Citation Nr: 0003515 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 96-08 077 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for right knee disability. 2. Entitlement to an evaluation in excess of 10 percent for left knee disability prior to September 6, 1996, and in excess of 30 percent from November 1, 1997. 3. Entitlement to a compensable evaluation for right foot disability. 4. Entitlement to an increased (compensable) evaluation for left heel disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Tierney, Counsel INTRODUCTION The veteran served on active duty from April 1955 to July 1980, and had an earlier period of active service of approximately three years. This matter came before the Board of Veterans' Appeals (Board) on appeal from an October 1995 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. At the veteran's request, the claims file was subsequently transferred to the RO in Montgomery, Alabama. A hearing was held before the undersigned Board Member in August 1997 in Washington, D.C., at which time the veteran withdrew from his appeal several issues. In a decision dated in October 1997, the Board noted the issues withdrawn from this appeal. The Board also partially granted the issue involving the evaluation of the left knee disability. In regard to all other issues on appeal, the Board remanded the case for further development. The Board notes that in the October 1997 remand, it requested that the RO contact the National Personnel Records Center and verify the veteran's active duty prior to April 30, 1955, and request any additional service medical records. A review of the record shows that the RO did not complete this requested development. However, because the decision herein grants the only service connection issue on appeal, the Board has determined that further delay of the appellate process for the purpose of obtaining verification of additional service time and any additional service medical records is not warranted. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. Service-connected disability caused or worsened the veteran's right knee disability. 3. The veteran's left knee disability prior to September 6, 1996, was manifested by degenerative joint disease with limitation of flexion to not less than 45 degrees. 4. The veteran's left knee disability since November 1, 1997, has been manifested by degenerative joint disease, status post total knee replacement, with limitation of extension to 15 degrees or less and limitation of flexion to not more than 30 degrees. 5. Instability of the left knee is not more than slight. 6. The right foot disability is manifested by moderate functional impairment. 7. The left heel disability is manifested by calcaneal spur with mild pain on pressure and moderate functional loss. CONCLUSIONS OF LAW 1. Right knee disability is proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). 2. For the period prior to September 6, 1996, the criteria for an evaluation in excess of 10 percent for left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256, 5257, 5260, 5261 (1999). 3. For the period from November 1, 1997, the criteria for an evaluation in excess of 30 percent for left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5055, 5256, 5257, 5260, 5261, 5262 (1999). 4. The criteria for an evaluation in excess of 10 percent for right foot disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5283, 5284 (1999). 5. The criteria for a 10 percent evaluation for left heel disability have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.10, 4.40, 4.59, 4.71a, Diagnostic Code 5284 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board finds that the veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). The Board is also satisfied that all relevant facts have been properly and sufficiently developed. I. Service Connection for Right Knee Disability The veteran contends that service connection is warranted for his right knee disability because it is the result of service trauma or his service-connected left knee disability. Service connection may be established for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Service incurrence of arthritis may be presumed if it is manifested to a compensable degree within a year of the veteran's discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). In addition, service connection may be granted for disability which is proximately due to or the result of a service- connected disease or injury. 38 C.F.R. § 3.310(a) (1999). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The service medical records show that the veteran was in a helicopter crash in November 1955 and sustained a cerebral concussion, multiple abrasions and lacerations of the face, abrasions of the right elbow, left thumb and compound fracture of the left patella. No right knee injury was noted. An annual flight examination in May 1956 showed scars on the right leg as well as the left leg. The November 1955 accident was noted. Another annual flight examination in July 1957 showed scars on the right knee and noted none on the left knee. An annual flight examination in February 1970 noted a scar on the left knee but noted no scars on the right knee or leg. A February 1971 flight examination showed small healed circular scars on both knees. The separation examination in April 1980 noted no right knee or leg injury or scars. In August 1980, the veteran filed a claim for VA benefits and