BVA9505223 DOCKET NO. 93-12 062 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Francisco, California THE ISSUES 1. Entitlement to service connection for a chronic disorder manifested by headaches. 2. Entitlement to an increased evaluation for postoperative instability of the left knee, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from March 1987 to March 1991. This appeal arose from a May 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Francisco, California. The RO, in relevant part, granted entitlement to service connection for traumatic arthritis of the left knee with loss of motion and assigned a 10 percent evaluation. The RO denied entitlement to an increased evaluation for disability of the left knee when it issued a rating decision in January 1992. The RO denied entitlement to service connection for headaches in a May 1992 rating decision. This determination was affirmed in November 1992. In a March 1993 rating decision, the RO reclassified the service- connected left knee disability to postoperative instability of the left knee and affirmed the prior denial of entitlement to an increased evaluation. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that service connection is warranted for headaches. He argues that he was treated for headaches in service and continues to suffer from headaches to the present. While he acknowledges that he denied a history of headaches when examined for separation from service, he argues that at that time he was not having a problem, but that his headaches have returned, thereby warranting a grant of service connection. The appellant further argues that his left knee disability is productive of severe incapacitating pain thereby warranting entitlement to a grant of 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 preponderance of the evidence is against grants of entitlement to service connection for a chronic disorder manifested by headaches, and an increased evaluation for postoperative instability of the left knee. FINDINGS OF FACT 1. During service the veteran was treated for frontal headaches; tension headaches were not shown in service. 2. The post service VA examination conducted in October 1992 shows the veteran was diagnosed with tension headaches, specifically noted by the examiner to be of a different etiology, and unrelated to frontal headaches reported in service. 3. Postoperative instability of the left knee is productive of not more than slight impairment. CONCLUSIONS OF LAW 1. A chronic disorder manifested by headaches was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.303(b) (1994). 2. The criteria for an evaluation in excess of 10 percent for postoperative instability of the left knee have not 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 Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially the Board finds that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a), in that it is at least plausible that the headaches the appellant currently suffers from may be related to headaches reported in service, and that his left knee disability has increased in severity. 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). I. Entitlement to service connection for a chronic disorder manifested by headaches. A review of the service medical records discloses that when examined for active duty in the United States Air Force in September 1986 the appellant denied a history of frequent or severe headache. The clinical evaluation of the head was normal and the neurologic examination was also reported as normal. In May 1989 he reported for evaluation of frequent headaches above the eyes around light or with reading. It was noted that he had seen an optometrist who told him the headaches were not related to his eyes. The claimant was noted to have pain in the tear ducts, above the eye and at the center of the eye of one year's duration. He had morning sinus congestion. There was a history of a cyst at the right maxillary sinus. An examination concluded in a clinical assessment of frontal headaches of unknown etiology. A few days later the appellant reported again for treatment of headaches. It was noted that a sinus series was done and disclosed continuation of a retention cyst/polyp at the right maxillary sinus, otherwise the series was within normal limits. The clinical assessment was frontal headaches of unknown etiology. An examination by a neurologist was recommended. A May 1989 neurology consultation report shows impressions of non-specific frontal cephalgia and history of astigmatism. It was noted the greatest aches occurred with eye strain. It was agreed that before the eye possibilities were considered the primary cause of the veteran's symptomatology, other differential possibilities must be ruled out. Additional diagnostic studies were recommended. A computerized axial tomographic scan of the head was interpreted as normal. In July 1989 it was noted the veteran had 2 to 3 headaches a week, but with use of Midrin, had noted sufficient symptom suppression to where he could function although there remained some residual headaches. The diagnostic impression was non- specific cephalgia, improved. The separation examination report shows the clinical evaluation of the head and neurological evaluation were normal. The veteran denied a history of frequent or severe headaches. At a February 1992 VA general medical examination, the veteran complained of bi-temporal/occipital and posterior neck headaches which were constant. He had occasional photophobia. He stated that his headaches had never subsided since 1988. The examiner diagnosed tension headaches. At an October 1992 VA neurology examination the veteran stated that his current headaches consisted of constant pain in the occipital area of his skull and down his cervical spine into the upper back. Pain was experienced day and night. He was able to sleep by taking large quantities of aspirin. When he tried to concentrate, his pain worsened and would radiate forward onto his scalp and the frontal area. The examination concluded in a diagnosis of tension headaches. The VA examiner noted that the veteran's current headaches which are tension in nature, are not of the same etiology as the frontal headaches he was having in service in 1989. The Board's evaluation of the evidence of record does not permit the conclusion that service connection is warranted for a chronic disorder manifested by headaches. In this regard, the Board observes that during service the veteran was treated for what were specifically diagnosed as frontal headaches. The frontal headaches resolved with no residual disability and no continuity of symptomatology is shown by the evidence of record. 