Citation Nr: 0001335 Decision Date: 01/14/00 Archive Date: 01/27/00 DOCKET NO. 95-16 680 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut THE ISSUES 1. Entitlement to a higher rating for mechanical low back pain, currently rated 20 percent disabling. 2. Entitlement to an increased rating for a right knee disorder, currently rated 10 percent disabling. 3. Entitlement to an increased rating for a left knee disorder, currently rated 10 percent disabling. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs ATTORNEY FOR THE BOARD Kimberly E. Harrison Osborne, Counsel INTRODUCTION The veteran had active military service from August 1990 to December 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1994 rating decision by the RO which granted service connection for mechanical low back pain and assigned a 10 percent rating; the veteran appealed for a higher rating. The case also comes before the Board on appeal from a May 1995 rating decision which denied an increase in a single 10 percent rating for bilateral patellofemoral pain syndrome. In July 1997, the Board remanded the claims to the RO for further development. In February 1999, the RO granted a higher rating of 20 percent for the low back disorder. The RO also granted a separate 10 percent rating for the right knee disorder and a separate 10 percent rating for the left knee disorder. The veteran has not indicated she is satisfied with these ratings; thus the claims for higher ratings are still before the Board. AB v. Brown, 6 Vet.App. 35 (1993). FINDINGS OF FACT 1. The veteran's low back disorder is manifested by no more than moderate limitation of motion or moderate lumbosacral strain. 2. The veteran's right knee patellofemoral pain syndrome is manifested by complaints of pain, but there is essentially full range of motion of the knee, and the joint is stable with the exception of slight recurrent subluxation of the patella. 3. The veteran's left knee patellofemoral pain syndrome is manifested by complaints of pain, but there is essentially full range of motion of the knee, and the joint is stable with the exception of slight recurrent subluxation of the patella. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Code 5292, 5295 (1999). 2. The criteria for a rating in excess of 10 percent for a right knee disorder have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Codes 5257, 5260, 5261 (1999). 3. The criteria for a rating in excess of 10 percent for a left knee disorder have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.71a, Codes 5257, 5260, 5261 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran had active military service from August 1990 to December 1993. Her service medical records show she complained of bilateral knee pain and wore knee braces. She was diagnosed as having bilateral patellofemoral malalignment. In November 1993, she was diagnosed as having mechanical low back pain. In December 1993, she filed a claim of service connection for a bilateral knee disorder. In 1994 she submitted statements to the effect that her physical activities were limited as a result of bilateral knee pain. She stated she could not do her job or take an aerobics class without experiencing pain. She stated that walking also caused discomfort. On January 1994 VA general examination, the veteran complained of low back pain and bilateral knee pain. She had a good range of motion but had mild spasm over the paraspinal muscles. Low back strain and bilateral chondromalacia of the patella were diagnosed. A January 1994 VA orthopedic examination reveals the veteran complained of bilateral knee pain. She stated she was markedly limited in her ability to ascend and descend stairs due to pain. Physical examination revealed a normal heel/toe gait with mild hyperpronation bilaterally. When standing, she had good flexibility. Her iliotibial bands and hamstrings were not tight bilaterally. She had underdevelopment of the vastus medialis oblique bilaterally. She demonstrated marked tenderness under the medial and lateral facets of the patella bilaterally. She had marked positive provocative maneuvers for retropatellar pain. The remainder of the knee was intact. Her ligaments were intact and there was no medial or lateral joint line tenderness. X- ray studies were unremarkable. The examiner assessed bilateral patellofemoral syndrome as a result of fitness training for the Air Force Academy. The examiner stated the veteran was markedly limited in her ability to perform daily activities as a result of pain and that she needed physical therapy. In August 1994, the RO granted service connection for mechanical low back pain, assigning a 10 percent rating. VA outpatient treatment reports from August 1994 and September 1994 show the veteran complained of back and bilateral knee pain. A September 1994 evaluation of the lumbar spine revealed the veteran complained of back pain. Range of motion studies revealed 30 degrees of extension, bilateral lateral flexion to 35 degrees, and bilateral rotation to 40 degrees. Physical examination of the knees in October 1994 revealed negative Lachman and anterior drawer signs. She had a full range of motion. Her strength was 5/5. She had no ligament laxity but had laxity of the patellae. She had no dislocations. The examiner diagnosed subluxating patellae. In October 1994, the orthopedic clinic referred the veteran to physical therapy due to bilateral subluxating of the patella. During a December 1994 RO hearing, the veteran stated she had pain and swelling of the knees. She stated she had problems bending. She stated she would have problems if she were to sit or walk for prolonged periods of time. She reported having problems performing physical