Citation Nr: 1318425 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 11-10 313 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for chronic pain syndrome. 2. Whether the reduction from a 20 percent rating to a noncompensable rating, effective April 1, 2010, for residuals of a partial left knee meniscectomy of the anterior horn lateral meniscus with instability was proper. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.M. Rutkin, Associate Counsel INTRODUCTION The Veteran served on active duty from June 2003 to September 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2008 and January 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Gretna and New Orleans, Louisiana, respectively. The November 2008 rating decision, in pertinent part, denied service connection for chronic pain syndrome, and the January 2010 rating decision, in pertinent part, reduced the 20 percent evaluation for left knee instability to a noncompensable rating. In February 2012, the Veteran testified at a Board hearing before the undersigned. A transcript of the hearing is in the claims file. During the pendency of this appeal, the Veteran submitted an increased rating claim for his service-connected left knee disability. A notification letter under the Veterans Claims Assistance Act of 2000 (VCAA) was sent to him in April 2011. However, the RO has not had an opportunity to adjudicate this claim. Accordingly, the Board does not have jurisdiction over the claim for an increase rating for the Veteran's left knee disability, and the claim is referred to the RO as agency of original jurisdiction (AOJ) for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran does not have a chronic pain syndrome, including rhabdomyolysis and myositis, related to a disease, injury, or event during active military service. 2. A separate 20 percent rating for moderate instability of the knee was assigned effective September 16, 2005 in an August 2007 rating decision based on a finding of moderate instability in a June 2007 VA examination report. 3. The preponderance of the evidence shows that under the ordinary conditions of life and work the Veteran's left knee instability has completely resolved since at least April 1, 2010. CONCLUSIONS OF LAW 1. A chronic pain syndrome was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The reduction from a 20 percent rating to a noncompensable rating, effective April 1, 2010, for residuals of a partial left knee meniscectomy of the anterior horn lateral meniscus with instability was proper. 38 U.S.C.A. § 5112 (West 2002); 38 C.F.R. §§ 3.105, 3.344, 4.71a, DC 5257 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104(d)(1) (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. See id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against a claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). I. The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), sets forth VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, a delay in timing of the notice is "cured," and therefore harmless, when a fully compliant VCAA notification letter is followed by readjudication of the claim (such as through issuing a statement of the case or supplemental statement of the case) after the claimant has had an opportunity to submit additional evidence. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). With regard to the service connection claim for chronic pain syndrome, a claim of entitlement to service connection consists of five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). Notification of what evidence is necessary to substantiate the claim under 38 U.S.C.A. § 5103(a) requires notice of these five elements. See id. at 486; Quartuccio, 16 Vet. App. at 187. Here, prior to the initial rating decision in this matter, a September 2008 letter informed the Veteran of all five elements of service connection, gave examples of the types of evidence the Veteran could submit in support of his claim, and provided notice of the Veteran's and VA's respective responsibilities for obtaining relevant records and other evidence on his behalf. Therefore, the duty to notify is satisfied. See id. The reduction of the evaluation assigned the Veteran's left knee instability does not involve a claim for benefits, such as a claim for an increased rating. Thus, the duty to notify under 38 U.S.C.A. § 5103(a) does not apply. Rather, VA must comply with the notification provisions set forth in 38 C.F.R. § 3.105(e)-(i). Moreover, the November 2009 proposed rating reduction and notice letter informed the Veteran that a recent VA examination showed no instability of the knee, and that a 20 percent rating required moderate subluxation or lateral instability. He was further informed that a 10 percent rating required evidence of slight subluxation or lateral instability. Thus, a reasonable person could be expected to understand from this notice what evidence was required to show that the rating reduction was not warranted. See Mayfield v. Nicholson, 19 Vet. App. 103, 121 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (holding, in relevant part, that lack of prejudicial harm may be shown if a reasonable person could be expected to understand from the notice what was needed). Moreover, the November 2009 notification letter also informed the Veteran that he could submit evidence, such as a statement by a physician who recently examined him, to show that the rating reduction was not warranted. Further, in a March 2012 statement, the Veteran requested VA to obtain additional VA treatment records in support of his appeal, thus showing actual knowledge of VA's responsibility for obtaining evidence on his behalf. See id. Finally, the Veteran had been sent an August 2009 VCAA notice letter with respect to an increased rating claim for his left knee disabilities, which was adjudicated in the same November 2009 rating decision proposing the reduction of the evaluation assigned his left knee instability. This letter fully complied with all notice provisions required under the VCAA. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 97-103 (2010) (Vazquez-Flores III); Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008) (Vazquez-Flores I), overruled in part sub. nom. Vazquez-Flores/Wilson v. Shinseki, 580 F.3d 1270, 1280-81 (Fed. Cir. 2009) (Vazquez-Flores II); Quartuccio, 16 Vet. App. at 187. The Veteran was thus clearly informed of what was required to show that the rating reduction was not proper. In sum, as the notification provisions under section 3.105 have been satisfied, and a reasonable person could be expected to understand what evidence was needed to support continued entitlement to a 20 percent rating for instability of the left knee, further notification is not required. VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Here, the Veteran's service treatment records and VA medical records are in the file. In a March 2012 statement, the Veteran requested that VA obtain additional VA treatment records from the VA Medical Centers (VAMC's) in Slidell and New Orleans, Louisiana with regard to the rating reduction issue. He stated that these records would show that he had been prescribed "many medications" for his left knee, and would also show ongoing chronic