BVA9503568 DOCKET NO. 92-22 036 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an increased evaluation for residuals of a total right knee replacement, currently evaluated as 30 percent disabling. 2. Entitlement to service connection for disorders of the low back, right hip and right foot, claimed as secondary to service- connected residuals of a total right knee replacement. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and wife ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Associate Counsel INTRODUCTION The veteran served on active duty from July 1942 to June 1945. This appeal arises from December 1991 and subsequent rating decisions of the Atlanta, Georgia, Regional Office (RO). The December 1991 rating decision continued the 30 percent evaluation for the veteran's service-connected right knee disability. A September 1992 rating decision denied entitlement to service connection for back, right hip and right foot disorders claimed as secondary to the service-connected residuals of a total right knee replacement. In July 1993, the Board of Veterans' Appeals (Board) remanded the case for additional development. Subsequently, a September 1994 rating decision of the St. Petersburg, Florida, regional office (SRO) continued the 30 percent rating for residuals of right total knee replacement and continued the prior denials of service connection for back, right hip and right foot disorders as secondary to the service-connected residuals of a total right knee replacement. In a statement received in March 1994, the veteran raised the issue of an increased evaluation for his service-connected heart disorder. This issue has not been developed or certified for appeal. Therefore, the issue is not properly before the Board at this time and is referred to the SRO for action deemed appropriate. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he is entitled to an increased evaluation for his service-connected residuals of right total knee replacement. He contends that he has pain, stiffness and weakness in the knee, particularly when walking. He also contends that he has right foot, right hip and low back disorders that were caused by his service-connected right knee disability and should be service connected on a secondary basis. His representative requests that all reasonable doubt be resolved in the veteran's favor. 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. 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 for an evaluation in excess of 30 percent for residuals of right total knee replacement, and that the preponderance of the evidence is against the claims for service connection for right foot, right hip and low back disorders, claimed as secondary to residuals of right total knee replacement. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's claim. 2. The veteran's service-connected residuals of a total right knee replacement are manifested by intermediate degrees of weakness, pain and limitation of motion, but there is no evidence of severe painful motion or weakness, ankylosis of the knee, limitation of leg extension to 30 degrees, or nonunion of the tibia and fibula. 3. The veteran's service-connected right knee disability does not present an exceptional or unusual disability picture rendering impractical the application of the regular schedular standards that would have warranted referral of the case to the Director of the Compensation and Pension Service. 4. The veteran's service-connected right knee disability did not cause or result in a right foot, right hip or low back disorder. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent for residuals of right total knee replacement have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Codes 5055, 5256, 5257, 5261, 5262 (1994). 2. Any failure by the SRO to refer the case to the Director of Compensation and Pension Service for extraschedular consideration was harmless error. 38 C.F.R. § 3.321(b)(1) (1994). 3. A right foot disorder is not proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (1994). 4. A right hip disorder is not proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (1994). 5. A low back disorder is not proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a)(West 1991). That is, he has presented claims which are plausible. All relevant facts have been properly developed and no further assistance is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). I. Residuals of Right Total Knee Replacement The service medical records show that the veteran injured his right knee in July 1942 while engaging in supervised athletics. In September 1942, he suffered a severe sprain of the right knee while playing supervised baseball. A VA examination in December 1946 found relaxed internal lateral ligaments with genu recurvatum in both knees. A VA examination in June 1948 showed internal derangement of the right knee. Service connection for bilateral genu recurvatum with relaxed internal lateral ligaments was granted in October 1948. A 10 percent evaluation was assigned under code 5263 from November 1945. In May 1951, the veteran underwent a removal of a torn right medial meniscus. In December 1987, a 20 percent evaluation was assigned from October 1987 under code 5257 for residue of previous injury of the right knee. In August 1988, the veteran underwent a right total knee replacement. A November 1988 rating decision assigned a 30 percent evaluation effective from November 1989 under codes 5055 and 5257 for right total knee replacement, residual of previous injury of the right knee. In September 1990, the veteran underwent a revision right total knee arthroplasty. The 30 percent evaluation has been continued in subsequent rating decisions. The veteran contends that he is entitled to a higher evaluation. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). Separate diagnostic codes identify the various disabilities. The veteran's right knee disability is currently rated under codes 5055 and 5257. Under code 5055 a 60 percent evaluation is contemplated for chronic residuals of knee replacement consisting of severe painful motion or weakness in the extremity. The current 30 percent evaluation is appropriate for intermediate degrees of residual weakness, pain or limitation of motion of the knee replacement and is determined by analogy to code sections 5256, 5261, and 5262. 38 C.F.R. Part 4, Diagnostic Code 5055 (1994). Code 5256 requires ankylosis of the knee for a higher rating. 38 C.F.R. Part 4, Diagnostic Code 5256 (1994). Code 5261 requires limitation of leg extension to 30 degrees for a rating above 30 percent. 38 C.F.R. Part 4, Diagnostic Code 5261 (1994). Code 5262 requires nonunion of the tibia and fibula, with loose motion, requiring a brace, for a 40 percent evaluation. 38 C.F.R. Part 4, Diagnostic Code 5262 (1994). The Board notes that the veteran is currently evaluated at the highest evaluation available under code 5257 for recurrent subluxation or lateral instability of the knee. The current 30 percent rating contemplates a severe level of impairment. 38 C.F.R. Part 4, Diagnostic Code 5257 (1994). A VA examination was conducted in August 1992. The veteran reported pain in the knee when he walked and drainage from his surgical scars. On examination, there was a 29 centimeter serpentine depressed disfiguring scar on the anteromedial aspect of the joint. The scar was nontender, and there was no evidence of inflammatory reaction along the locus of the scar. Ranges of motion were reported as 30 degrees of knee extension and 60 degrees of flexion. Efforts to increase the ranges of motion elicited discomfort. The veteran was unable to squat and had difficulty standing on toes and the heel of the right foot. X-rays showed the veteran to be status post revision of total knee arthroplasty with patellar resurfacing component. The components appeared well-seated. There was no radiographic evidence of complication. Extensive vascular calcification was present. The diagnosis was postoperative status right knee meniscectomy and arthroplasties with subjective and objective findings as described. A report from John G. Sullivan, M.D., dated in March 1994, indicates that the veteran was seen with complaints of knee pain. The veteran reported that the pain was worse with activity and after sitting but better when he layed flat. On examination, the range of right knee motion was limited to 10 degrees extension and 85 degrees flexion with pain at the extremes. There was a tender intermedial scar and tenderness over both joint lines. The ligaments were intact. X-rays showed a satisfactory revision of total knee replacement with slight lateral subluxation of the patella. The impression was painful post operative course following revision right knee total replacement. The most recent VA examination was conducted in April 1994. The veteran complained of persistent pain over the anterior aspect of the right knee, with a constant snapping and crunching along the outer aspect of the patella, and marked stiffness and weakness of the knee with inability to completely extend or flex it. On examination, the veteran used a cane for support and walked with a noticeable limp shifting slightly the upper body to the right on walking. There was an 11 inch long well-healed medial parapatellar incision over the right knee. The scars were not tender and no drainage was noted. The right knee lacked the final 13 degrees to complete extension. Flexion was to 80 degrees. There was no evidence of effusion, good lateral stability in full extension, and modest laxity of the medial collateral ligament at 35 degrees and more particularly at 80 degrees. There was definite tenderness around the patella and beneath the lateral margin of the patella. On flexion and extension there was obvious crepitation beneath the patella and patellar components. X-rays showed calcification of the popliteal artery. The diagnoses were status post total knee replacement right side with subsequent revision, marked restriction of motion in the right knee with tilt of the patella and impingement of the lateral margin of the patella against the lateral femoral condyle-symptomatic. The veteran's right knee extension was measured at 30 degrees in August 1992. However, in March 1994 it was measured at 10 degrees and in April 1994 it was at 13 degrees. The recent examination findings demonstrate that the veteran's right knee disability is currently manifested by some pain, stiffness, weakness and loss of motion. However, there is no demonstration of ankylosis of the knee, limitation of leg extension to 30 degrees, or nonunion of the tibia and fibula which would permit a higher evaluation by analogy. 