activities. In a February 1995 statement, the veteran asserted she was entitled to a rating in excess of 10 percent for her service- connected back disorder. She stated she had pain and weakness of the back. She reported that sitting, standing, or driving would sometimes cause back pain. She stated that she was no longer able to perform physical activities due to her back disorder. In March 1995, the RO hearing officer granted service connection for bilateral patellofemoral pain syndrome and assigned a single 10 percent rating. During an April 1995 VA examination, the veteran reported she developed back and knee pain in service. Physical examination revealed she wore a right knee support brace. She was in no acute distress. Evaluation of her back demonstrated her to have full flexion with mild aching in the region of the lower lumbar musculature, but no spasm. Hyperextension was possible to -10 degrees but she did have a mild increase in low back muscle discomfort. On lateral bending she was able to reach approximately 20 degrees with only some increase in discomfort in the left lower lumbar musculature, but not on the right when she went to either side. Lateral rotation appeared to be fairly normal to approximately 20 to 30 degrees with similar discomfort elicited in the left lower lumbar musculature. Straight leg raising tests bilaterally were negative and strength in the lower extremities was normal. She had a full range of motion of both knees without evidence of swelling or effusion. There was mild aching bilaterally, right side greater than the left, when passive patellar subluxation was attempted. The examiner stated that the overall impression was that the veteran continued to suffer from relatively significant subjective pains in the low back on a fairly regular basis, requiring her to take muscle relaxants and Motrin on a regular basis. He stated the veteran used a lumbar support pillow which helped only moderately with discomfort. He stated the veteran had patella subluxation and chondromalacia patella of the knees which was common in woman. He related that most of her complaints were relatively subjective but real. In May 1995, the RO denied a rating in excess of 10 percent for low back pain and denied a rating in excess of 10 percent for bilateral patellofemoral syndrome. In June 1995, the veteran complained of back pain and was noted to have a chronic low back strain. In July 1995, physical examination revealed no patella subluxation. At that time, she wore a knee brace. She was diagnosed as having bilateral patellofemoral syndrome. Other reports in 1995 show continued complaints of bilateral knee pain. From August to October 1995, the veteran had physical therapy sessions due to low back pain and bilateral knee pain. In September 1995, she had almost a full range of motion of the knees. She had 0 to 135 degrees of knee flexion with pain at the end range. She had full motion of the lumbar spine. Outpatient treatment reports from 1996 show the veteran complained of bilateral knee pain. A January 1996 report from Richard A. Matza, M.D. reveals the veteran had tenderness over her low back, no spasm, and limited range of motion of her back with pain. She had positive grab sign with high-riding patella and crepitus on range of motion of her knees. She had minimal effusion in the right knee with no instability other than patellofemoral. Review of MRI studies of the knees showed she had patellofemoral tilting without any evidence of wear. The impression was bilateral patellofemoral chondromalacia, right worse than the left, and low back strain. Dr. Matza stated the veteran had a 15 percent permanent partial disability of the right knee and 12 percent disability of the left knee. A February 1996 VA report reveals the veteran was treated for continued complaints of daily-weekly subluxation episodes of the right and left patella, with greater problems on the right. She stated she had anterior knee pain. Physical examination of the right knee revealed decreased palpable lateral subluxation of the patella at 30 degrees of knee flexion with pain. There was retropatellar tenderness and facet tenderness. There was also patellar ligament tenderness and mild effusion. She had negative Lachman and posterior drawer. She was stable with varus and vulgus testing. She had lateral retinacular tightness. She had an increased Q angel to 17 degrees. X-ray studies of the left knee revealed a lateral tilt of the patella with minimal subluxation. The impression was patellofemoral syndrome, right greater than left. February 1996 X-ray studies of the knees revealed patella lata on the right, no evidence of fracture or dislocation, and no other apparent abnormalities. March 1996 X-ray studies of the knees showed an impression of no evidence of patellofemoral subluxation bilaterally. In February and March 1996, the veteran continued to have bilateral knee pain which was worse on the right. As a result, she was schedule for right knee surgery. In March 1996, she also complained of low back pain. A March 1996 operation report reveals the veteran had a history of approximately 2-3 years duration of bilateral, right greater than left, anterior knee pain related to patellofemoral problems. She had chronic pseudo subluxation episodes as well as anterior knee pain associated with loading the patellofemoral joint. Examination was remarkable for lateral retinacular tightness and lateral facet tenderness. She tended to track laterally in her patellofemoral joint and her radiographs confirmed this with plain X-ray and CT scans preoperatively. She had no evidence of degenerative arthritis of the knees and had no other symptoms related to the knee. Due to failed