alleged no right knee disability. A VA examination in December 1980 showed that the veteran did not complain of right knee pain and the knee was not examined. A VA orthopedic examination of the veteran's joints in September 1995 shoed that the knees were somewhat fixed in flexion position at rest due to degenerative changes in the knee. Range of motion of the right knee was 90 degrees flexion and 0 degrees extension. The relevant diagnoses were chronic osteoarthritic changes in both knees, probably post- traumatic, and old contusion and lacerations of the knees. Medical records from Lyster Army Hospital show that the veteran had a total left knee arthroplasty in September 1996 due to degenerative arthritis of the left knee. In addition, the veteran had a total right knee arthroplasty in January 1997. Radiographs had revealed severe tricompartmental degenerative arthritis in the right knee. It was noted that the veteran had a history of left knee injury in a helicopter crash in 1955 and no specific history of right knee injury. It was noted further that over the past five years, the veteran had complained of progressively increasing pain to the point that the pain had recently become debilitating. At a personal hearing in August 1997 before the undersigned Board Member, the veteran testified that he had been in a helicopter crash during service and had sustained multiple injuries, to include injuries to the knees. According to the veteran, he was unconscious for about two days after the helicopter crash and in the hospital for three months. He testified that both legs were in a cast. He received physical therapy thereafter and was returned to duty. The veteran testified that over the years, the knees, especially the left knee, had given him trouble. He stated that an orthopedic surgeon at Fort Rucker had taken X-rays, said that knee replacement surgery had to be done, and told him that because of the way he walked, it caused the right knee disability. A VA orthopedic examination of the veteran's joints in November 1997 showed that the veteran reportedly was still receiving physical therapy on his knees after the knee replacements. In regard to the etiology of the right knee disability, the examiner provided an opinion that relating the right knee problem to service injury was totally speculative and not supported by the record. The examiner did not provide an opinion as to any secondary relationship between the right knee disability and any service-connected disability. A VA orthopedic examination was completed in December 1998. The examiner noted that the veteran's claims file had been reviewed. The medical history reported included the helicopter crash in 1955. It was noted that both knees were traumatized but there were no fractures of the knees. X-rays in December 1998 showed bilateral knee prosthesis with no complications. The veteran reported that with any ambulating, even a quarter of a block, his feet and knees hurt and he would have to sit down. The right knee had a well-healed anterior scar with no hypertrophy and no evidence of complications. There was no hindrance of range of motion from the scar and no pain over the scar area. The range of motion was 5 to 90 degrees. There was mediolateral stability. The pertinent diagnosis was bilateral knee secondary to post-traumatic arthritis, total knee arthroplasty, stable. The examiner provided a medical opinion that the veteran's left foot, left knee, and right foot disabilities caused or increased the veteran's right knee condition. The examiner also opined that the veteran's right knee disability most probably was related to the helicopter crash in service. The Board notes that the evidence does not support the medical opinion provided by the examiner at the December 1998 VA examination that the veteran's right knee disability most probably is related to the helicopter crash in service. In this regard, the Board notes that service medical records are negative for a right knee injury at the time of the helicopter crash. The examiner at the November 1997 VA examination noted that relating the right knee problem to a service injury was totally speculative and not supported by the record. The Board further notes that there is no medical evidence of arthritis of the right knee within one year of separation from service. Although the Board does not find that service connection is warranted on a direct or presumptive basis, there is no evidence which contradicts the medical opinion provided by the examiner at the December 1998 VA examination that the service-connected disabilities caused or increased the veteran's right knee disability. This medical opinion was based on a review of the claims file and a physical examination of the veteran. The clinical evidence does not contradict this medical opinion. Accordingly, the evidence supports an award of service connection for right knee disability as secondary to service-connected disability. II. Evaluations of Service-Connected Disabilities In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (1999) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities currently on appeal. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities, except as described below. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (1999). The Board attempts to determine the extent to which the veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10 (1999). Where there is a question as to which of two evaluations should 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). With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. 