38 C.F.R. § 3.303(b). The post service VA examination report shows the veteran has tension headaches, the clinical and symptomatologic descriptions of which are different from those reported in service. Moreover, a VA examiner has specifically distinguished the two on a clinical and etiological basis. As reported above, the VA examiner clearly noted that the veteran's current tension headaches are not of the same etiology as the frontal headaches reported in service. The tension headaches were not reported in service. Frontal headaches reported in service are no longer shown by the evidence of record. The veteran is not shown to have a chronic disorder manifested by headaches which was incurred in or aggravated by his active service. The Board finds no basis upon which to predicate a grant of entitlement to service connection. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303(b). II. Entitlement to an increased evaluation for postoperative instability of the left knee. In accordance with 38 C.F.R. §§ 4.1 and 4.2, 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 appellant's left knee disability. The Board has found nothing in the historical record which would lead to a conclusion that the current evidence of record is inadequate for rating purposes. The service medical records show that in November 1987 the veteran sustained a twisting injury of his left knee. He was initially diagnosed with a patellar dislocation. Due to continuing problems with left knee symptomatology, the appellant was hospitalized in late 1989 for arthroscopic surgery for patellar subluxation, loose body, and degenerative joint disease. He was rehospitalized in August 1990 for arthroscopic removal of an additional loose body, and underwent more physical therapy. At the time of his separation examination he had continuing pain and pressure, multiple scars, and tenderness of the patellar tendon and at the medial/lateral joint line. At a December 1991 VA examination, the veteran complained of pain, giving out, and stiffness of the left knee. He had not fallen, occasionally wore a brace, and did not take any medications. On examination of the left knee was seen three arthroscopy scars. There was slight tenderness laterally. The patella was normal in position and mobility. The ligaments were intact. Range of motion of the knee with crepitus was 130 out of 140 degrees. The diagnosis was postoperative left knee with traumatic arthritis. An x-ray of the left knee was interpreted as negative for any abnormalities. At a January 1993 VA orthopedic examination the appellant reported that he injured his knee while wrestling in service. He required arthroscopic surgery on two occasions. His current symptoms consisted of constant ache and giving out. He did not wear a brace. There was no locking, swelling, or stiffness. The claimant took enteric-coated aspirin. On examination of the left knee was seen a well healed, non-tender, non-adherent, and non- depressed surgical scar. The scar ran vertically on the lateral aspect of the knee and measured 2.5 by .5 centimeters. The patella was normal in position and mobility, and non-tender. There was mild laxity of the lateral collateral ligament. Range of motion of the knee was to 140/140 degrees without pain or crepitus. The examination diagnosis was status postoperative times 2 for left knee injury with degenerative joint disease. An x-ray of the left knee was interpreted as negative for any abnormalities. The appellant's left knee disability is evaluated as 10 percent disabling under diagnostic code 5257 of the VA Schedule for Rating Disabilities. The 10 percent evaluation contemplates not more than slight recurrent subluxation or lateral instability of the knee. The next higher evaluation of 20 percent requires moderate recurrent subluxation or lateral instability of the knee. It is the judgment of the Board that the veteran's left knee disability is properly rated. The criteria for the next higher evaluation of 20 percent have not been satisfied. The VA examination reports of record show that the veteran takes aspirin for symptomatology reported primarily as pain. He has denied most other knee symptomatology. Radiographic studies have been negative for any abnormalities. The veteran has not required outpatient treatment by VA or non-VA health care professionals. No gait abnormalities or ambulatory difficulties have been reported. While there has been some giving way of the knee, the veteran has not been subject to falling. No question has been presented as to which of two or more evaluations would more properly classify the severity of the appellant's left knee disability. 38 C.F.R. § 4.7. The 10 percent evaluation under diagnostic code 5257 compensates the veteran for his pain thereby precluding assignment of an increased evaluation under 38 C.F.R. § 4.40 for functionally incapacitating pain. As left knee flexion is not shown to be limited to 30 degrees, an increased evaluation of 20 percent under diagnostic code 5260 is not warranted. As left knee extension is not shown to be limited to 15 degrees, an increased evaluation under diagnostic code 5261 is not warranted. Postoperative left knee instability has not rendered the veteran's disability picture unusual or exceptional in nature and has not markedly interfered with employment. It has not required frequent inpatient care as to render impractical the application of regular schedular standards thereby precluding a grant of an increased evaluation on an extraschedular basis. 38 C.F.R. § 3.321(b)(1). In view of the foregoing discussion, it is the finding of the Board that no basis exists upon which to predicate a grant of an increased evaluation for postoperative left knee disability. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.7, 4.40, 4.71(a), Diagnostic Code 5257. ORDER Entitlement to service connection for a chronic disorder manifested by headaches is denied. Entitlement to an increased evaluation for postoperative instability of the left knee is denied. ALBERT D. TUTERA 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.