pain, thus verifying that there had been no improvement in his left knee disability. The Board finds no need to obtain these outstanding VA treatment records. The VA treatment records in the claims file already show that the Veteran has been prescribed narcotic pain medications for his left knee pain, and that he has reported chronic knee pain. The separate 10 percent rating assigned the Veteran's left knee osteoarthritis includes pain and painful motion. Whether this evaluation is sufficient for his left knee pain is not relevant to the issue of whether he continues to have instability of the left knee, for which the separate 20 percent rating at issue here was assigned. The Veteran has not indicated that the outstanding VA treatment records would show such instability, but rather that they would serve as evidence of that which has already been established, namely ongoing knee pain. In the face of several VA examination reports showing clinical findings based on examination of the knee by a medical doctor that the Veteran does not have instability or subluxation of the left knee, as well as VA treatment records dating up to November 2009 showing complaints of knee pain but no complaints or findings of instability, there is no reasonable possibility that the recent outstanding VA treatment records would show such instability. Accordingly, a remand is not warranted to obtain them. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (holding that VA is not required to "obtain records in every case in order to rule out their relevance," but rather only "if there exists a reasonable possibility that the records could help the veteran substantiate his claim for benefits"); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). The Veteran has not identified any other records or evidence that remains outstanding. Thus, the duty to obtain relevant records on the Veteran's behalf is satisfied. See 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate, and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Here, VA examinations of the knee were performed in September 2009, October 2009, and August 2010. The VA examination reports are adequate for the purpose of determining whether the rating reduction was proper. Specifically, the examiner conducted an examination of the Veteran, recorded the clinical findings, and described the Veteran's left knee disability and resulting functional impairment in sufficient detail to enable the Board to make a fully informed decision on this issue. Although the examiner did not have the claims file available for review, the examination reports document the Veteran's history of having twisted his left knee and torn his meniscus, and undergoing two surgical repairs of the meniscus during active service. Moreover, it includes the results of a June 2007 VA MRI and March 2008 VA x-ray study of the left knee. There does not appear to be any pertinent evidence of record with regard to instability or subluxation of the left knee overlooked by the examiner. Thus, the Veteran's pertinent medical history with regard to the left knee was in fact reviewed by the examiner. Moreover, there is no apparent reason why a review of the claims file would alter the examiner's clinical findings with regard to instability of the knee, especially as the examiner was able to review previous x-ray and MRI studies, and his diagnosis of chondromalacia patella is consistent with the earlier findings. See Mariano v. Principi, 17 Vet. App. 305, 311-312 (2003) (holding that range of motion measurements are not conclusions drawn by a VA examiner that would be affected by review of the claims file and therefore failure to review the Veteran's claims file in conducting an orthopedic examination did not undermine the objective findings recorded by the VA examiner). Notably, the claims file does not otherwise show a history of instability of the left knee apart from the June 2007 VA examination report, as discussed below. Also significant is the fact that the VA physician who conducted the examination had an opportunity to examine the Veteran several times from October 2008 to August 2010, and did not once find instability of the knee during those examinations. Accordingly, the examiner's findings are adequate for determining whether the rating reduction was proper. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion" (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). At the February 2012 Board hearing and in an October 2012 statement, the Veteran expressed his opinion that the VA examinations upon which the rating reduction is based were not adequate as the examinations seemed quick and the examiner did not alter the findings in the examination reports. The examination reports do show that the examiner did not alter his findings. However, there would be no reason to alter such findings if there were no changes in the Veteran's left knee disability in terms of its objective clinical presentation with regard to instability, range of motion, or other significant symptoms. The Veteran has not specified in what ways the examinations were inadequate other than that they were performed quickly. As there are no apparent inconsistencies or ambiguities in the examination reports, and as the VA examiner is a licensed medical doctor, the Board assumes that the physical examinations were sufficient to yield an accurate clinical assessment of the Veteran's left knee as determined by the examiner. See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-1291. Accordingly, VA's duty to assist with respect to obtaining a VA examination has been met with regard to the issue of whether the rating reduction was warranted. See 38 C.F.R. §§ 3.159(c)(4); 3.326(a); McLendon, 20 Vet. App. at 83; Barr, 21 Vet. App. at 312. With regard to the Veteran's service connection claim for a chronic pain disorder, a VA examination has not been provided, and the Board finds that one is not warranted. In this regard, in McLendon, 20 Vet. App. at 83, the Court held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. Here, as will be discussed in more detail below, there is no indication that the Veteran has a discrete chronic pain disorder related to active service or to a service-connected disability. Most of his complaints of chronic pain are associated with his service-connected bilateral knee disabilities and thus do not constitute evidence of a distinct disability for which service connection has not been established. To the extent his pain is associated with his knee disabilities, such is factored into their evaluation, which is not an issue on appeal before the Board. There is also evidence of more widespread pain in both arms, the distal part of both thighs, and both calves, as documented in a November 2009 VA treatment record and as described by the Veteran in his February 2012 hearing testimony. However, the credible evidence shows that this more widespread pain did not manifest during service or until late October 2009, according to a November 2009 VA treatment record which states that this condition had its onset two days after the Veteran presented with flu-like symptoms in late October 2009. This record further states that the Veteran had been hospitalized at a private facility and