trials at physical therapy, the veteran underwent right knee diagnostic arthroscopy and a lateral release to correct a lateral compression problem. Following the March 1996 operation, the veteran underwent physical therapy to decrease pain and edema of the right knee. The goal was also to improve range of motion and strength of the right knee. Examination revealed the knee had flexion to 110 degrees. Her right quadriceps were 3+/5. The veteran made progress with physical therapy and by April 1996 her range of motion was within normal limits. Physical therapy reports also show the veteran received therapy for treatment of low back pain. In May 1996, she continued to complain of right knee pain but had a full range of motion. She was noted to have mild infrapatellar edema of the right knee. An April 1996, VA outpatient treatment report shows the veteran complained of back pain at the bottom of the spine. She stated the pain radiated upward to the shoulder blade. The assessment was continuous back pain. During that time, she also complained of bilateral knee pain which was worse on the right. In April 1996, physical examination of the right knee revealed some effusion. She had a full range of motion. A July 1996 VA outpatient treatment report shows the veteran had medial and lateral facet tenderness on the right and lateral facet tenderness on the left. She had a full range of motion of the knees without pain. The diagnosis was patellofemoral syndrome. The plan was for her to wear a brace. An August 1996 physical therapy report reveals the veteran's right patella was no longer displaced laterally after lateral release but was rotated medially. She was instructing on knee taping. Right knee strength was 4-/5 when using 25 to 35 pound weights during knee extension. Straight leg raising and hip abduction and adduction was so painful that she was able to use only a one 1 pound weight. Her pain was decreased with new taping procedure. Range of motion of the knee was within normal limits. She continued to be in pain but appeared to be more active. When treated in September 1996, the veteran stated that she continued to have right knee pain which was similar to the pain she had before her operation. She stated she had minimal relief from surgery. She reported that during the last two months she had been wearing a right knee brace and doing physical therapy exercises on her own. She stated that there had been some improvements over the past 2 months. Physical examination revealed full range of knee motion bilaterally. She had a positive right knee grind test. She was tender bilateral over the femoral condyles. Examination of the left knee revealed a negative grind test. She was tender over the patella ligament. The impression was patellofemoral syndrome. In December 1996, the veteran was diagnosed as having bilateral patellofemoral syndrome. The examiner noted she was status post arthroscopic and lateral release without improvement. It was reported that she still was doing physical therapy and taking non-steroidal anti-inflammatory drug with minimal results. December 1996 X-ray studies of the knees revealed no evidence of osteoarthritis. In a December 1996 statement, the veteran stated she suffered from back and bilateral knee pain. She stated she was unable to live a normal active life. She stated should could not walk up stairs normally or open doors. She claimed she had trouble showering and walking. She stated she constantly had to take medication and wear braces and that she still felt her knees go out two to three times a day. She reported her right knee was significantly worse than her left. She claimed she was entitled to a rating in excess of 10 percent for her bilateral knee disorder. In December 1996, the RO granted a temporary total rating convalescent rating based on the March 1996 right knee surgery. The rating was made effective from March 1996 to April 1996. An April 1997 VA neurological examination of the back revealed mild discomfort in a non-localizing manner to percussion of the spine. There was no sciatic notch tenderness identified. Straight leg raising was possible to approximately 75 degrees without any associated pain. She ambulated normally. Walking in tandem, on heels and on her toes was possible without any limitation. The Romberg sign was absent. Motor and sensory examination disclosed intact muscle bulk, tone, and strength throughout. Sensation to primary modalities including touch, pinprick, temperature, vibration, and position sense were intact. Deep tendon reflexes were normal. The examiner diagnosed chronic knee discomfort felt to be secondary to repeated mild trauma. He stated the veteran was reportedly diagnosed as having subluxation of the right patella. He also diagnosed chronic back discomfort which was of a non-localizing nature. He stated there were no associated neurological deficits by examination. A July 1997 post-employment offer physical examination by Dr. Kenneth Johnson states the veteran had no forward flexion or extension of the back, and she had no shoulder motion above 90 degrees. He also noted her right and left knee disorder. In a July 1997 letter Dr. Johnson wrote that after a review of the functional job description and based on history and physical examination, the veteran was not recommended for the position. He stated she could do no lifting or over shoulder tasks and that she needed to frequently change positions. On a July 1998 orthopedic examination, the veteran reported her back pain had increased over the years. She stated she had pain every day when she awoke in the morning. She reported she had stiffness and spasm on a nearly daily basis and interference with her activities with