38 C.F.R. Part 4, Diagnostic Codes 5055, 5256, 5261, 5262 (1994). As noted above, the veteran's disability is already at the highest evaluation available under code 5257 for lateral instability of the knee. 38 C.F.R. Part 4, Diagnostic Code 5257 (1994). While the veteran clearly has pain and weakness in his right knee, he was able to walk with the aid of a cane and the examiners did not describe the severe level of painful motion or weakness that is required for a 60 percent evaluation. The Board notes that the current 30 percent evaluation does contemplate an intermediate level of pain and weakness. 38 C.F.R. Part 4, Diagnostic Code 5055 (1994). Based upon the foregoing, the Board finds that an evaluation in excess of 30 percent for the veteran's residuals of right total knee replacement is not appropriate. There is no equipoise between the positive and negative evidence, therefore no reasonable doubt issue is raised. 38 C.F.R. § 3.102 (1994). The schedular evaluations are adequate to compensate the veteran's right knee disability. This is not an exceptional case where the schedular evaluations are shown to be inadequate. It does not present an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (1994). Any failure by the RO to refer the case to the Director of the Compensation and Pension Service for extraschedular consideration was harmless error. 38 C.F.R. §§ 3.321(b)(1) (1994). II. Right Foot, Right Hip and Low Back Disorders The veteran contends that he has disorders of the right foot, right hip and low back which resulted from his service-connected residuals of right total knee replacement. He contends that he is entitled to service connection on a secondary basis for these disorders. Service connection may be established for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1994). No right foot, right hip or low back complaints are shown in the service medical records. On VA examination in June 1948, the veteran complained of occasional low backaches. On examination, all motions of the low back were within normal limits with full flexion and hyperextension. There was no ankylosis or tenderness. X-rays showed no evidence of bone or joint disease or injury. The right transverse process of the last lumbar vertebra showed evidence of sacralization. The impression was sacralization, transverse process, L-5. The Board remanded the case in July 1993 for an examination by a VA orthopedist in part to determine whether the veteran had any chronic right foot, right hip or low back conditions and whether they were causally related to his right knee disability. The veteran complained of marked stiffness in the lower back with constant dull ache in the upper lumbar region with recurrent sharp pains in the low back and legs down to the level of the feet; recurrent numbness in the toes of the right foot particularly at night; weakness in the right lower leg and foot with pain in the ball of the foot on standing and weight-bearing; pain in the bottom of the right heel; and a cold feeling the right foot. The veteran did not have any right hip complaints. The veteran reported a history of having injured his back in 1952 while attempting to lift a freezer with four other persons. He reported that he developed pain and stiffness in the lower back at that time with numbness in both lower legs and feet and recurrent sharp pains in both legs. He further reported that he underwent removal of a herniated disk. He then had a bony fusion in 1953 followed by a bilateral fusion in approximately 1960. In 1970 he apparently "cracked" his fusion. A refusion was done in 1972. In 1978 or 1979 he had a lysis of scar-bound nerves. In 1981 adipose tissue was wrapped around the nerve roots to protect them from scarring. On examination, the back displayed a modest right dorsal lumbar curvature with a shift of the upper body to the right, C-7 projecting one and one-half inch to the right of the midline. Three surgical scars were noted. There was some evidence of muscle spasm but on digital pressure tenderness was elicited mainly in the upper lumbar region at approximately L-2. There was no particular soreness across the lumbosacral junction over sciatic notches and over the greater trochanters. The range of motion of the low back was limited with active flexion of 65 degrees, active extension of 5 degrees, active flexion to the left of 3-5 degrees, active flexion to the right of 5-8 degrees, rotation to the left of 12 degrees, and rotation to the right of 15 degrees. The diagnoses were mechanical low back syndrome, with bilateral leg radiation; status post 7 surgical interventions on the low back including disc decompression, spinal fusions and lysis of scar-bound nerve roots; solid fusion from L-2 down to the sacrum with extensive central laminectomy extending from L-3 down to the upper sacrum; and moderate degeneration of the lumbar disc L-1/L- 2 with significant anterior and lateral spurring. The examiner stated that in his opinion the low back condition developed independently of the right knee injury. He stated that the low back problems began with the 1952 incident but that the subsequent deterioration in the condition of the right knee has undoubtedly affected untowardly his low back condition; the veteran's inability to straighten the right knee completely has forced him to tilt the pelvis to the right and to shift the upper body to the right which is affecting the L1-L2 disk. With respect to his right foot, the veteran reported that he began experiencing pain in the ball of the foot following knee surgery in 1988. He further stated that the pain was associated with an intermittent numbness, and that over the past 2 or 3 