diagnosed with rhabdomyloysis secondary to a viral infection. The VA treating physician also thought this condition, which he characterized as "myositis," might be a side effect of medication the Veteran was taking for the flu. Thus, as competent evidence shows that the Veteran's more diffuse pain, diagnosed as rhabdomyloysis or myositis, did not manifest until several years after he separated from active service, and has been attributed to post-service or "intercurrent" causes, including a flu virus or medication, there is no indication that it may be related to a disease, injury, or event during active service or to a service-connected disability. Thus, a VA examination is not needed to decide this claim. See id. In sum, VA's duty to notify and assist under the VCAA has been satisfied. The Veteran has had ample opportunity to participate in the development of his claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . . must be considered prejudicial")). Any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication." See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, any error in the notice or assistance provided was harmless, and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show that the error was harmful by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) (West 2002). Accordingly, the Board may proceed with appellate review. II. Procedural Due Process As noted above, the Veteran testified at a February 2012 Board hearing before the undersigned. Under 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two distinct duties under section 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining to the claimant that these issues were material to substantiating the claim). Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id., at 496-97. Importantly, the Court observed that the rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c). See id. at 498. Citing Sanders, 556 U.S. at 407, 410, the Court noted in this regard that the rule of prejudicial error requires a case-by-case determination as to whether the error in question was harmless. Id. Thus, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA examination, and there was no indication that the appellant had any additional information to submit. Here, with regard to the service connection claim for chronic pain syndrome, the outstanding issue is whether the Veteran has a diagnosed disorder associated with chronic pain syndrome and whether it is related to active service. With regard to the propriety of the reduced rating, the outstanding issue is whether the Veteran's left knee instability improved to the point where a rating reduction from 20 percent to noncompensable was warranted. Although the undersigned did not explicitly identify these issues for the Veteran, the Veteran had an opportunity at the hearing to provide testimony as to the nature and history of his chronic pain and also to describe his current left knee symptoms. Any deficiencies in the Board hearing under section 3.103(c)(2) were not prejudicial. Specifically, with regard to the service connection claim for chronic pain syndrome, VA has otherwise developed this claim, to include obtaining VA treatment records. These records clearly show that the pain in multiple parts of his body did not occur until many years after service and was attributed to a virus or medication he was taking. To the extent the Veteran's chronic pain is associated with his service-connected bilateral knee disabilities, as he originally indicated in his claim for benefits, such pain does not constitute a discrete disability but is a symptom of an already service-connected disability. Thus, there is no indication of any evidence that may have been overlooked, as there is no reasonable possibility that such evidence exists in light of the record clearly documenting that the manifestation of pain in various parts of the Veteran's body did not occur until many years after service and was attributed to post-service causes. Moreover, the Veteran did not raise any new issues with respect to this claim at the hearing. Thus, the "clarity and completeness of the hearing record [is] intact" and the purpose of section 3.103(c)(2) to develop the record has been fulfilled. Id. at 498-99. With regard to the rating reduction issue, VA has likewise already developed the record, including obtaining VA treatment records on the Veteran's behalf and providing several VA examinations which specifically address the outstanding issue in this case, namely whether the Veteran continues to have instability of the left knee, as discussed above. Moreover, the Veteran did not raise any new issues pertaining to his left knee instability at the hearing, and there is no indication of any outstanding evidence that may have been overlooked. See id. at 499. As already noted, there is no reasonable possibility that any outstanding evidence would show instability of the knee when the VA treatment records have been negative for such instability and in the face of repeated findings in the VA examination reports that the Veteran does not have instability of the left knee. Thus, given the development undertaken by VA with respect to this issue, and in light of the Veteran's testimony at the hearing, the "clarity and completeness of the hearing record [is] intact" and the purpose of section 3.103(c)(2) to develop the record has been fulfilled. Id. at 498-99. Accordingly, the Veteran's right to a Board hearing has been satisfied and no prejudicial error exists with regard to the hearing officer's duties under section 3.103(c)(2). See id.; see also Sanders, 556 U.S. at 407, 410. III. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit held that a three-element test must be satisfied in order to establish entitlement to service connection. Walker v. Shinseki, 708 F.3d 1331, 1333 (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Id. However, claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b). See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases"). Specifically, when a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain in a claim for arthritis or abnormal heart action in a claim for heart disease) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service under subsection 3.303(b) is a distinct and lesser evidentiary burden than the nexus element of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Walker, 708 F.3d at 1338-1339. Thus, showing a continuity of symptomatology after service is an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation" for chronic diseases. Id. at 1338; see also id. at 1336 (observing that section 3.303(b) provides a "second route by which a veteran can establish service connection for a chronic disease"). A continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. at 1338. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the more relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimed disability is not one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "the 'nexus' requirement of the three-element test" must be satisfied in order to establish entitlement to service connection benefits. Id. For example, the Federal Circuit held in Walker that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as it found that the claimant's hearing loss was not among the chronic diseases listed in section 3.309(a)). Id. at 1336-37, 1340. Here, at the February 2012 Board hearing, the Veteran testified that he had chronic pain in his back, hips, and both knees, and stated that it had been present since 2004. He indicated that he had not been treated for chronic pain during active service apart from as a symptom of his knee injuries. See Transcript, pages 3-4. Apart from the Veteran's bilateral knee disorders and associated symptoms, for which service connection has already been established, the service treatment records do not show complaints of wide-spread or diffuse pain, and do not otherwise suggest that the Veteran had a discrete disorder at the time manifested by chronic pain. The Veteran was not deployed to the Southwest Asia Theater of Operations and thus did not have Persian Gulf service. Therefore, the issue has not been raised as to whether he may have developed an undiagnosed illness or medically unexplained chronic multisymptom illness associated with chronic pain related to active service. See 38 C.F.R. § 3.317 (2012). There is no evidence of more widespread pain until late October 2009, which is over four years after the Veteran's discharge in September 2005. Specifically, the Veteran submitted the service connection claim for "chronic pain syndrome" in August 2008, but did not describe the nature or location of the pain. VA treatment records dated in 2008 show complaints of increased knee pain, which was described as "ongoing intolerable pain of both knees" in an April 2008 record. He was prescribed narcotic pain medication and received a series of injections in his knees at this time. However, apart from "diffuse bodyaches [sic]" associated with a bout of influenza documented in a February 2008 VA treatment record, there is no evidence of more widespread pain or pain in other areas of the Veteran's body. The earliest evidence of such pain is an early November 2009 VA treatment record, which states that the Veteran had an onset of "myalgias" in both arms, the distal part of both thighs, and both calves two days after he presented to VA with influenza a week earlier in late October 2009. These symptoms included "sudden onset [of] malaise," subjective fever, body aches, and a cough with wheezing. The record further states that he was prescribed Tamiflu and Zithromax and then developed "increased bodyaches [sic] . . . more specifically the myalgias mentioned above" [ellipsis in original]. It was also noted that the Veteran also developed "intolerable" epigastric pain the week before. According to this record, the Veteran sought treatment at a private facility due to his increased symptoms and was hospitalized for two days with a diagnosis of "rhabdomyolysis secondary to viral infection." The treatment record further states that the Veteran continued to feel ill, but that his acute symptoms, including the myalgias, were "receding." The treating physician observed that the etiology of the Veteran's myalgias, which the physician also characterized as "myositis," may have been viral but that the Tamiflu or Zithromax may also have played a role in their onset as there was a case report of a man developing rhabdomyolysis after taking Tamiflu, although such a relationship was "statistically rare." The Board has considered the Veteran's testimony at the Board hearing asserting that he experienced chronic pain in multiple parts of his body, including his back, hips, and knees, since active service in 2004. The Veteran is competent to provide this history. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge). However, the competency of evidence differs from the weight assigned to the evidence, which varies according to its credibility, probative value, and relationship to other items of evidence. See Layno, v. Brown, 6 Vet. App. 465, 469 (1994) (holding that the weight and credibility of testimony, as distinguished from its competency, is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted); accord Rucker v. Brown, 10 Vet. App. 67, 74 1997); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); Washington, 19 Vet. App. at 368 (noting that the witness's credibility affects the weight to be given to his testimony). The Veteran's allegation that he has experienced chronic pain in multiple areas of his body apart from his knees since active service is not credible. Not only are the service treatment records silent for such pain, but the post-service treatment records clearly show that the Veteran only reported ongoing pain in his knees until an acute onset of myalgias in his arms, thighs, and calves in late October 2009 while he had symptoms of influenza. Moreover, there is no mention of back or hip pain. Thus, as the Veteran's statements directly conflict with more probative evidence in the form of the contemporaneous VA and service treatment records, they are not credible and thus not entitled to any weight. See Caluza, 7 Vet. App. at 511 (holding that when determining whether lay evidence is satisfactory, the Board may properly consider, among other things, its consistency with other evidence submitted on behalf of the Veteran); Madden, 125 F.3d at 1480 (observing that "lay evidence which is in fundamental conflict with other lay evidence and is, for that reason, found not credible in a given case, is surely suspect"); see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). In sum, the credible and competent evidence shows that the Veteran's pain in multiple parts of his body did not occur until over four years after separation from service, and has been attributed to the virus he had at the time or possibly to medications he was taking at the time. Thus, based on the long period of time that elapsed between the Veteran's period of service and the onset of pain in multiple parts of his body, which has been diagnosed as rhabdomyolysis secondary to a viral infection or myositis, as well as the fact that these diagnoses were attributed to post-service causes, the preponderance of the evidence weighs against a relationship to service or a service-connected disability. See 38 C.F.R. §§ 3.303, 3.310; see also See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a proper consideration for the trier of fact is the amount of time that has elapsed since military service). To the extent the Veteran's chronic pain is associated with his service-connected bilateral knee disorders, such pain is contemplated in the evaluation assigned his service-connected disabilities and does not constitute a discrete disorder for which service connection may be established. Accordingly, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for chronic pain syndrome is denied. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. IV. Restoration of Rating The Veteran contends that the reduction of the rating assigned his service-connected left knee instability from 20 percent to noncompensable was improper and that the 20 percent rating should be restored. For the following reasons, the Board finds that the rating reduction was proper. VA regulations provide that where reduction in evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance is to be prepared setting forth all material facts and reasons. See 38 C.F.R. § 3.105(e); see also VAOPGCPREC 71-91 (Nov. 1991), see also VAOPGCPREC 29- 97 (Aug. 1997). The Veteran must also be given 60 days to present additional evidence showing that compensation should be continued at the present level. See 38 C.F.R. § 3.105(e). The Veteran must further be informed that he may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. If no additional evidence is received within the 60 day period and no hearing is requested, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the veteran of the final rating action expires. Id. In this case, the above procedural requirements were met. The RO issued a rating decision in November 2009 which proposed the reduction in the disability rating for the Veteran's service-connected left knee instability. The Veteran was advised of the proposed reduction in a November 2009 letter and offered an opportunity to testify at a hearing as well as to submit evidence showing that a rating reduction was not warranted. A copy of the November 2009 rating decision proposing the reduction was included with the letter. In response, the Veteran submitted a November 2009 hearing request with regard to the proposed reduction. A hearing at the RO was therefore scheduled for January 20, 2010, and the Veteran was informed of the hearing date, time, and location in a December 2009 letter. However, he did not report for the hearing and did not provide a reason for his failure to appear. As no additional information or evidence had been submitted, the RO implemented the rating reduction effective April 1, 2010 in a January 2010 rating decision. The Veteran was notified of the reduction in a January 2010 letter and timely appealed. Thus, the procedural requirements under section 3.105(e) for rating reductions have been met, and the April 1, 2010 effective date of the reduction was proper. See id. (providing that the effective date of the reduction is the last day of the month in which a 60-day period from notice of the final rating action expires). The question that remains is whether the evidence on which the reduction was based supported the reduction. In this regard, disability ratings are intended to compensate reductions in earning capacity as a result of the specific disorder. The ratings are intended, as far as practicably can be determined, to compensate the average impairment of earning capacity resulting from such disorder in civilian occupations. 38 U.S.C.A. § 1155 (West 2002). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. §§ 4.1, 4.2 (2012); Peyton v. Derwinski, 1 Vet. App. 282 (1991). The disability must be evaluated from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2012). If there is a question as to which evaluation to apply to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7 (2012). Otherwise, the lower rating will be assigned. Id. Any reasonable doubt regarding the extent of the disability is resolved in the veteran's favor. 38 C.F.R. § 4.3 (2012). Because the issue in this case is whether the RO was justified in reducing the rating of the Veteran's left knee instability from 20 percent to noncompensable, VA is required to establish by a preponderance of evidence that the rating reduction was warranted. See Brown v. Brown, 5 Vet. App. 413, 421 (1993); Kitchens v. Brown, 7 Vet. App. 320, 324 (1995) (holding that the burden of proof is on VA to establish that a reduction is warranted by a preponderance of the evidence). A reduction in rating must be based upon review of the entire history of a veteran's disability. See Brown, 5 Vet. App. at 420; see also 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). VA must then ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based on thorough and adequate examinations. See Faust v. West, 13 Vet. App. 342, 349 (2000); see also Tucker v. Derwinski, 2 Vet. App. 201 (1992) (holding that the failure of the examiner in that case to review the claims file rendered the reduction decision void ab initio). VA is not limited, however, to medical indicators of improvement. Faust, 13 Vet. App. at 349. Rather, VA may rely on non-medical indicators of improvement to show that a Veteran is capable of more than marginal employment. Id. The usual reduction procedure contemplates a situation where an actual change in the conditions has occurred and not merely a difference in thoroughness of the examinations or in use of descriptive terms. See Brown, 5 Vet. App. at 420-21 (citing 38 C.F.R. § 4.13 (2012)). Alternatively, decisions made on the basis of clear and unmistakable error are to be reversed or amended, including determinations as to degree of disability. See 38 C.F.R. § 3.105(a). There is no requirement for a showing of actual improvement in reducing a rating originally granted on the basis of clear and unmistakable error. Id. In Brown, the Court articulated three questions that must be addressed in determining whether a rating reduction was warranted by the evidence. Brown, 5 Vet. App. at 421. First, a rating reduction case requires ascertaining "whether the evidence reflects an actual change in the disability." Id. Second, it must be determined whether the examination reports reflecting such change were based upon thorough examinations. Id. Third, it must be determined whether the improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. Id. With respect to disabilities that are likely to improve, re-examinations disclosing improvement in such disabilities will warrant a rating reduction. 38 C.F.R. § 3.344(c). In this regard, not only must it be determined that an improvement in a disability has actually occurred, but also that such improvement reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 420-421; see also Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). There are other specific requirements that must be met before VA can reduce a disability rating that has been in effect for a long period of time. See 38 C.F.R. § 3.344(c). The regulation indicates in parentheses that such ratings would be in effect for five years or more. However, in Lehman v. Derwinski, 1 Vet. App. 339 (1991), the Court noted that use of parentheses suggests that the five year time frame is merely a guideline and not a mandatory minimum for when a disability is considered to have stabilized. The five-year period is calculated from the effective date of the establishment of the former rating to the effective date of the reduction. See Brown, 5 Vet. App. at 417-18. In this case, the 20 percent rating for the Veteran's left knee instability, which was assigned in an August 2007 rating decision, has been in effect since September 16, 2005. Because this evaluation had not been in effect for five years as of April 1, 2010, the effective date of the reduction, and because there is no evidence showing that the Veteran's left knee instability had otherwise stabilized (and indeed shows the contrary), the more rigorous standards for reducing a rating set forth in subsections (a) and (b) of 38 C.F.R. § 3.344 do not apply. These provisions only apply to ratings which have continued for long periods at the same level. See 38 C.F.R. § 3.344(c). They do not apply to disabilities which have not become stabilized and are likely to improve. In addressing whether