Citation Nr: 0005090 Decision Date: 02/28/00 Archive Date: 03/07/00 DOCKET NO. 94-16 958 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to a higher initial rating for deep vein thrombosis of the left lower extremity, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Johnson, Associate Counsel INTRODUCTION The veteran served on active duty from March 1983 to July 1992. These matters came to the Board of Veterans' Appeals (Board) from a March 1993 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, which made the following determinations: granted service connection for deep vein thrombosis of the lower left extremity and assigned a 20 percent rating; granted service connection for hepatitis C; granted service connection for right thigh and left scrotum varicose veins; granted service connection for hammertoes; denied service connection for a left knee disability; and denied service connection for exposure to volcanic ash. Notification of the decision was issued in April 1993. The veteran submitted a notice of disagreement with the determinations regarding the rating of his deep vein thrombosis and hepatitis C, as well as the denial of his claim of service connection for a left knee disability and exposure to volcanic ash. A statement of the case, which addressed the issues set forth in the notice of disagreement, was issued in July 1993. The veteran submitted his substantive appeal in March 1994. In June 1995, the veteran appeared and testified at the RO before a hearing officer. At that time, he raised the issue of an increased rating for dysthymia. This was accepted as an informal claim. See June 1995 transcript of personal hearing at pages 1 to 3. However, further action has not been taken regarding that matter, and is referred to the RO for the appropriate action. Also, he withdrew the issue of service connection for exposure to volcanic ash. See June 1995 transcript of personal hearing at page 1. In May 1999, the veteran appeared and testified at the RO before the undersigned, and at that time he withdrew his appeal of the issue of an increased rating for hepatitis C. See May 1999 transcript of personal hearing at page 2. At the time of the hearing, the veteran submitted additional evidence and waived consideration by the Agency of Original Jurisdiction as provided under 38 C.F.R. § 20.1304. See May 1999 transcript of personal hearing at page 2. Additional evidence, received by the Board in July 1999, was received and covered by the waiver of May 1999. See May 1999 personal hearing transcript at page 13. In a September 1995 decision, the RO determined that a higher initial rating of 30 percent was warranted for the veteran's left lower extremity deep vein thrombosis. As a 30 percent evaluation is not the maximum rating available for this disability, the appeal continues. AB v. Brown, 6 Vet. App. 35 (1993). FINDINGS OF FACT 1. All available relevant evidence necessary for disposition of the veteran's appeal has been obtained by the RO. 2. There is clear and unmistakable evidence that the veteran had injured his left knee and experienced subluxation prior to service, since the service and post-service medical records show that there was a history of an injury to the left knee when the veteran was in the 9th grade. 3. Service records show treatment for chronic left knee subluxation after being asymptomatic for approximately 10 years, therefore the disability resulting from the veteran's pre-service left knee injury increased in severity during service. 4. The veteran's deep vein thrombosis of the left lower extremity is manifested by chronic pain, some discoloration, the reported development of an ulcer, and edema relieved by elevation of the extremity, comparable to persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. CONCLUSIONS OF LAW 1. Service connection is warranted for left knee subluxation. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153, 5107 (West 1991); 38 C.F.R. §§ 3.103, 3.306 (1999). 2. The prior criteria for an evaluation greater than 30 percent for service-connected deep vein thrombosis of the left lower extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.114(a) (1999), 4.104, Diagnostic Code 7121 (effective prior to January 12, 1998). 3. The current criteria for an evaluation of 40 percent for service-connected deep vein thrombosis of the left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.103, 4.7 (1999), 4.104, Diagnostic Code 7121 (effective January 12, 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background Left Knee The veteran's enlistment examination and medical history reports of March 1984 are negative with regard to knee disorders. In April 1986, the veteran was seen for possible patellar subluxation of the left knee. It was noted that he had injured the knee in the 9th grade and that there were subsequent episodes of patellar subluxation. He was placed on physical profile in April and June 1986. X-rays of the left knee, taken in 1986 and 1990, were negative. Records dated from March to June 1990, reflect a finding of chronic subluxation of the left knee and the veteran's placement on physical profile. In June 1990, a brace was ordered. The veteran was afforded a VA examination in September 1992. He reported his history of subluxation dating back to 1976, and the subsequent problems with subluxation during service. At the time of the examination, he did not have a problem. Private medical records associated with the claims folder show that the veteran injured his knee in February 1995 when he twisted it while moving a barrel. It was noted that the veteran had a type two malalignment. In a February 1995 record, Dr. Steven F. Schutzer noted that the veteran had not done well with conservative treatment and that he would be a candidate for arthroscopic lateral release and tibial tubercle anteromedialization. In March 1995, further