BVA9504091 DOCKET NO. 92-54 150 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to an increased evaluation for a total left knee replacement, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESSES AT HEARING ON APPEAL Appellant, and his wife ATTORNEY FOR THE BOARD William J. Jefferson, III Counsel INTRODUCTION The veteran had active service from March 1943 to February 1947. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Los Angeles, California, Regional Office (RO). Initially, in this case, an increased evaluation for residuals of a shell fragment wound of the left knee was denied in a June 1990 rating decision. At that time it was also determined that the veteran's traumatic arthritis of the left knee was not related to the service connected left knee shell fragment wound. The veteran disagreed with both determinations and he filed a timely substantive appeal. Personal hearings were held at the RO in November 1990 and October 199. In determinations by hearing officers at the RO in May 1991 and October 1991, denials of the veteran's claims were confirmed and continued. In December 1992 the case was remanded by the Board to obtain additional clinical information. Subsequent rating decisions confirmed the denials of service connection for arthritis of the left knee, and an increased evaluation for residuals of a shell fragment wound of the left knee. In a January 1994 decision, the Board granted service connection for traumatic arthritis of the left knee secondary the left knee shell fragment wound residuals. The case was also remanded at that time for an orthopedic examination of the left knee, and for consideration of the veteran's disability evaluation in light of the service connection grant. The veteran had had a total left knee replacement during pendency of his claim. In an April 1994 rating decision, it was determined that the combined disability evaluation for residuals of the shell fragment wound, traumatic arthritis, and left knee replacement, now characterized as a total left knee replacement, was 30 percent disabling. CONTENTIONS OF APPELLANT ON APPEAL The veteran argues that his left knee is numb, stiff, and painful and he is unable to engage in certain physical activities. He maintains that his left knee is disorder is far more disabling than the current 30 percent evaluation indicates, and an increased evaluation is warranted. 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(s). 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 claim of an increased evaluation for a total left knee replacement. FINDING OF FACT The total left knee replacement results in some discomfort on physical activity and limitation of motion of the left knee; but it is not productive of chronic left knee replacement residuals consisting of severe painful motion or weakness; left knee ankylosis; tibia and fibula impairment; or limitation of extension of the left leg to 45 degrees. CONCLUSION OF LAW A rating in excess of 30 percent for a left total knee replacement is not warranted. 38 U.S.C.A. § 1110, 5107 (West 1991); 38 C.F.R. § § 3.321 (b), 4.7, Part 4, Codes 5055, 5256, 5261, 5262 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION We find that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is we find that he has presented a claim which is not implausible. We are also satisfied that all relevant facts have been properly developed. 38 U.S.C.A. § 5107(a). The RO has assigned a 30 evaluation for total left knee replacement under the provisions of Diagnostic Code 5055 of the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4, knee replacement (prosthesis). The rating provisions of Diagnostic Codes 5256, 5261, 5262, involving knee ankylosis, limitation of extension, and tibia and fibula impairment, are applicable and will also be considered here. Service medical records show that in August 1944, the veteran sustained an avulsed type mortar shell fragment wound to the medial aspect of the left knee, three inches to the right of the patella which was 3 inches long; along with a puncture wound 4 inches above the patella, with very little deep reaction or hemorrhage. The wounds were cleaned and debrided. X-rays of the left knee revealed several artifacts near the location of the wounds, but not near any vital structures; these were considered to be of no serious consequence. There were no fractures. In October 1944, it was reported that the veteran's wound was practically healed and he was returned to duty. At discharge from service no, abnormalities of the joints were reported. A VA physical examination of the left knee in March 1950 showed a tender scar in the medial aspect and some underlying tissue damage, bit no muscle damage or atrophy. X-rays were negative. VA clinical records from the mid 1980's reveal complaints of severe left knee pain. Severe chronic hypertrophic degenerative changes in the left knee were shown by X-ray. A total