improvement is shown, the comparison point generally is the last examination on which the rating at issue was assigned or continued. See Hohol v. Derwinski, 2 Vet. App. 169 (1992). Where, however, the rating was continued in order to see if improvement was in fact shown, the comparison point may include prior examinations as well. Collier v. Derwinski, 2 Vet. App. 247 (1992). Importantly, the reduction of a rating must have been supported by the evidence on file at the time of the reduction, rather than only by post-reduction evidence. However, pertinent post-reduction evidence favorable to restoring the rating must also be considered and may show that the rating reduction was improper. See Dofflemeyer v. Derwinski, 2 Vet. App. 277 (1992). By way of background, the Veteran initially injured his left knee during active service in January 2004 while running during physical training, as reflected in a June 2005 Medical Evaluation Board (MEB) report. According to the report, an MRI showed a partial tear of the distal anterior cruciate ligament. He underwent a left knee arthroscopy in March 2004, which further revealed an anterior horn break tear and an anterior lateral meniscal junction fibrosis synovitis. A partial meniscectomy of the medial meniscus with a limited synovectomy of the anterior lateral joint capsule was performed. The MEB report further states that the Veteran continued to have swelling of the left knee after the surgery was performed, and an August 2004 MRI revealed a severe partial tear involving the anterior cruciate ligament, a Grade II injury to the medial collateral ligament, and a mild joint effusion. A second arthroscopic surgery was performed in August 2004, consisting of a partial meniscectomy of the anterior horn of the lateral meniscus, a resection of the tear of the posterior horn lateral meniscus, and a partial chondroplasty of the condyle defect of the lateral femoral condyle. According to the report, the Veteran attended physical therapy and had persistent left knee pain. He was seen in the emergency room and diagnosed with hemarthrosis. At this time blood was drained from his knee. Subsequently, he was diagnosed with patella tendonitis. A December 2004 MRI showed a probable recurrent tear of the most lateral aspect of the anterior horn of the medial meniscus and some bone bruising and edema in the lateral tibial plateau. He was diagnosed with osteoarthritis status post two arthroscopic surgeries. In a June 2006 rating decision, service connection for osteoarthritis of the left knee was granted, with an evaluation of 10 percent. A separate 20 percent evaluation was assigned in an August 2007 rating decision for residuals of the left knee partial meniscectomy with moderate instability. The discussion in the rating decision specifically states that the separate 20 percent rating under Diagnostic Code (DC) 5257 of the rating criteria was based on a finding of moderate instability of the left knee, as shown in a June 2007 VA examination report. See 38 C.F.R. § 4.71a. In this regard, DC 5257 pertains to recurrent subluxation or lateral instability of the knee. Id. Under DC 5257, a10 percent rating is assigned for slight impairment of the knee, a 20 percent rating is assigned for moderate impairment of the knee, and a 30 percent rating is assigned for severe impairment of the knee. Id. The June 2007 VA examination report reflects that the Veteran's left knee symptoms included giving way, pain, stiffness, weakness, weekly locking episodes, repeated effusion, and instability characterized by the examiner as "moderate." The Veteran was able to stand for 15 to 30 minutes and walk for a quarter of a mile. His range of motion of the left knee was from 0 to 140 degrees, with pain beginning at 140 degrees and no additional limitations on repetitive use. An MRI study performed as part of the examination showed a mild amount of fluid in the knee but no Baker's cyst, a possible ACL strain, and grade I chondromalacia patellae. It was also noted in the MRI report that the Veteran had knee pain following a motor vehicle accident in May 2007. Since the June 2007 VA examination report, there have been no findings or complaints of instability, subluxation, or frequent locking of the left knee. Specifically, an October 2007 VA treatment record states that the Veteran had been doing "lots of running" in the police academy and the knee was found to be "quite swollen" and difficult to examine. The treating physician thought there might be a tear of the medial meniscus or anterior cruciate ligament. An examination could not be continued due to the Veteran's complaints of pain. A steroid injection was administered. A November 2007 VA MRI report reflects that the Veteran had hurt his left knee two weeks earlier when running. When compared with the June 2007 MRI, it was found that his grade I chondromalacia remained unchanged, but that there was some mild increased signal intensity in the anterior cruciate ligament consistent with mucoid degeneration or a strain that was more apparent than in the previous MRI. It was also noted that a slight amount of fluid had developed in the deep infrapatellar bursa since the prior MRI and clinical correlation was advised. There was no evidence of a meniscal tear on either side. A March 2008 VA x-ray study of the left knee was normal. In April 2008, the Veteran was seen at VA with "intolerable" left knee pain which occurred intermittently and disrupted his ability to work. It was noted that he worked as a security guard at a local hospital and had to stand for long periods of time, which aggravated his pain. He stated that he had been unable to pass the police academy's running test and was short by 20 seconds. The Veteran was prescribed narcotic pain medication at this time. He also underwent a series of injections of a visco-elastic agent in the left knee in May 2008. In August 2008, the Veteran again reported ongoing left knee pain which had not resolved with treatment. An October 2008 VA examination report reflects that the Veteran used a knee brace intermittently but frequently. He was able to stand for 15 to 30 minutes and walk more than a quarter of a mile but less than a mile. The Veteran stated that he had been in a motor vehicle accident (MVA) in 2006 and struck the left knee against a dashboard, resulting in his being off of work for 30 days. He was also in an MVA in June 2007 and again struck his left knee against the dashboard, resulting in his being off of work for 20 days. In April 2008 he twisted his left knee while running and was off work for seven days. On examination, the Veteran's left knee had crepitus but did not exhibit instability or a meniscus abnormality. Range of motion of the left knee was from 0 to 130 degrees, with pain beginning at 130 degrees. There was no objective evidence of pain, and there were no additional limitations on repetitive use. In a December 2008 VA treatment record, the Veteran reported increased left knee pain with the cold weather. His pain had been responsive to medication but he was unable to tolerate vigorous activity. An April 2009 VA treatment record reflects that the Veteran had increased left knee pain after he had been pacing "for miles" in a hospital's hallways. The