discussion of surgical intervention was mentioned. The veteran underwent surgery in April 1995. In June 1995, it was noted that the veteran was status post knee surgery, and the veteran expressed concerns about episodes of the knee giving out. In June 1995, the veteran testified that his left knee condition was aggravated during service. He initially injured his knee while in the 9th grade, around 1976. During service he experienced subluxation on a continual basis. He re-injured his knee in November 1994 and was given another brace for his knee. He noticed problems with the kneecap slipping in February. He had knee surgery in April 1995, and he has had problems with losing control of the leg. Records dated in 1995 and 1996 reflect his complaints of knee pain. In an October 1995 letter, Dr. Schutzer reported that the veteran provided him with copies of his service medical records which clearly indicated that the veteran was having recurrent patellar instability of the left knee and that these episodes occurred while the veteran was on active duty. Despite conservative treatment, he continued to have problems with the knee following his discharge from service. Eventually, in 1995, he had surgery. Dr. Schutzer opined that the veteran's left patellar problem has been an ongoing and progressive difficulty since his active tour of duty. Treatment records dated from 1997 to 1999, reflect ongoing complaints and treatment for left knee and leg pain. In June 1998, the examiner noted that the veteran's chronic knee pain had improved somewhat with the removal of hardware. The examiner commented that surgical changes were to be expected. In May 1999, the veteran testified that he initially experienced the knee cap sliding over when he injured his left knee during the 9th grade, and that he did not have problems with the knee until he began to experience chronic subluxation during service. Since the surgery in 1995, the kneecap does not slide out of place, but he has had ongoing problems with it. Deep Vein Thrombosis of the Left Lower Extremity The service medical records document the diagnosis and treatment of deep vein thrombosis of the left lower extremity in 1992. A medical board report shows that temporary retirement was recommended. At the time of his VA examination of September 1992, the veteran complained of left leg pain, particularly in the calf and thigh. He also experienced numbness and tingling in the left foot. The examiner observed that the left foot and lower leg were a darker color of bluish hue when dependent, and normal color when both legs were elevated. At nine inches above the knee, the left thigh measured 22 inches compared to 21.5 inches on the right. At knee level, the knee circumference was 16 inches and 15 for the right. At six inches below the knee, circumference was 13 1/4 inches on the left, and 13 1/8 on the right. Both ankles measured 8 inches. There was no apparent edema in the lower leg. The only difference was 1 inch at the knees. There were no scars. The examiner diagnosed history of deep vein thrombosis of the left popliteal and superficial femoral vein on the left, both clinically and by MRI, ultrasound, and venogram. In October 1992, the following was noted on an examination of the extremities: normal pulses; increased sudomotor and vasomotor tone (mild); calves and thighs measured 12 1/2 inches at five and one half inches below the patella and 21 inches at eight inches above; left calf might have been 1/4 inch larger with slight calf tenderness, but none in the left popliteal fossa; and no edema. The examiner did not notice any stasis changes or significant varices. The left foot veins were slightly more prominent than the right. Venous Doppler at the groin showed good variation with respiration and good transmission. There was minimal venous reflux and no obstruction found. In March 1993, the RO granted the claim of service connection for deep vein thrombosis of the left lower extremity. A 20 percent rating was assigned, effective July 28, 1992. In a March 1993 letter, Dr. Philip D. Allmendinger reported that on examination, there was no gross swelling or discoloration of the leg, although the left leg appeared larger than the right. There was a 2-centimeter enlargement at the level of the calf and at the thigh. It was noted that the severe acute deep venous thrombosis that the veteran experienced had not left him with any significant venous insufficiency at that time. He suspected that the pain at the calf and ankle level was secondary to ischemia of the peripheral nerves, and resolution of the symptomatology was not certain. The physician went over a possible method of treatment involving the peripheral and sural nerves, but did note that the veteran should wear support stockings over the calf to prevent the complications of venous insufficiency and hopefully bring about a slow resolution of the peripheral nerve injury. He had tried amitriptyline and anti- inflammatories, but without any results. In a May 1993 note, Dr. Allmendinger reported that the veteran continued to have discomfort in the left leg, which he described as a burning pain in the calf. Dr. Allmendinger felt that it was likely secondary to ischemia of the peripheral nerves during a bout of severe thrombophlebitis. The matter was discussed with another physician and the veteran was to be given a trial of sympathetic blocks. Records from Dr. Paul Dolinsky show that the veteran was evaluated in January and February 1994. On examination, the left calf measured 35 centimeters in circumference compared to 33.5 centimeters on the right. Arterial pulses were intact, but the medial ankle was slightly edematous with a bluish discoloration that became more prominent in the dependent position. The venous system was remarkable for very prominent serpiginous bulging veins on the scrotum and venous fullness in the inguinal area. In November 1994, it was noted that the veteran was evaluated in March, July and November 1994. He continued to have significant leg discomfort and dependent discoloration and swelling. The March 1994 venous Doppler study failed to reveal a deep venous thrombosis, but did show an old thrombosis of the femoral vein and proximal saphenous vein. Collaterals had developed. Arthritic complaints were investigated serologically in November 1994. He had been treated with non-steroidal anti-inflammatory medications with limited effect. The occasional use of acetaminophen with codeine had been recommended. A May 1995 venous study showed no significant change in the left leg when compared to a preoperative study. It was also noted that the old deep vein thrombosis remained with no change. In June 1995, the veteran testified that at the end of the day, he has to elevate his leg. He wears a vascular stocking, and the toes are discolored. The left leg is bigger than the right due to swelling, and he experiences pain on a continual basis. Recently, he noticed an ulceration at the heels. He noted that a physician told him that the decreased activity due to the leg is one of the reasons he has gained weight. He experiences numbness in his left foot on a daily basis. The left foot is larger than the right, and is swollen in appearance. He also noted that his varicose veins had increased in size on the left as well. He has been treated with Coumadin, and given Tylenol with codeine for pain. In July 1995, he complained of four to five days of distal left leg pain and swelling. The examiner reported an assessment of possible localized thrombophlebitis and doubted proximal involvement. In October 1996, the veteran was treated for left leg pain. The examiner reported an assessment of chronic left knee pain with probable fasciitis associated with chronic venous insufficiency. Treatment records dated from 1997 to 1999 reflect ongoing complaints and treatment for left knee and leg pain, including the veteran's venous insufficiency. In June 1998, the examiner noted that the veteran was reassured that the most reasonable course of treatment involved the use of the compression stocking and isometric exercises. Stabilization was to be expected, but substantial improvement would be unlikely. The veteran was afforded a VA examination in July 1998. It was noted that the veteran had been wearing Jobst stockings up to calf. He has had increased varicosities of the left thigh and left and right scrotum. He experiences discomfort in his entire left leg, but particularly around the ankle and calf. His left ankle and legs swell at the end of the day, and there is discoloration about his ankles. He could wear shoes, but they become tight and he has to wear a wide shoe rather than the medium he used to wear. His left foot and ankle become blue when standing. He is under the care of an internist, and is seen on a monthly basis for hepatitis, problems with the left knee and the deep vein thrombosis. He takes Motrin four times a day, and Tylenol two to three times week when the pain is more severe. There have been no side effects so far from the medication. His employment duties mostly involve computer work, but there are times when he is on his feet all day. At those times, his shoes become tight. Generally, he is on his feet around half of the time at work, and he works fifty hours a week. Most days, he has to elevate his legs when he comes home from work. Occasionally, he has to take a narcotic. He has varicose veins, and experiences fatigue, pain, discoloration, and edema. This occurs primarily in the left lower extremity, but he has been experiencing some pain in the right thigh and scrotum on both sides. He complained of numbness and tingling in the left foot which come on at anytime, but are not related to standing or what he is doing. The edema is relieved by elevation of his extremity and wearing Jobst stockings. The examiner noticed visible and palpable varicose veins, as well as spiders on the right thigh and a 4-inch tortuous vein anteriorly on the right side. On the left leg, the examiner saw an 11 inch tortuous vein on the left anterior thigh, and a 10 inch varicosity on the anterior tibia. The veins on the left foot were engorged, and there was discoloration of the left foot up to his ankles, bluish both medially and laterally, and brownish discoloration medially and laterally at the ankle. There was no edema. There was a three inch scar on the anterior knee with pigmentation, and was stabilization of patellar dislocation. He had two surgeries with removal of hardware. On the scrotum, the examiner noticed tortuous veins, on the right and left side which measured about 5 to 6 inches. There were no abdominal varicosities at that time. There were no varicosities posteriorly, and they were mostly on the anterior portion of both legs. There were no ulcers. He has edema at the end of the day, and there was stasis pigmentation around the ankle. The examiner diagnosed deep vein thrombosis of the superficial femoral vein and left popliteal in 1992 from the knee to the thigh. The examiner also diagnosed varicose veins of the entire left anterior legs, scrotum, and some on the right thigh with pigmentation of the left ankle and discoloration of the left foot, blue color up to the ankle, edema at the end of the day and discomfort of the left leg all the time and cramping in the left calf on stretching. There was no cramping on walking. In May 1999, the examiner noted that the veteran's chronic left leg pain was due to multiple etiologies, one orthopedic with chronic left knee discomfort despite multiple medical intervention, and left ankle discomfort with history of varicosities. In May 1999, the veteran testified that his foot is blue when he wakes up in the morning. He was to undergo surgery that June. An