38 C.F.R. § 4.59 (1999). A. Evaluation of Left Knee Disability In January 1995, the veteran filed a claim to include entitlement to service connection for a left knee disability. Service medical records show that the veteran sustained a compound fracture of the left patella in a helicopter crash in November 1955. A VA orthopedic evaluation of the veteran's joints in September 1995 showed that the left knee was somewhat fixed in flexion position at rest due to degenerative changes within the knee. The range of motion of the left knee was 90 degrees flexion and 0 degrees extension. The pertinent diagnoses were chronic osteoarthritic changes, both knees, probably post-traumatic, and old contusion and lacerations of the knees. In a rating decision of October 1995, service connection was granted for status post compound fracture of the left patella with post traumatic osteoarthritic changes. A 10 percent rating was assigned from January 31, 1995, pursuant to Diagnostic Code 5010-5257. A VA outpatient treatment record dated in February 1996 shows that the veteran complained of bilateral knee pain relieved with Naprosyn. Medical records from Lyster Army Hospital show that the veteran had a total left knee arthroplasty in September 1996. The diagnosis at that time was degenerative arthritis of the left knee. At a personal hearing in August 1997 before the undersigned Board Member, the veteran testified that he injured his knees during service and the left knee gave him more trouble than the right knee. The veteran stated that he had had a complete left knee replacement which had helped and allowed him to get around without pain. The veteran also stated that he did not have to take pain medication anymore. However, he testified that when he stood up, walked, or drove a car for an hour, his knee would swell. The veteran stated that since the knee surgery, he was told not to lift weight over 20 pounds. He could not climb ladders and he could not get on his knees. In addition, he could no longer play tennis or racquetball, jog or run. A VA orthopedic examination of the veteran's joints in November 1997 showed that the veteran reported that he was still getting physical therapy on his knees due to the knee replacements. He reported some difficulty in getting in and out of certain types of cars and in arising from a sitting position. He stated that he could walk 50 to 60 yards. He also reported that he had stiffness in both knees with prolonged sitting. He also had pain in the knees with prolonged sitting or walking. On physical examination, he could not completely extend the left knee. There was no edema or tenderness in either knee. The stability of the left knee was normal in the anterior-posterior direction. However, on lateral-medial motion of the left knee there was a clicking and slight instability on valgus movement. The range of motion of the left knee was 77 degrees flexion and 11 degrees extension. X-ray of the knee revealed knee replacement without complication. The diagnosis was severe degenerative joint disease both knees status post bilateral knee replacement. The examiner noted that functional loss due to pain in the knees was minimal. In an October 1997 decision, the Board noted that the veteran was hospitalized in September 1996 for a total left knee arthroplasty. The Board concluded that the veteran was entitled to an increased schedular evaluation of 100 percent for left knee disability for the one year period from November 1, 1996, through October 1997, pursuant to Diagnostic Code 5055. The Board remanded the issue of entitlement to a temporary total rating for convalescence based on the September 1996 surgery, and the issue of the appropriate rating for the left knee disability from November 1, 1997. In a rating decision of November 1998, the RO continued the 10 percent rating for status post compression fracture of the left patella with osteoarthritic changes until September 5, 1996, under Diagnostic Codes 5010, 5257. The RO also granted service connection for left knee replacement (formerly evaluated as status post compression fracture of the left patella with post osteoarthritic changes) and assigned a 100 percent rating from September 6, 1996, and a 30 percent rating from November 1, 1997, pursuant to Diagnostic Codes 5010, 5055. A VA orthopedic examination in December 1998 showed that the veteran reported that with any ambulating, even a quarter of a block, his feet and knees hurt and he had to sit down. X- rays in December 1998 revealed bilateral knee prosthesis with no complications. A physical examination of the left knee showed an anterior scar with no complications and range of motion from 5 degrees extension to 85 degrees flexion. Both lower extremities showed no edema, varicosities, or phlebitis. The pertinent diagnosis was bilateral knee disability secondary to post-traumatic arthritis, total knee arthroplasty, stable. The examiner noted that the functional impairment because of the knees bilaterally was moderately significant. The examiner further noted that the veteran's joint movements were tested against standard testing against the active as tolerated and there was no incoordination or ataxia. During the pendency of the current appeal, the left knee disability was evaluated as 10 percent disabling from January 