treating physician noted increased pain in the past few weeks "probably due to excessive pacing." There was no mention of instability, subluxation, or locking in this record. A September 2009 VA treatment record shows that the Veteran reported increased pain following a physical assessment for retraining that involved physical exercise. A September 2009 VA examination report reflects findings essentially identical to those recorded in the October 2008 VA examination report. The report notes the Veteran's history of two meniscal repair surgeries, but states that no instability was found on examination, no meniscus abnormality, and no other significant physical findings other than crepitus. The examiner found that the Veteran's left knee disability impacted his occupational functioning due to weakness and pain. An October 2009 VA examination report again reflects findings essentially identical to the October 2008 VA examination report, and is again negative for instability on physical examination. Range of motion of the left knee was from 0 to 130 degrees, with no additional limitations on repetitive testing. An August 2010 VA examination report, dated four months after the April 1, 2010 effective date of the rating reduction, likewise reflects that the Veteran's left knee did not exhibit instability on physical examination, and that no significant findings were made other than crepitus. His gait was also noted as normal. Range of motion of the left knee was again 0 to 130 degrees, with no additional limitation on repeat testing. There was also no objective evidence of pain. At the February 2012 Board hearing, the Veteran testified that he had pain and weakness of the left knee. When asked whether he had locking, popping, or stiffness, he responded in the affirmative and stated that it occurred just ten minutes earlier while he was sitting, although he did not specify which of these three symptoms occurred. He also stated that he could only stand on the knee for ten or fifteen minutes before it became painful. When asked how far he could walk, he responded that he "never just tried to walk." Based on the above evidence, the Board finds that the rating reduction was proper as there is no evidence of instability, subluxation, or locking of the left knee since the June 2007 VA examination report. Although the Veteran had ongoing left knee pain, the VA treatment records do not reflect complaints or findings of instability, subluxation, or locking of the left knee. Moreover, the VA examination reports dated in October 2008, September 2009, and October 2009 all reflect that the VA examiner found no instability of the left knee, and likewise did not note locking or subluxation. It is implausible that such symptoms would not be noted or observed by a VA staff physician if they had in fact been present. Rather, the lack of such notations is in keeping with the VA treatment records, which are likewise negative for instability or locking of the knee, and instead only reflect complaints of pain and some notations of swelling. There is no indication that the VA examinations performed in 2008, 2009, and 2010 were less thorough than the June 2007 VA examination in terms of assessing instability and other symptoms and functional impairment of the knee. Although diagnostic imaging was not performed, such imaging would not have affected the findings with regard to the actual working movements of the knee, which as a matter of logic could only be determined by physical examination. Significantly, the VA treatment records do not otherwise show instability, subluxation, or locking of the knee despite documenting other symptoms. Moreover, the notations of swelling and increased pain in the VA treatment records were generally contemporaneous with incidents that aggravated the Veteran's left knee symptoms. For example, the June 2007 VA examination was performed shortly after the Veteran reportedly injured his left knee in an MVA. The October 2007 VA treatment record stating that the Veteran's left knee was "quite swollen" and difficult to examine due to pain also notes that the Veteran had been doing "lots of running" and possibly re-tore his medial meniscus or anterior cruciate ligament. However, the November 2007 MRI did not yield a diagnosis of a torn meniscus or ACL. Similarly, when the Veteran reported "intolerable" left knee pain in the April 2008 VA treatment record, he had recently twisted it while running, according to the October 2008 VA examination report. The April 2009 and September 2009 VA treatment records reflecting increased left knee pain also attribute such pain to excessive pacing "for miles," and physical exercise as part of a retraining program, respectively. In sum, notwithstanding these exacerbations of left knee pain due to acute injuries or intensive use such as "lots of running" or "excessive pacing," the evidence does not show findings or complaints of instability of the left knee, subluxation of the left knee joint, or frequent episodes of locking and effusion. See 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2012) (providing that a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint). The November 2009 rating decision proposing the reduced evaluation of the Veteran's left knee instability from 20 percent to noncompensable was based on the VA examinations dated in 2008 and 2009 showing no instability of the left knee, and this finding was further confirmed by the August 2010 VA examination report, which is dated four months after the reduction went into effect on April 1, 2010. Thus, probative evidence after the rating reduction went into effect does not call into question its propriety but rather confirms it. Importantly, the Veteran's ongoing left knee pain is already compensated by the assignment of a 10 percent rating under DC 5010, which pertains to arthritis. See 38 C.F.R. § 4.71a. Diagnostic Code 5010 provides that traumatic arthritis is to be rated as degenerative arthritis under DC 5003. Id. Under DC 5003, degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See id. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. Id. In the absence of limitation of motion, a 20 percent rating is assigned for arthritis when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. If there are no incapacitating exacerbations, a 10 percent rating is assigned. Id. In application of Diagnostic Code 5003, the Court has held that "painful motion of a major joint . . . caused by degenerative arthritis, where the arthritis is established by X-ray, is deemed to be limited motion and entitled to a minimum 10-percent rating, per joint, combined under Diagnostic Code 5003, even though there is no actual limitation of motion." See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also 38 C.F.R. § 4.59. In this regard, with any form of arthritis, painful motion is an important factor of disability. 38 C.F.R. § 4.59. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. Id. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id.; see Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). In the recent case of Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011), the Court clarified its holding in Lichtenfels, explaining that the evaluation of painful motion as limited motion only applies to the evaluation of arthritis under DC 5003, as mandated by the express language in that provision, and only when limitation of motion is noncompensable under the applicable diagnostic code. The Court further explained that although painful motion is entitled to a minimum 10 percent rating under Lichtenfels and DC 5003, it does not follow that the maximum rating is warranted under the applicable diagnostic code pertaining to range of motion simply because pain is present throughout the range of motion. See id. Rather, the pain "must actually affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance' [under] 38 C.F.R. § 4.40 in order to constitute functional loss" warranting a higher rating. See id. at 43. With regard to limitation of the motion of the knee, under DC 5260, a 0 percent disability rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent disability rating is assigned when flexion is limited to 45 degrees; a 20 percent disability rating is assigned when flexion is limited to 30 degrees; and a 30 percent disability rating is assigned when flexion is limited to 15 degrees. See 38 C.F.R. § 4.71a. Under DC 5261, a 0 percent disability rating is assigned for extension limited to 5 degrees; a 10 percent disability rating is assigned for extension limited to 10 degrees; a 20 percent disability rating is assigned for extension limited to 15 degrees; a 30 percent disability rating is assigned for extension limited to 20 degrees; a 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See id. Normal range of motion of the knee is defined as extension to 0 degrees and flexion to 140 degrees. See id., Plate II. Separate ratings may be assigned for limitation of flexion and limitation of extension for disability of the same joint. See VAOPGCPREC 9-2004 (Sept. 17, 2004). The VA examination reports dated after June 2007 show range of motion of the left knee from 0 to 130 degrees, including after repeat testing. There is no evidence that the Veteran's pain effected the normal working movement of his left leg during the VA examinations. Thus, the criteria had not been met for a compensable rating based on limitation of motion of the knee under the DC's specific to range of motion, namely DC's 5260 and 5261. See id. Accordingly, the 10 percent rating currently assigned the Veteran's left knee arthritis, which has been in effect since September 2005, effectively compensates him for pain and painful motion. See 38 C.F.R. §§ 4.59; 4.71a, DC 5003. Whether a higher rating is warranted for these symptoms or functional impairment is not at issue here. Rather, the purpose of this discussion is to show that the reduction in the 20 rating for instability of the knee under DC 5257 is distinct from whether there has been a worsening in the Veteran's left knee pain, which is separately compensated under DC 5010. See VAOPGCPREC 9-98 (August 14, 1998) and VAOPGCPREC 23-97 (July 1, 1997) (both holding that separate ratings may be assigned for instability of the knee and arthritis of the knee with limited motion). In this case, the preponderance of the evidence clearly shows that the Veteran's instability of the left knee has improved to the point of not being present since June 2007, and certainly since the April 1, 2010 effective date of the reduction. The preponderance of the evidence also shows that the Veteran's left knee instability is not present under the ordinary conditions of life and work. As shown in the April 2008 VA treatment record, the Veteran worked as a security guard at a local hospital and had to stand for long periods of time, which aggravated his pain. Likewise, the October 2009 VA examination report reflects that the Veteran was employed full time with the "museum police." Although he subsequently discontinued working, an October 2009 VA treatment record, the August 2010 VA examination report, and a September 2010 VA mental health examination report all show that the Veteran was not working due to issues unrelated to his knee. Thus, the preponderance of the evidence, in the form of several VA examination reports reflecting affirmative findings of no instability of the knee on examination and a lack of mention of instability of the knee in numerous VA treatment records documenting ongoing knee pain, shows that the Veteran's left knee instability has resolved under the ordinary conditions of life and work. The Board has considered the Veteran's statements at the Board hearing and at VA examinations asserting that he has weakness of the left knee with popping or locking, that he could not stand for more than 15 to 30 minutes and could not walk for a quarter of a mile. However, these statements are inconsistent with the VA treatment records showing that the Veteran engaged in "lots of running" when enrolled in the police academy, that he was employed full time as a guard in which he stood for long periods of time, and that he paced "for miles" in a hospital's corridors, among other evidence. Thus, the Board does not find these statements credible and accords more weight to the objective clinical findings made on several VA examinations of the Veteran's knee, as the latter were documented by medical professionals with the expertise to assess accurately the Veteran's left knee disability. See Caluza, 7 Vet. App. at 511 (holding that when determining whether lay evidence is satisfactory, the Board may properly consider, among other things, its consistency with other evidence submitted on behalf of the Veteran); see also Madden, 125 F.3d at 1481 (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the medical issue in question). Whether the Veteran's left knee disability may have worsened by the time of the February 2012 hearing is not material to the issue of whether a rating reduction was warranted as of April 1, 2010 based on the preponderance of the evidence both prior to and several months after the effective date of the reduction. He has a pending claim for an increased rating for the left knee, and whether there has been a subsequent worsening will be addressed in that determination. Whether separate ratings may be warranted based on other disorders of the knee is also not contemplated by the present appeal, which is limited to the issue of whether the reduction in the 20 percent rating expressly based on moderate instability of the knee was proper. Accordingly, although the Veteran continues to experience significant left knee pain with concomitant limitations in functioning, for which a separate 10 percent rating is currently assigned, the preponderance of the evidence shows that his separately compensated moderate instability of the left knee has improved to the point of no longer being present since at least April 1, 2010. Therefore, the benefit-of-the-doubt rule does not apply, and the reduction of this separate rating was proper. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 3.105. ORDER Entitlement to service connection for chronic pain syndrome is denied. The reduction from a 20 percent rating to a noncompensable rating, effective April 1, 2010, for residuals of a partial left knee meniscectomy of the anterior horn lateral meniscus with instability was proper. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs