Citation Nr: 0004219 Decision Date: 02/17/00 Archive Date: 02/23/00 DOCKET NO. 94-03 861 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an increased evaluation for patellofemoral pain syndrome of the left knee, currently evaluated as 10 percent disabling. 2. Entitlement to an increased (compensable) evaluation for patellofemoral pain syndrome of the right knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Orfanoudis, Associate Counsel INTRODUCTION The veteran had active service from September 1983 to November 1990. This matter arises before the Board of Veterans' Appeals (Board) on appeal from a January 1993 rating decision of the Atlanta, Georgia, Regional Office (RO) which confirmed a 10 percent rating evaluation for the veteran's service connected bilateral knee disability. The veteran filed a timely notice of disagreement and perfected a substantive appeal. This matter was previously before the Board in February 1998 wherein the issues currently before the Board were Remanded for additional development. By rating action dated in October 1998, the RO assigned a 10 percent evaluation for the veteran's patellofemoral pain syndrome of the left knee and assigned a noncompensable evaluation for the veteran's patellofemoral pain syndrome of the right knee. This matter was also before the Board in May 1999, but was Remanded for additional development. FINDINGS OF FACT 1. All of the evidence necessary for an equitable disposition of the claim has been obtained. 2. The patellofemoral pain syndrome of the left knee is manifested by subjective complaints of intermittent pain and a negative patella tilt and diminished mediolateral excursion. 3. The patellofemoral pain syndrome of the right knee is knee is manifested by subjective complaints of intermittent pain, less severe than the left knee pain, with no objective abnormality shown during the recent VA examination. CONCLUSIONS OF LAW 1. The schedular criteria for a rating evaluation greater than 10 percent for patellofemoral pain syndrome of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, § 4.20, Diagnostic Codes 5299-5010 (1999). 2. The schedular criteria for a rating evaluation of 10 percent for service connected patellofemoral pain syndrome of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4 § 4.20, Diagnostic Codes 5299- 5010 (1999) REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board has found that the veteran's claims for entitlement to an increased rating evaluation for service connected patellofemoral pain syndrome of the left knee and for service connected patellofemoral pain syndrome of the right knee are well grounded pursuant to 38 U.S.C.A. § 5107 (West 1991) in that the claims are plausible, that is meritorious on their own or capable of substantiation. This finding is based upon the veteran's assertion that his knee disabilities have increased in severity. Proscelle v. Derwinski, 2 Vet. App 629 (1992). Once it has been determined that a claim is well grounded, VA has the statutory duty to assist the appellant in the development of evidence pertinent to that claim. The Board is satisfied that all relevant evidence is of record. Under the laws administered by VA, disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 1991). Where 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 (1999). The veteran underwent a VA examination July 1992. The veteran reported chronic knee pain since his motor vehicle accident which he described as a constant aching which intermittently worsened. He denied any exacerbating or alleviating factors. He indicated that he did not feel that increased work or physical labor caused any increase in the knee pain. He denied any instability or weakness. Physical examination revealed that there was no effusion or swelling, no instability or subluxation, and no crepitus or manipulation. Both knees were noted to have full range of motion. A diagnosis of probable degenerative joint disease bilaterally was provided. X-rays were recommended VA outpatient treatment records dated from November 1990 to February 1996 reveal that the veteran received occasional treatment for his knee disabilities. He reported pain in both knees and popping and locking of the left knee. November 1993 x-rays of the knee showed no abnormality. The veteran submitted a private examination report dated in August 1995 which suggested that the veteran had degenerative arthritis of both knees. The report indicated that a medical report on the degenerative arthritis of the knees was pending. A September 1995 statement from a prospective employer is to the effect that due to his degenerative arthritis he was medically unsuitable for the position of maintenance mechanic. The veteran underwent a VA examination in May 1996. He reported that his knees ached constantly. He denied any giving out or locking of the knees. Physical examination showed that there was no swelling or deformity of the knee. Anterior drawer, Lochman's and McMurray's tests were all negative. There was loose medial collateral cruciate ligament on the right knee. There was no instability or subluxation, and no crepitus or manipulation. Both knees exhibited a full range of motion. Radiological reports were unremarkable. A diagnosis of loose medial collateral cruciate ligament on the right knee was provided. A VA examination was conducted in August 1998. At that time the veteran reported that he worked as an airplane mechanic. He described pain in the anterior peripatellar regions. The pain