenerative arthritis, worse on the lateral side. The veteran is currently assigned a 10 percent evaluation for his right knee disability due to removal of semilunar cartilage and to arthritis. The above evidence shows that the veteran has limitation of right knee extension and flexion, but not to a sufficient degree to warrant a higher evaluation under the schedular criteria. However, the record also shows that the veteran has had some locking of his right knee, that he ambulates with an antalgic gate because of the right knee disability and that significant pain is a component of the disability. The Board is satisfied that the manifestations of the disability are sufficient in combination to produce moderate impairment, as required for a 20 percent evaluation. However, in view of the relatively good range of right knee motion and the absence of significant instability or frequent episodes of locking, the Board is unable to conclude that the disability is more than moderate. The Board has also considered the provisions of 38 C.F.R. 3.321(b)(1) regarding the assignment of extraschedular evaluations. However, the disability picture for the veteran's service-connected right knee disability is not so exceptional or unusual, with such related factors as marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. ORDER Service connection for a back disability and for shortening of the right lower extremity, as secondary to the veteran's service- connected right knee disability, is denied. An evaluation of 20 percent for postoperative residuals of a meniscectomy of the right knee with arthritis is granted, subject to the criteria governing the awards of monetary benefits. SHANE A. DURKIN 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.