years he had also experienced pain in the bottom of the right heel. The veteran also stated that over the past 10 years he had suffered from arteriosclerosis of the vessels of the lower extremities, particularly the right, and he had experience a cold feeling in the right foot. On examination, both lower legs showed evidence of varicosities in the veins, more particularly on the right side, and there was purplish discoloration of the right lower leg and foot. The right foot was colder than the left. The right popliteal pulse, dorsalis pedis and tibialis posterior pulses could not be palpated. The ankle mortises were snug but the right ankle displayed only 5 degrees of active dorsiflexion as compared to 8 degrees on the left. Both feet presented 15 degrees of active plantar flexion. The right foot presented 5 degrees of eversion and inversion as compared to 8 degrees of inversion and 5 degrees of eversion on the left. There was no evidence of sensory deficit in the right lower leg, but there was definite decreased vibratory sensation in the right foot. Knee jerk and ankle jerk reflexes were not obtainable. There was no weakness of dorsiflexion in the feet and straight leg raising produced on the right discomfort in the buttock with 75 to 80 degrees of raising. The diagnoses were arteriosclerosis in both lower extremities with impaired arterial circulation in the right lower leg and foot and varicosities in both lower legs and feet, more prominent on the right-symptomatic; modest pronation of both feet with degenerative changes in the talonavicular and navicular cuneiform joints-symptomatic; and inferior calcaneal spur, right foot- symptomatic. The examiner stated that the right knee condition undoubtedly affected untowardly the right foot. He also stated that the vascular findings in the right leg were significant and contributed to the right foot and lower leg pain. He concluded by stating that while the condition of the right knee is placing strain on the lower back and right foot, the vascular and neurological findings explained a greater part of the lower leg and foot pain. The veteran told the examiner that he did not recall having ever complained of pain in the right hip. On examination, there was a good range of motion with minimal limitation of flexion. X-rays of the hips were normal. No hip pathology was diagnosed. The Board notes that the VA examiner stated that the veteran's low back pathology developed independently of the right knee injury. He also stated that the vascular and neurological findings explained the greater part of the right foot pain. It is apparent that the veteran's right knee pathology has contributed to the pain picture, however it is important to note that no medical professional has implicated the right knee disability as a cause of the degenerative changes in the right foot and back or of the vascular and neurological problems in the right foot and leg. Additionally, the recent examiner did not find any right hip pathology and the veteran did not complain of any pain in the right hip. The veteran clearly has multiple physical problems which combine to cause his present level of disability. The issue for the Board is causation, not aggravation. The veteran suffers from discretely diagnosed right foot and back pathology which causes his pain symptoms, and this pain is undoubtedly worsened by the right knee condition. The Board has analyzed the examiner's report closely. His opinion is that the right knee condition is "placing strain on" and has "affected untowardly" the right foot and back. The examiner has provided an unequivocal statement as to the separate etiology of the low back pathology; the veteran's 1952 back injury. There is no indication in the record that the veteran's right knee condition caused any back pathology prior to 1952, or that the knee injury was responsible for the freezer-lifting incident which caused the back injury at that time. The examiner has also stated that the greater part of the right foot pain is explained by the vascular and neurological findings. This leaves the right knee responsible for some degree of right foot pain, but, as noted above, the examiner does not implicate the right knee condition as a cause of any of the diagnosed right foot conditions. The VA examiner's opinion does not provide a basis upon which to conclude that any of the veteran's right foot or low back diagnoses are proximately due to or the result of his service-connected residuals of total right knee replacement. Based upon the foregoing, the Board concludes that the veteran is not entitled to service connection on a secondary basis for disorders of the right foot , right hip and low back. 38 C.F.R. 3.310(a) (1994). There is no equipoise between the positive and negative evidence, therefore no reasonable doubt issue is raised. 38 C.F.R. 3.102 (1994). ORDER An evaluation in excess of 30 percent for residuals of right total knee replacement is denied. Service connection for a right foot disorder, claimed as secondary to service-connected residuals of right total knee replacement, is denied. Service connection for a low back disorder, claimed as secondary to service-connected residuals of right total knee replacement, is denied. Service connection for a right hip disorder, claimed as secondary to service-connected residuals of right total knee replacement, is denied. JOAQUIN AGUAYO-PERELES 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.