was said to localize laterally on occasion and increased with squatting and riding in a car. It was said not to increase with stairs. The veteran denied swelling but reported occasional night pain. The pain was described as somewhat intermittent and did not change with the weather. The left side was greater than the right. The veteran reported a three week old difficulty in extending the left early in the morning, but this was not a chronic occurrence. Physical examination revealed that both knees were relatively unremarkable. There was full extension with 140 degrees of flexion. The anterior cruciate ligaments appeared intact bilaterally. There was no evidence of posterior drawer and no effusions were evident. The knees were stable to varus and valgus examination. The right patella would tilt to neutral, but the left patella had a negative tilt and diminished mediolateral excursion. Q angle was 12 degrees on the right and 15 degrees on the left. BMO strength appeared to be good and calves had good muscle tone. The associated X-ray reports of both knees were unremarkable. The impression of patellofemoral syndrome, left greater than right was provided with no evidence of intra-articular pathology noted at this time. The veteran's bilateral knee disabilities are analogously evaluated under Diagnostic Code 5010 (1999), which provides for the evaluation of traumatic arthritis. 38 C.F.R. § 4.20 (1999). Diagnostic Code 5010 provides that arthritis due to trauma will be rated under Diagnostic Code 5003. Diagnostic Code 5003 provides that degenerative arthritis established by X- ray findings will be rated on the basis of limitation of motion. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Diagnostic Code 5260 provides for the evaluation of flexion of the knee. When flexion is limited to 45 degrees, a 10 percent rating is warranted. When flexion is limited to 30 degrees a 20 percent rating is warranted. When flexion is limited to 15 degrees, a 30 percent rating is warranted. Diagnostic Code 5261 provides for the evaluation of extension of the knee. When extension of the knee is limited to 10 degrees, a 10 percent rating is warranted; when extension is limited to 15 degrees, a 20 percent rating is warranted; and when extension is limited to 25 degrees, a 30 percent rating is warranted. Diagnostic Code 5257 provides for the evaluation of other impairment of the knee, to include recurrent subluxation or lateral instability. A 10 percent evaluation is warranted when the impairment of the knee is slight. A of 20 percent rating is warranted when the impairment is moderate. It is the intent of the Schedule to recognize painful motion with joint or periarticular pathology as productive of disability. This is to say that, even absent a definable limitation of motion, where there is functional disability due to pain, supported by adequate pathology, compensation may be warranted. 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999). The Board notes that the Court has held that when a diagnostic code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 (1999) must be considered, and examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202 (1995). The veteran's statements describing his symptoms are considered to be competent evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). However, these statements must be viewed in conjunction with the objective medical evidence. I. Left Knee During the recent VA examination the veteran described the pain in the left knee as intermittent which increased in squatting and riding in a car. The examination showed the left knee was relatively unremarkable with full range of motion, no swelling, and no instability or subluxation. Additionally, x-rays were negative. The examination showed that the left patella had a negative tilt and diminished mediolateral excursion. After reviewing the medical evidence in conjunction with the veteran's symptoms, it is the Board's judgment that a rating in excess of 10 percent is not warranted. The functional impairment as envisioned by the Deluca case is adequately reflected in the 10 percent rating. The evidence is not in equipoise and the benefit of the doubt doctrine is not applicable. II. Right Knee The recent VA examination showed no objective abnormality involving the left knee. The only subjective abnormality was intermittent pain, which increased in squatting and riding in a car. However, there was no increase in symptoms when using the stairs. Additionally, the veteran described the pain as being less that the pain in the left knee. After reviewing the medical evidence in conjunction with the veteran's symptoms, it is the Board's judgment that the criteria for a compensable rating have not been met. The Board finds that the degree of functional impairemnt caused by the intermittent complaint of pain as indicated by the Deluca case is not the equivalent of flexion limited to 45 degrees or extension to 10 degrees. Accordingly, the claim is denied. Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4 as required by Schafrath, 1 Vet.App. at 589, and various regulations, including 38 C.F.R. §§ 3.102, 4.7, 4.40, 4.45, 4.59 (1999). However, the Board finds no basis which would support a compensable rating. ORDER Entitlement to an increased evaluation for patellofemoral pain syndrome of the left knee is denied. Entitlement to an increased evaluation for patellofemoral pain syndrome of the right knee is denied. ROBERT P. REGAN Member, Board of Veterans' Appeals