daily living. With respect to her knees, she described problems with her right knee. She described popping, grinding, and pain in the right knee with negotiating stairs and squatting-type activities. She stated after her knee operation her pain had improved mildly, allowing her to do some exercise. She related her left knee caused episodic pain and a constant sense of weakness. The examiner noted bilateral plain films and CT scans showed no evidence of osteoarthritis and no evidence of subluxation. Examination of the lumbar spine revealed some dysemmetry with spasm and tightness in the right paraspinal muscle in the lower lumbar region. Her range of motion of the spine demonstrated flexion of 80 degrees, extension of 20 degrees, bilateral lateral bend to 15 degrees, bilateral rotation was to 20 degrees. Her strength was intact on the lower extremities. Her deep tendon reflexes were intact and her sensation was intact. Examination of the right knee demonstrated healed arthroscopic portal sites. She had 1 cm of quad atrophy. Through active range of motion, she was a mild J sign indicating mild lateral subluxation of the patella and full extension. There was also reproducible clunking of the patella through active extension. Static examination of the knee demonstrated the ligaments to be intact. There was significant medial and lateral facet tenderness. She was markedly positive for provocative maneuvers for patella femoral syndrome. The Q-angle was slightly increased. Examination of the left knee revealed no evidence of effusion or surgical scars. There was no atrophy compared to the contralateral leg. Range of motion was full. There was no crepitus or clunking through range of motion. There was no J sign present. The Q-angle was slightly increased. On static examination, the ligaments were intact. There was no joint line tenderness. She had palpable tenderness along the medial and lateral facets of her patella and was positive for provocative maneuvers for patella femoral syndrome. The examiner's assessments were that the veteran had long- standing problems with her back and knees. He stated her back diagnosis was mechanical low back pain with paraspinous muscle spasm. Her diagnosis for the right knee was patellofemoral syndrome with crepitus and mal-tracking. He stated the right knee may require more extensive surgical procedure for tibial tubercle elevation and medialization to correct the problems. The diagnosis on the left was also patellofemoral syndrome. He stated he did not see a surgical indication on the left side. In February 1999, the RO granted a higher rating of 20 percent for mechanical low back pain. The RO also granted a separate 10 percent rating for right knee patellofemoral pain syndrome and a separate 10 percent rating for left knee patellofemoral pain syndrome. II. Analysis A. Higher rating for a low back disorder The veteran's claim for a higher rating for her service- connected lumbosacral strain is well grounded, meaning plausible. The file shows that the RO has properly developed the evidence, and there is no further VA duty to assist the veteran with her claim. 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The veteran has complaints of low back pain and claims an increase in the current 20 percent rating assigned for the condition. Her low back disorder is rated 20 percent rating under Code 5295, lumbosacral strain. Lumbosacral strain is 20 percent disabling when there is muscle spasm on extreme forward bending, and unilateral loss of lateral spine motion in the standing position. A 40 percent rating requires that the lumbosacral strain be severe, with listing of the whole spine to the opposite side, positive Goldthwait's sign, marked limitation of forward bending in the standing position, loss of lateral spine motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Code 5295. VA examination in January 1994 revealed the veteran had mild spasm over the paraspinal muscles. In April 1995, she had mild aching in the region of the lower lumbar musculature, but no spasm. In January 1996, she was noted to have tenderness over her low back with no spasms. In April 1997, she had mild discomfort in a non-localizing manner to percussion of the spine. Examination in July 1998 revealed some dysemmetry with spasm and tightness in the right paraspinal muscle in the lower lumbar region. Although reports show periodic muscle spasms of the lumbar area, the presence of muscle spasm is contemplated in a 20 percent rating currently assigned under Code 5295. The medical reports fail to show she has listing of the whole spine to the opposite side, marked limitation of forward bending in the standing position, or loss of lateral spine motion. Thus, the evidence supports no more than a 20 percent rating under Code 5295. Signs of severe lumbosacral strain, as required for a higher rating, are not evident. The veteran's back disorder can also be evaluated under Code 5292, limitation of motion of the lumbar spine. Moderate limitation of motion of the lumbar spine warrants a 20 percent rating, and a 40 percent rating requires severe limitation of motion. 