left knee arthroplasty at some point was recommended. A VA medical examination in April 1990 reported that the veteran was unable to bear full weight on the left leg due to left knee pain. It was reported that flexion of the left knee was to 45 degrees and extension was to 10 degrees. He could not squat or walk on his toes, but could walk on his heels. In November 1990 and October 1991 personal hearings at the RO, the veteran reported that his left knee had increased in symptomatology, including pain, due to degenerative processes. He also reported that he had a limp and used a cane. Private clinical records from January 1993 reported that the veteran had a cemented total left knee replacement due to end stage arthritis without significant complications. A VA orthopedic examination was performed in March 1994. The veteran complained of pain, stiffness, and fluid in his left knee. Objective findings revealed an antalgic gait. Toe heel walk was possible. Squatting was limited due to previous surgery. Left knee scars were sensitive to palpation. There was no swelling, redness, temperature or fluid in the joints. Range of motion of the left knee was indicated as 90 degrees flexion and 180 degrees extension. It was indicated that an October 1993 X-ray revealed that the total knee was in place. At a VA orthopedic examination in July 1994 the veteran complained of aching and pain below the patella. It was reported that he was able to extend his left knee from 180 and 135 degrees flexion. The left knee shrapnel wound was healed. It was indicated that an X-ray revealed that the total knee prosthesis was in good position. The diagnosis was total knee prosthesis of the left knee that has been put in position for arthritis through an incision line about 3 inches extending from above the knee to below the knee. A private orthopedic examination of the left knee was performed in September 1994. It was indicated that the veteran continued to complain of left knee discomfort after arising from a sitting position, climbing up and down stairs, and with prolonged driving. It was reported that the left knee had satisfactory stability. Range of motion of the knee was unchanged at 0 degrees extension and 130 degrees flexion. Residuals symptoms were reported as an inability to kneel; a sensation of stiffness; swelling with weather changes; left side knee numbness; difficulty getting in and out of bathtub; and stiffness after prolonged sitting or standing. It was indicated that the veteran was occasionally awaked from sleep with a sharp pain. He had to hold a hand rail to go up steps. The physician indicated that the veteran's symptoms were likely permanent and that he was to continue his usual activities as tolerated. Analysis The Board has reviewed the entire evidentiary data of record and concludes that the preponderance of the evidence is against the veteran's claim of an increased evaluation for left knee replacement. An increased evaluation in the present case under Diagnostic Codes 5055, 5256, 5261, and 5262, respectively, require that there be chronic left knee replacement residuals consisting of severe painful motion or weakness; left knee ankylosis; tibia and fibula impairment; or limitation of extension of the left leg to 45 degrees. The record shows that subsequent to a total left knee replacement in January 1993, the veteran continues to have left knee symptoms, including complaints of pain and stiffness, along with discomfort on certain physical activities. Objectively, the left knee prosthesis has been reported as stable. No severe painful motion or weakness has been reported. Furthermore, there is no evidence of ankylosis. Extension of the left leg is shown as 0 degrees, which is within normal limits. (38 C.F.R. § 4.71 Plate II indicates that normal knee or leg extension is to 0 degree). There is also no evidence of impairment of the tibia or fibula, severe instability or severe limitation of motion. In view of these findings, the Board concludes that the veteran's left knee disability picture does not more nearly approximate the criteria necessary for a higher evaluation. 38 C.F.R. § 4.7. Additionally, this case does not present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, requiring consideration on an extra-schedular basis. 38 C.F.R. § 3.321 (b). The testimony elicited at the personal hearings in 1990 and 1991 which were afforded the veteran, are primarily for complaints and symptoms prior to his left knee replacement, and as a result is limited in probative value. The testimony does not establish an increased evaluation for the left knee replacement. We conclude that the preponderance of the evidence is against the veteran's claim, and an increased evaluation for a total left knee replacement is not warranted. ORDER An increased evaluation for a total left knee replacement is denied. SAMUEL W. WARNER 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.