31, 1995, through September 5, 1996, 100 percent disabling from September 6, 1996, through October 31, 1997, and 30 percent disabling from November 1, 1997. Accordingly, the first matter to be addressed in regard to the veteran's claim for a higher rating is whether a rating in excess of 10 percent is warranted prior to September 6, 1996. A 30 percent rating is warranted for ankylosis of a knee with favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent rating is warranted for ankylosis of a knee in flexion between 10 and 20 degrees. A rating of 50 percent is warranted if the ankylosis is in flexion between 20 and 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256 (1999). A 10 percent rating is warranted for slight knee impairment with recurrent subluxation or lateral instability, a 20 percent rating is warranted for moderate impairment of the knee, with recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999). A 10 percent rating is warranted where flexion of the leg is limited to 45 degrees, a 20 percent rating is warranted where flexion is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A 10 percent rating is appropriate where extension of the leg is limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees and a 30 percent rating is warranted for extension limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The evidence does not support a rating in excess of 10 percent for the left knee disability prior to September 6, 1996. At the September 1995 VA orthopedic examination, motion of the left knee was from 0 degrees of extension to 90 degrees of flexion. The recorded range of motion does not satisfy the criteria for even a 10 percent rating on the basis of limitation of motion. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 concerning disability factors such as lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; and the provisions of 38 C.F.R. § 4.45 concerning disability factors such as weakened movement, excess fatigability, and incoordination are for consideration. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The Board notes that no weakness, atrophy or incoordination was found on the VA neurologic examination in September 1995. The veteran's gait was described as normal by one examiner in September 1995 and as slow by another examiner in September 1995. Neither examiner identified objective evidence of pain or any other significant functional impairment associated with the service-connected disability. Since the assigned evaluation of 10 percent contemplates limitation of flexion to 45 degrees or limitation of extension to 10 degrees and the veteran in fact had the ability to flex to 90 degrees and to extend to 0 degrees, the Board must conclude that even when all pertinent disability factors are considered, the disability did not more nearly approximate the limitation of motion criteria for an evaluation in excess of 10 percent. There is no objective evidence of instability or subluxation during the period prior to September 7, 1996. Therefore, the disability did not did not meet the criteria for a compensable evaluation under Diagnostic Code 5257 during this period. The left knee disability was assigned a 100 percent rating from November 1, 1996, through October 31, 1997, due to the left knee replacement on September 6, 1996. 38 C.F.R. §§ 4.30, 4.71a, Diagnostic Code 5055. Effective November 1, 1997, a 30 percent rating was assigned for the left knee disability. A 100 percent evaluation is assigned for prosthetic replacement of the knee joint for one year following implantation of the prosthesis. A 60 percent evaluation is assigned for prosthetic replacement of the knee joint when there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain, or limitation of motion are to be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating under this code is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (1999). The evidence does not support a rating in excess of 30 percent for the left knee disability. The November 1997 VA orthopedic examination of the veteran's joints showed range of motion of the left knee from 11 degrees extension to 77 degrees flexion. The December 1998 VA orthopedic examination showed improved range of motion of the left knee from 5 degrees extension to 85 degrees flexion. The November 1997 orthopedic examiner characterized the functional impairment due to pain as minimal. The December 1998 examiner found the functional impairment to be moderate. Therefore, when all pertinent disability factors are considered, the Board must conclude that the limitation of motion does not more nearly approximate the criteria for a 20 percent rating than those for a 10 percent rating. Although the veteran was found to have slight stability on the November 1997 examination, it would not be to the veteran's advantage to separately rate the components of the disability on the basis of instability and arthritis with limitation of motion since slight instability warrants only a 10 percent evaluation and the veteran's limitation of motion does not warrant a rating in excess of 20 percent. Diagnostic Code 5055 provides for a rating in excess of 30 percent where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. The medical evidence shows that the veteran does not have severe painful motion of the left knee or weakness in the left leg. The most recent medical evidence shows that functional impairment of the left knee was