BVA9500557 DOCKET NO. 93-10 640 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES Entitlement to service connection for a bilateral knee disorder. Entitlement to an increased rating for hypertension, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD J. L. Prichard, Associate Counsel INTRODUCTION The veteran had active service from October 1967 to March 1971. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he developed a bilateral knee disorder during active service. He states that he injured his knee during service, and that he was seen on many occasions for treatment for knee pain. In addition, the veteran contends that his service- connected hypertension is productive of a greater degree of disability than is reflected by the 10 percent evaluation currently in effect. He notes that he recently had problems keeping his blood pressure under control, and has complained of headaches. DECISION OF THE BOARD The Board of Veterans' Appeals (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 the veteran's claims for entitlement to service connection for a bilateral knee disorder, and for entitlement to an increased rating for hypertension. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. There is clear and unmistakable evidence that the bilateral knee disability that was treated during active service pre- existed service and did not increase in severity during service. 3. Gout of the knees treated during active service was acute and transitory, and resolved without residual disability. 3. A bilateral knee disability demonstrated years after active service is unrelated to service. 4. The veteran's diastolic pressure is not predominately 110 or more with definite symptoms. CONCLUSIONS OF LAW 1. A bilateral knee disorder was not incurred in or aggravated by active service. §§ 1110, 1111, 1153, 5107 (West 1991); 38 C.F.R. §§ 3.303(b), 3.306(b) (1993). 2. The criteria for an evaluation in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.7, 4.104, Code 7101 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that the veteran's claims are "well grounded" within the meaning of 38 U.S.C.A. § 5107. That is, we find that he has presented claims which are plausible. We are also satisfied that all relevant facts have been properly developed. The record is devoid of any indication that there are other records available which might assist the Board in reaching a decision. The record is complete, and no further assistance to the veteran is required to comply with the duty to assist the veteran mandated by 38 U.S.C.A. § 5107. I. Service Connection The veteran contends that he developed a bilateral knee disorder due to active service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. A review of the service medical records indicates that the November 1967 entrance examination was negative for bilateral knee pain or a knee disability, as were medical histories obtained from the veteran in August 1967 and November 1967. The veteran was seen for complaints of knee pain on several occasions during active service. He complained of water on his left knee in December 1967. He was seen for multiple complaints of knee pain in April 1969. On his initial complaint, the veteran stated that his knees kept going out. He said that the pain was severe, and he was unable to work on his knees. No cause was found for his knee pain. Additional records from April 1969 note that the veteran had experienced fluid in the left knee for eight years. The knee was aggravated by standing. There was no heat or effusion, but there was a bilateral McMurray's click. The initial impression was of a possible torn cartilage, but the examiner was of the opinion that this was unlikely. An X-ray study of the knees conducted at this time was negative for any significant pathology. A cast was placed on the veteran's left knee in April 1969. It was removed less than one week later. The veteran continued to complain of pain in his knees. Other records from April 1969 show that he continued to have pain in both knees. The veteran noted that he had experienced trouble with his knees since a football injury in the sixth grade. An X-ray study was normal. The impression was knee pain. The veteran was seen again for complaints of knee pain in June 1969. He stated that he had experienced trouble with his left knee since the sixth grade. He was not able to run or squat. On examination, the knee was stable, with a full range of motion. There was no effusion, but the veteran had a mild patella click. There was no chondromalacia, and the patella was stable. Records from June 1969 indicate that the veteran complained of knee pain. He stated that he had experienced knee pain since the sixth grade. He was noted to have a history of gout and joint pain. The diagnosis was gout. The veteran completed a medical history in February 1971 prior to discharge. A history of knee pain was noted. The February 1971 discharge examination was negative for knee pain. Extensive post service medical records are contained in the claims folder, including private treatment records from 1977 to 1991. These records indicate treatment for a variety of disorders, but are completely negative for treatment of a bilateral knee disorder. The earliest post service medical records to indicate the presence of a knee disability are July 1991 Department of Veterans Affairs (VA) treatment records. These records show that the veteran had chronic left knee pain with swelling. The knee was noted to have been reinjured in June 1991. The diagnosis was left knee medial collateral ligament tenderness. Records from August 1991 indicate that the veteran is a construction worker, and that he had recently injured his knee. The left knee was noted to not be healing. He complained of pain and giving way without effusion. Additional records from August 1991 indicate that the veteran had experienced left knee instability since June 1991. October 1991 VA treatment records reveal that the veteran sustained a twisting injury to the left knee in June 1991 with resulting intermittent instability, locking and effusion. The provisional diagnosis was medial meniscus tear. The veteran was afforded a VA examination in November 1991. The right knee had flexion to 135 degrees and extension to 0 degrees. The left knee had flexion to 145 degrees and extension to 0 degrees. Normal range of motion is 140 degrees of flexion and 0 degrees extension. 