ulcer had formed on his left inside heel. He experiences a pins and needles sensation, which accompanies changes in the weather. In a June 1999 consultation report, Dr. James J. Gallagher reported that the examination revealed that arterial circulation down to and including pedal pulses, was completely normal in terms of strength and contour. The feet were warm and well perfused. There were varicosities on the upper inner aspect of the thigh in the range of 2/4, and not much else was seen down in the more distal thigh or calf area, and there were no stigmata of any chronic venous insufficiency. On the left leg, there was some varicose veins tracking along the anterior thigh down towards the knee, which were visibly apparent, and did not appear particularly large by visible examination, but were fairly substantial when palpated and under significant pressure when standing. The veins in the calf area were in the range of 2/4. The left leg was slightly increased in size compared to the right. There was an increase in the predominance of spider type telangiectasia, and at the time of the examination, the color was fairly stable in comparison to the opposite side. There was no particular thickening or dermatoliposclerosis of the gaiter area of the left leg and just a few very scattered skin pigmentation changes. The scrotal area was remarkable for some cutaneous varicosities on the surface. Dr. Gallagher determined that the veteran had postphlebitic syndrome and that he had a previously known totally occluded common femoral vein and that the initial approach should be directed towards better control of the edema and discomfort at the end of the day. The stocking that he uses could be increased in terms of strength, and the examiner felt that this should work. If this course of action did not produce satisfactory results, then surgical options would be explored. The options would include ligation and stripping of the varicose veins, which would include evaluating the veteran for a venous bypass type procedure if the common femoral vein remained occluded. II. Legal Analysis Service Connection for a Left Knee Disability The Board finds that the veteran's claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). That is, the claim presented is plausible. The Board is satisfied that all relevant facts have been properly developed and that the VA has fulfilled its duty to assist the veteran as mandated by 38 U.S.C.A. § 5107 (West 1991) and 38 C.F.R. § 3.103(a). Under applicable criteria, service connection will be granted for a disability resulting from personal injury suffered or disease incurred or aggravated during service. 38 U.S.C.A. §§ 1110 (West 1991). A veteran who served during a period of war or during peacetime service after December 31, 1946, is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A. § 1111 (West 1991). A preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connection unless the disease or injury is otherwise aggravated by service. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306(a), (b) (1999). In this case, it is clear from the evidence that the veteran initially injured his knee while in the 9th grade. This is apparent from the veteran's testimony and the reported medical history that appears in the service and post-service medical records. Therefore, the matter now before the Board is whether the condition was aggravated during service. The Board finds that the evidence favors the veteran's claim in this regard. In this case, the service medical records and the veteran's testimony show that his problem with the left knee did not resurface until some years after the initial injury, about a year into his period of active service. Thereafter, he experienced chronic subluxation, which has been documented in the service and post-service medical records. Therefore, it is reasonable to conclude that the condition was aggravated during service since the subluxation resurfaced and became chronic after years of being asymptomatic. Furthermore, in the letter of October 1995, the veteran's treating physician, Dr. Schutzer, reported that the veteran's left patellar problem appeared to be ongoing and progressive in difficulty since his period of service. Therefore, overall, the evidence favors the veteran's claim with regard to demonstrating aggravation of a left knee disability during service, and the appeal is granted. Deep Vein Thrombosis of the Left Lower Extremity The Board finds that the veteran's claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The United States Court of Appeals for Veterans Claims (Court) has held that, when a veteran claims that a service-connected disability has increased in severity, the claim is well grounded. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed and that VA has fulfilled its duty to assist the veteran as mandated by 38 U.S.C.A. § 5107(a) and 38 C.F.R. § 3.103(a). Disability evaluations are based upon the average impairment of earning capacity resulting from a disability. 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 (1997). Consideration is to be given to all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the veteran is in disagreement with the initial rating assigned for his deep venous thrombosis of the left lower extremity. Thus the Board must consider the rating, and, if indicated, the propriety of a staged rating, from the initial effective date forward. See Fenderson v. West, 12 Vet. App. 119 (1999). With regard to the disability at issue, the Board finds that the evidence does not demonstrate that there was in increase or decrease in the disability that would suggest the need for staged ratings. Service connection is currently in effect for deep venous thrombosis of the left lower extremity, rated 30 percent disabling under the provisions of 38 C.F.R. § 4.104, Diagnostic Code 7121 (1999). Since the veteran initiated this appeal, amendments were made to the rating criteria used to evaluate cardiovascular disabilities. 62 Fed. Reg. 65207- 65224 (1997). The new rating criteria took effect January 12, 1998. The Court has stated that where the law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant will apply unless Congress provides otherwise. Karnas v. Derwinski, 1 Vet. App. 308 (1990). Here, the amended criteria are more favorable and will be applied as of their effective date. See 38 C.F.R. § 3.114(a) (1999). The Court has further stated that when the Board addresses in its decision a question that was not addressed by the RO, the Board must consider the question of adequate notice of the Board's action and an opportunity to submit additional evidence and argument. If not, it must be considered whether the veteran has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384, 393 (1993). In addition, if the Board determines that the claimant has been prejudiced by a deficiency in the statement of the case, the Board should remand the case to the RO pursuant to 38 C.F.R. § 19.9, specifying the action to be taken. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Here, the Board acknowledges that the most recent supplemental statement of the case of August 1998, addressed the new rating criteria. Therefore, the veteran has been informed of the new criteria and their application. Under the prior version of Diagnostic Code 7121, the disability is described as phlebitis or thrombophlebitis, unilateral with obliteration of deep return circulation including traumatic conditions. A 30 percent rating is assigned under the following conditions: when there is persistent swelling of leg or thigh, increased on standing or walking 1 or 2 hours, readily relieved by recumbency; moderate discoloration, pigmentation and cyanosis or persistent swelling of arm or forearm, increased in the dependent position; moderate discoloration, pigmentation or cyanosis. A 60 percent rating is assigned for persistent swelling, subsiding only very slightly and incompletely with recumbency elevation with pigmentation cyanosis, eczema or ulceration. A 100 percent rating is assigned when there is massive board-like swelling, with severe and constant pain at rest. Under the current version of Diagnostic Code 7121, the disability is characterized as post-phlebitic syndrome of any etiology. A 20 percent rating is assigned when there is persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating is assigned when there is persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent rating is assigned when there is persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 100 percent rating is assigned when there is massive board-like edema with constant pain at rest. Under the old criteria, there is no basis for a rating greater than the 30 percent already awarded. The evidence shows swelling that is readily relieved by recumbency, and mild discoloration. The relief offered by elevation is considerably greater than "only very slight", which is the finding required for 60 percent. However, the Board finds that the application of the new criteria permits the assignment of an increased rating for the deep venous thrombosis of the left lower extremity. From the examination findings of record, it is clear that the veteran experiences pain and that the left leg tends to be larger than the right leg. He needs to use stockings and elevate the leg at the end of the day, and takes medication for the discomfort. He has noticed the appearance of an ulceration and there have been notations regarding discoloration. Also, the problems with the leg are increased when he spends most of the day standing. Therefore, when applying the old criteria, the disability picture presented is no more than persistent swelling of the leg, increased on standing or walking 1 or 2 hours, readily relieved by recumbency, and some discoloration, and there would not be a question as to which evaluation should apply. 38 C.F.R. § 4.7 (1999). However, when applying the new criteria, the disability picture presented can be described as persistent edema, incompletely relieved by elevation of extremity, with pigmentation but with or without beginning ulceration. Therefore, a 40 percent rating is warranted, as of the effective date of the new criteria. Even though a higher rating of 40 percent is warranted when applying the new criteria, there is not a question as to whether the disability picture approximates the new criteria for a 60 percent rating. 38 C.F.R. § 4.7 (1999). Aside from the veteran's need to elevate the leg due to edema at the end of the day and findings noted regarding the condition of his skin, the evidence does not indicate that there is persistent ulceration, which is also required for 60 percent rating under the current version of Diagnostic Code 7121. The Board has considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). After a careful review of the available Diagnostic Codes and the medical evidence of record, the Board finds that Diagnostic Codes other than 7121, do not provide a basis to assign an evaluation higher than that assigned herein. Here, the preponderance of the evidence is against the veteran's claim for a rating greater than 30 percent for deep venous thrombosis of the left lower extremity, therefore the application of the benefit of the doubt doctrine contemplated by 38 U.S.C.A. § 5107 (West 1991) is inappropriate in this case. ORDER Entitlement to service connection for left knee subluxation has been established, and the appeal is granted. Entitlement to an increased rating of 40 percent effective January 12, 1998, for deep vein thrombosis of the left lower extremity has been established, and the appeal is granted subject to regulations applicable to the payment of monetary benefits. J. E. Day Member, Board of Veterans' Appeals