moderately significant. At the August 1997 hearing, the veteran testified that he was on pain medication prior to the left knee replacement surgery and that the surgery had helped so that he could get around without the pain and did not have to take pain medication. At the November 1997 VA orthopedic examination, the veteran reported some pain in the knees with prolonged sitting or walking more than 50 to 60 yards, and swelling after prolonged sitting or prolonged driving. It was noted that the only medication he was taking for this problem was aspirin. Painful motion is a criterion under Diagnostic Code 5055 and has been considered in determining the evaluation warranted for the current severity of the veteran's left knee disability. Accordingly, the evidence of record does not support a rating in excess of 10 percent for the left knee disability prior to September 6, 1996. In addition, the evidence does not support a rating in excess of 30 percent for the left knee disability from November 1, 1997. B. Evaluation of Right Foot Disability A VA orthopedic examination of the veteran's feet in September 1995 showed that his feet functioned normally. There was no significant deformity and he had a normal gait. The diagnoses included old fracture of the right cuboid bone and old fracture of the right fourth and fifth metatarsals. In a rating decision of October 1995, service connection was granted for residuals of fracture of the fourth and fifth metatarsals and cuboid of the right foot. A noncompensable rating was assigned from January 31, 1995. A VA orthopedic examination of the veteran's feet in November 1997 showed that the right foot had a slight bony prominence on the dorsum of the right foot over the base of the fourth metatarsal. The bony prominence was nontender. Examination of the right heel showed a bony prominence on the posterolateral aspect two centimeters above the sole. This bony prominence also was nontender. X-ray of the right foot showed osteoporosis and focal deformity of the cuboid and base of the fifth metatarsal, with possible old fracture of the cuboid and base of the first metatarsal. The pertinent diagnoses were fracture of the third, fourth and fifth metatarsals of the right foot status post remote injury, and fracture of the cuboid bone of the foot status post remote injury. At the personal hearing in August 1997, the veteran testified that his right foot bothered him because of the way the heel was broken in the helicopter crash in service. In addition, the veteran testified that since the heel bone was broken, it has stuck out and become irritated from rubbing against shoes. He testified that there were no other problems with his right foot. In a rating decision of November 1998, the right foot disability, status post fracture of the right fourth and fifth metatarsals and cuboid, was reevaluated as 10 percent disabling, effective from January 31, 1995, pursuant to Diagnostic Code 5299-5283. At a VA orthopedic examination in December 1998, the examiner reviewed the veteran's claims file. The examiner noted that X-rays in 1997 showed right heel cuboid bone focal deformity and at the base of the fifth metatarsal, some osteoporosis, and the possibility of an old fracture of the cuboid on the base of the fifth metatarsal, with good healing. Examination of the right foot showed a bony prominence on the dorsum of the right foot, most probably over the base of the fourth metatarsal. There was a tiny spur area on the right heel but no evidence of any complications. The range of motion of the right ankle was 10 degrees dorsiflexion, 30 degrees plantar flexion, 18 degrees inversion and 15 degrees eversion. The examiner noted that the range of motion was mildly short of appropriate, but functional enough, with mild pain in the heel area. The claims file contains some VA outpatient treatment records. Such records are negative for treatment of any right foot disability pertinent to the current claim. Under Diagnostic Code 5283, a 10 percent rating is assigned for moderate malunion of or nonunion of the tarsal or metatarsal bones. A 20 percent rating is assigned for moderately severe malunion of or nonunion of the tarsal or metatarsal bones. A 30 percent rating is assigned for severe malunion of or nonunion of the tarsal or metatarsal bones. With actual loss of use of the foot, a 40 percent rating is assigned. Under Diagnostic Code 5284, a 10 percent rating is assigned for moderate foot injuries, a 20 percent rating is assigned for moderately severe foot injuries, and a 30 percent rating is assigned for severe foot injuries. The evidence does not support a rating in excess of 10 percent under Diagnostic Code 5283. The evidence does not show malunion of or nonunion of the tarsal or metatarsal bones. There is no more than moderate malunion of or nonunion of the tarsal or metatarsal bones. The evidence shows old fractures of the third, fourth , and fifth right foot metatarsals and old fracture of the cuboid bone, which are well healed. A rating in excess of 10 percent for the right foot disability is not warranted under Diagnostic Code 5284 because more than moderate foot injury is not shown. The evidence shows that the veteran has a bony prominence on the dorsum of the right foot over the base of the fourth metatarsal, and a tiny spur area on the right heel. He complained of pain in the right heel where the bony prominence rubs against shoes and irritates the heel. The evidence shows that the veteran's right foot disability causes pain. Therefore, at least the minimum compensable rating is warranted. 