38 C.F.R. 4.71a, Code 5292. On VA examination in January 1994, the veteran was noted to have a good range of motion. In September 1994, she had 30 degrees of extension, bilateral flexion to 35 degrees, and bilateral rotation to 40 degrees. An April 1995 VA examination reveals she had full flexion, -10 degrees of hyperextension, lateral bending to 20 degrees, and lateral rotation between 20 and 30 degrees. A July 1997 private employment physical reported the veteran had "no" forward flexion or extension of the back. However, this report is inconsistent with earlier and later medical records and is not deemed credible for rating purposes. On July 1998 VA examination the veteran had 80 degrees of flexion, 20 degrees of extension, 15 degrees of lateral bending bilaterally, and bilateral rotation was to 20 degrees. The overall evidence, including the most recent 1998 VA examination, shows no more than moderate limitation of motion of the low back. Thus, a rating in excess of 20 percent under Diagnostic Code 5292 is not warranted. There is no objective evidence that pain on use of the low back results in limitation of motion to a degree which would support a higher rating. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The evidence of record depicts a low back disorder which is productive of no more than moderate limitation of motion or moderate lumbosacral strain. This supports no more than a 20 percent ratings under Codes 5292 or 5295. The preponderance of the evidence is against the claim for a rating in excess of 20 percent rating for the low back disorder. Consequently, the benefit-of-the doubt doctrine is inapplicable and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). B. Increased ratings for right and left knee disorders The veteran's claims for increased ratings for service- connected right knee patellofemoral pain syndrome (rated 10 percent) and left knee patellofemoral pain syndrome (rated 10 percent) are well grounded, meaning plausible. The file shows that the RO has properly developed the evidence, and there is no further VA duty to assist the veteran with her claims. 38 U.S.C.A. § 5107(a). When rating the veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the present level of disability is of primary concern in a claim for an increased rating; the more recent evidence is generally the most relevant in such a claim, as it provides the most accurate picture of the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55 (1994). The veteran is currently assigned a 10 percent rating for her right knee disorder and a 10 percent rating for her left knee disorder under 38 C.F.R. § 4.71a, Code 5257. This code provides a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, and a 20 percent is assigned when it is moderate. The medical evidence from 1994 to 1998 shows the veteran at times was diagnosed as having a subluxating patellae. However, most reports show that she had a negative Lachman and posterior drawer and that she was stable to varus and vulgus testing. March 1996 X-ray studies of the right knee showed no evidence of subluxation. An August 1996 medical report reveals the veteran's right patella was no longer displaced after the lateral release. In July 1998, a VA examiner noted bilateral plain films and CT scans showed no evidence of subluxation. Physical examination in July 1998 revealed mild lateral subluxation of the patella. The medical evidence from 1994 to 1998 shows that the veteran at any given time has had at best slight subluxation of the right knee patella, although the rest of the knee joint is stable. There is no evidence during 1994 to 1998 showing that she has moderate subluxation or instability of the right knee. Thus a rating higher than 10 percent under Code 5257 is not warranted for the right knee disability. With respect to the left knee, the medical evidence shows that in 1994, she had negative Lachman and anterior drawer signs. She had no ligament laxity but had laxity of the patella. The diagnosis was subluxating patellae. February 1996 X-ray studies reveal minimal subluxation of the patella, and March 1996 studies showed no evidence of subluxation of the patella. In 1998 a VA examiner noted that plain films and CT scans showed no evidence of subluxation. A review of the evidence between 1994 and 1998 shows that at most the veteran has had minimal subluxation of the left patella, and the rest of the knee joint is stable. There is no evidence of moderate instability of subluxation of the left knee. Thus a rating higher than 10 percent for the left knee disability is not warranted under Code 5257. Standard motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. A 0 percent rating is warranted for limitation of leg flexion when it is limited to 60 degrees, a 10 percent rating is warranted when it is limited to 45 degrees, and a 20 percent rating is warranted when it is limited to 30 degrees. 38 C.F.R. § 4.71a, Code 5260. A 0 percent rating is warranted when leg extension is limited to 5 degrees, a 10 percent rating is warranted when it is limited to 10 degrees, and a 20 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Code 5261. In April 1995, the veteran was noted to have a full range of motion of her knees. In September 1995, she had 0 to 135 degrees of motion of the knees. From April 1996 to July 1998, reports show she had full range of motion of her knees. If the veteran's knee disorders were rated under either Code 5260 or 5261, she would be assigned noncompensable ratings for each knee. Moreover, there is no objective evidence of additional limitation of motion of the knees due to pain on use, and certainly not additional limitation to the extent necessary for compensable ratings under the limitation of motion codes. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board finds that the preponderance of the evidence is against the veteran's claims for higher ratings for right and left knee disorders. Thus, the benefit-of-the-doubt rule is inapplicable, and the claims must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 20 percent for a low back disorder is denied. A rating in excess of 10 percent for a right disorder is denied. A rating in excess of 10 percent for a left knee disorder is denied. L. W. TOBIN Member, Board of Veterans' Appeals