38 C.F.R. § 4.71, Plate II. The remainder of the examination showed no heat, redness, tenderness, swelling, or abnormal motion of the knee. The diagnoses included massive obesity, but no pathologic diagnosis of the knees was noted. An X-ray study conducted at this time showed normal knees. VA treatment records from April 1992 also show that the veteran had left knee instability dating from June 1991. May 1992 VA records indicate that the veteran stated he injured his knee in the military. It had now become worse, and was unstable and painful. The range of motion was 110 degrees of flexion and 0 degrees of extension. The assessment was of chronic insufficiency of the medial collateral ligament and the anterior cruciate ligament. After careful consideration of the veteran's contentions and the evidence of record, the Board is unable to find that service connection is merited for the veteran's bilateral knee disorder. Every veteran shall be taken to have been 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. The evidence indicates that the veteran was treated for a bilateral knee disorder during active service, but that this disorder existed prior to active service. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This include 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. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306(b) (1993). The November 1967 entrance examination was negative for a knee disability. However, the veteran clearly indicated in April 1969 and June 1969 that his knee disability had pre-existed service. He reported on two separate occasions that he had experienced knee pain since the sixth grade, and attributed the pain to a football injury. The Board believes that this constitutes clear and unmistakable evidence that the disorder pre-existed active service. The evidence does not indicate that the veteran's knee disability increased in severity during active service. After the veteran was seen on a single occasion in December 1967 for water on the left knee, his knees became symptomatic from April 1969 to June 1969. No complaints pertaining to knee pain were shown after this time, and while a history of knee pain was noted at discharge, the February 1971 discharge examination is negative for a knee disability. There is no evidence of additional treatment for a knee disability until July 1991, and this was attributed to a recent injury. Therefore, the evidence does not indicate that there was an increase in severity of the veteran's disability during active service. The Board notes that the veteran was also treated for gout of the knees in June 1969. No other treatment for this disorder was shown in service, and the February 1971 discharge examination was negative for gout. There is no evidence of additional complaints of knee pain until 1991, 20 years after discharge from active service. The gout treated in service was not shown to be chronic, and there is no evidence of continuity of treatment to establish chronicity and demonstrate a relationship with the veteran's current disability. 38 C.F.R. § 3.303(b). In addition, there is no current evidence of gout. Therefore, without any evidence of an increase in severity of the veteran's pre-existing knee disorders, or evidence of the development of the veteran's current knee disorder during active service, service connection for a bilateral knee disorder is not merited. II. Increased Rating The veteran states that an increased rating is warranted for his service connected hypertension. The evaluation of service- connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C.A. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet.App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. A review of the record indicates that the veteran was initially service connected for hypertension in an April 1992 rating decision. This decision considered the veteran's service medical records, private medical records, and the findings of a November 1991 VA examination. The decision evaluated the veteran's disability as 10 percent disabling, and this evaluation is currently on appeal. In order for the veteran to receive a 20 percent evaluation for hypertension, his diastolic pressure must be predominately 110 or more on examination, with definite symptoms. Diastolic pressure of predominately 100 or more but less than 110 merits a continuation of the 10 percent evaluation now in effect. If continuous medication is shown necessary for control of hypertension with a history of diastolic blood pressure predominantly 100 or more, a minimum rating of 10 percent is assigned. 38 C.F.R. § 4.104, Code 7101. VA treatment records from March 1991 to June 1992 are of record, as are the findings of the November 1991 VA examination. Although there are some blood pressure readings with diastolic pressures of 110 or higher, the readings are predominately in the range of 100. The veteran's blood pressure readings in March 1991 were noted to be 140/100 and 200/114. April 1991 records show readings of 180/116, 140/100, 158/100, and 126/92. These records further note that he had experienced problems with his blood pressure in February 1990, but that there had been some improvement. Other April 1991 records reveal that the veteran complained of dizziness and weakness. A reading of 152/97 was taken in May 1991. Readings of 150/100 and 162/112 were obtained in July 1991, 146/102 in August 1991, and 160/108 in September 1991. Measurements of 140/80, 160/120, and 120/90 were taken in October 1991, and 163/109 in November 1991. The veteran was afforded a VA examination in November 1991. Blood pressure readings were 150/100 and 150/90 sitting, and 154/100 standing. His blood pressure was noted to be treated with Vasotec, with no complications. Treatment records from December 1991 show a reading of 146/98. His blood pressure was 140/90 in January 1992, 163/109 in February 1992, and 158/98 in April 1992. The most recent blood pressure readings of record were obtained in June 1992, and they were 140/98 and 152/98 at that time. The veteran's diastolic pressure is not predominately 110 or more. While some readings of 110 or more were obtained in 1991, the majority of the readings were less than 110. In addition, the most recent instance of a reading of 110 or greater was in July 1991, and treatment records reveal that every blood pressure reading taken between August 1991 and June 1992 shows a diastolic pressure of less than 110. Therefore, an increased rating for hypertension is not warranted. In reaching this decision, the Board has considered an extraschedular evaluation under 38 C.F.R. § 3.321, but marked interference with employment, frequent hospitalizations, or other evidence of an unusual disability picture has not been shown. The veteran's symptomatology does not more nearly approximate that of the next higher evaluation. 38 C.F.R. § 4.7. ORDER Entitlement to service connection for a bilateral knee disorder is denied. Entitlement to an increased rating for hypertension is denied. WILLIAM J. REDDY 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.