38 C.F.R. § 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). However, the examiner at the December 1998 VA orthopedic examination noted that the pain in the heel area was mild. Accordingly, the right foot disability does not involve more than a moderate foot injury. C. Evaluation of Left Heel Disability In a rating decision of February 1981, service connection was granted for status post compression injury of left heel (claimed as bursitis). A noncompensable rating was assigned from August 12, 1980, pursuant to Diagnostic Code 5299. The disability has been evaluated as noncompensable since then. Medical records from the Homestead Air Force Base include a radiology report of X-ray of the veteran's left foot dated in November 1994. No fracture or dislocation was seen. Vascular calcification was demonstrated in the left foot and ankle. A spur formation was demonstrated at the posterior inferior aspect of the left calcaneus. The joint mortise of the left foot appeared intact. VA outpatient treatment records dated in March 1995 show that the veteran complained of a painful left heel. X-ray showed a bone spur formation plantar calcaneus. A record dated two weeks later indicates that he had had a prior injection into the left heel and did not notice much relief. He had pain to palpation and received another injection into the left heel. Another record dated in April 1995 shows tenderness to palpation of the left medial calcaneus. There was a medial calcaneus spur. A VA orthopedic examination of the veteran's feet in September 1995 showed that the veteran had satisfactory posture, as well as standing, squatting and walking. The feet showed mild edema which was vascular in nature and not due to orthopedic problems. The feet functioned normally. There was no significant deformity and the veteran had a normal gait. The diagnoses included old fracture of calcaneal bone. Another VA orthopedic examination of the veteran's joints in September 1995 provided no findings with regard to the left heel. The diagnoses, however, included calcaneal bone spur on left. A VA orthopedic examination of the veteran's feet in November 1997 showed slight tenderness on the sole of the left foot to pressure. There was no edema or deformity. X-ray of the left heel revealed medial calcaneal spur. The diagnoses included plantar fasciitis of the left heel and calcaneal spur on left. The examiner commented that functional loss due to pain in left heel was minimal. It was further noted that although there was X-ray evidence of calcaneal spur on the left heel, there was little clinical findings to suggest disabling pain. At the personal hearing in August 1997 before the undersigned Board Member, the veteran testified that he developed spurs on his left foot during service and was given shoe inserts which helped. The veteran stated that he still had pain when he walked but it was not so severe that he could not walk. He further testified that the left heel hurt when pressure was put on it. According to the veteran, he was given Cortisone shots and the pain went away for several months but gradually came back. He indicated that he continued to wear some shoe inserts to relieve the left heel pain. A VA orthopedic examination in December 1998 showed that the examiner had reviewed the veteran's claims file. In regard to the veteran's left foot, there was mild pain on left heel pressure and mild tenderness in calcaneal and plantar fascia site, but no evidence of inflammation. Examination of the left foot showed no clinical evidence of tarsal tunnel syndrome. The diagnoses included left heel chronic, recurrent, mild pain with plantar myofascitis and with calcaneal spur on left. The examiner noted that there was moderate functional impairment in the feet bilaterally. The RO rated the veteran's left heel disability, status post compression injury, as noncompensably disabling under Diagnostic Code 5284. Under Diagnostic Code 5284, a moderate foot injury is assigned a 10 percent rating, a moderately severe foot injury is assigned a 20 percent rating, and a 30 percent rating is assigned for severe foot injury. The medical evidence shows that the veteran has calcaneal spur formation on the left heel. Although the examiner at the November 1997 VA orthopedic examination of the veteran's feet found that there was minimal functional loss due to pain in the left heel, the December 1998 VA examiner concluded that there was moderate foot impairment. Therefore, with resolution of reasonable doubt in the veteran's favor, the Board concludes that the disability warrants a rating of 10 percent. There is no medical or other objective evidence of more than moderate left foot impairment. Therefore, a rating in excess of 10 percent is not warranted. ORDER Service connection for right knee disability is granted. Entitlement to a rating in excess of 10 percent for left knee disability, prior to September 6, 1996, is denied. Entitlement to a rating in excess of 30 percent for left knee disability, from November 1, 1997, is denied. Entitlement to a rating in excess of 10 percent for right foot disability is denied. Entitlement to a 10 percent rating for left heel disability is granted, subject to the criteria applicable to the payment of monetary benefits. SHANE A. DURKIN Member, Board of Veterans' Appeals