Citation Nr: 1337378 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 07-14 236 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an increased rating for left knee disability, currently rated as 10 percent disabling. 2. Entitlement to an increased rating for right knee disability, currently rated as 10 percent disabling prior to December 17, 2009 and as 30 percent disabling thereafter. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from April 2002 to September 2002 and February 2003 to June 2004. This matter is on appeal from the Atlanta, Georgia Department of Veterans Affairs (VA) Regional Office (RO). In a September 2005 rating decision, the RO granted service connection for left knee and right knee disabilities, both assigned at 10 percent disabling from April 23, 2005. In November 2006, the Veteran filed an untimely notice of disagreement with the September 2005 rating decision, thus the Board interprets that correspondence as the claim for increase on appeal. In a July 2012 rating decision, the RO increased the initial 10 percent disability rating for right knee disability to 30 percent disabling from December 17, 2009. The Veteran was advised of the July 2012 rating decision, but did not express agreement with the decision or withdraw the appeal. Because the assigned 10 percent and 30 percent disability ratings are not the maximum benefits available for the service-connected right knee disability, this appeal continues for the respective increased rating periods. See AB v. Brown, 6 Vet. App. 35 (1993). In November 2010, the Veteran testified at a Board hearing held before the undersigned Veterans Law Judge in Atlanta, Georgia. The Veteran submitted a waiver of RO review of additional VA outpatient treatment records. The waiver, additional records, and a transcript of the hearing have been associated with the claims file. In February 2011 and May 2013 decisions, the Board, in pertinent part, remanded the claims for additional development and adjudicative action. The case has been returned to the Board for further appellate review. The Board apologizes for the delay in the adjudication of this case. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system and the "Virtual Benefits Management System (VBMS)" to ensure a total review of the evidence. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal has been obtained. 2. The service-connected left knee disability more closely approximates a manifestation of painful motion of a major joint due to arthritis, and no occasional incapacitating exacerbations, impairment of the tibia and fibula, or ankylosis. 3. The service-connected left knee disability more closely approximates a manifestation of compensable limitation of flexion to 45 degrees and no additional functional loss. 4. Prior to December 17, 2009, the service-connected right knee disability more closely approximates manifestations of painful motion of a major joint due to arthritis, noncompensable limitation of motion, and no occasional incapacitating exacerbations. 5. As of December 17, 2009, the service-connected right knee disability does not more closely approximate manifestations of ankylosis, impairment of the tibia and fibula, limitation of flexion to 30 degrees or higher, or additional functional loss. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating in excess of 10 percent for left knee disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes (DCs) 5010-5260 (2013). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for a separate 10 percent disability rating, and no higher, for limitation of flexion of the left knee have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5260 (2013). 3. The criteria for an increased disability rating for right knee disability in excess of 10 percent prior to December 17, 2009 and in excess of 30 percent thereafter have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.59, 4.71a, DCs 5010-5260 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the United States Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims on appeal. Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155 (West 2002). Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2 (2013); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2013). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2013); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When evaluating musculoskeletal disabilities based on limitation of motion, a higher rating must be considered where the evidence demonstrates additional functional loss due to pain, pursuant to 38 C.F.R. §§ 4.40 and 4.45. The diagnostic codes pertaining to range of motion do not subsume these provisions, and the rule against pyramiding does not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including use during flare-ups. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pursuant to the rating criteria for the knee, the Veteran's service-connected left knee disability is rated at 10 percent disabling as of April 23, 2005 for painful motion of a major joint with noncompensable limitation of motion. His service-connected right knee disability is rated at 10 percent disabling from April 23, 2005 to December 16, 2009 for painful motion of a major joint with noncompensable limitation of motion and at 30 percent disabling from December 17, 2009 to the present for flexion limited to 15 degrees. See 38 C.F.R. § 4.71a, DCs 5010-5260 (2013). DC 5010 provides that traumatic arthritis is to be rated as degenerative arthritis. Under DC 5003, degenerative arthritis is 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. 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. These 10 percent evaluations are combined, not added, under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. Similarly, VA's General Counsel has held that a compensable rating may be granted for arthritis by virtue of 38 C.F.R. § 4.59, which provides that arthritis productive of actually painful motion warrants at least the minimum compensable evaluation for the joint, i.e., 10 percent under DC 5260 or 5261 for the knee joint. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that pain actually sets in); 63 Fed. Reg. 56704 (1998). Normal range of motion of the knee is flexion to 140 degrees and extension to 0 degrees. See 38 C.F.R. § 4.71a, Plate II. Flexion of either leg limited to 45 degrees warrants a 10 percent rating; to 30 degrees warrants a 20 percent rating; and to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260. Extension of either leg limited to 10 degrees warrants a 10 percent rating; to 15 degrees warrants a 20 percent rating; to 20 degrees warrants a 30 percent rating; and to 30 degrees warrants a 40 percent rating. 38 C.F.R. § 4.71a, DC 5261. The Board notes that in a January 2010 rating decision, the RO granted a separate 10 percent evaluation for left knee instability and a separate 10 percent evaluation for right knee instability. 38 C.F.R. § 4.71a, DC 5257. Separate ratings may be assigned for arthritis under DC 5003 or DC 5010 for instability under DC 5257 without constituting pyramiding, as long as the separate rating is based on additional disability. See VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997). In this case, the currently-assigned disability ratings encompass the Veteran's ongoing complaints and treatment for pain in the left and right knees, as documented in VA outpatient treatment records, March 2007, December 2009, and June 2013 VA examination reports, January 2009 private pain evaluation report, and at the November 2010 Board hearing. See 38 C.F.R. § 4.59; DeLuca, 8 Vet. App. at 205; Mitchell, 25 Vet. App. at 32; VAOPGCPREC 9-98. The pertinent evidence of record shows that on VA examination in March 2007, the Veteran reported experiencing flare-ups of his knee pain while sleeping. The examiner noted the Veteran did not identify any other precipitating or alleviating factors, and the Veteran does not have any additional activity limitations from his flare-ups as they usually occur while in bed and he remains there for alleviation. On physical examination, the Veteran exhibited left knee flexion limited to 70 degrees with pain and full extension to 0 degrees, and right knee flexion limited to 90 degrees with pain and full extension to 0 degrees. On VA examination through QTC Medical Services (QTC) on December 17, 2009, the Veteran reported that, in the past 12 months, his knee disability has not resulted in any incapacitation. On physical examination, the Veteran exhibited left knee flexion limited to 36 degrees with pain and full extension to 0 degrees, and right knee flexion limited to 40 degrees with pain and full extension to 0 degrees. The examiner concluded that objective factors of tenderness upon palpation and moderate guarding on examination prevented accurate range of motion testing. As a result, the Board finds that the range of motion findings, as documented in the December 2009 VA QTC examination report are inadequate, thus are not competent and credible medical evidence and lack probative value for use in adjudicating these claims on appeal. Therefore, the competent and probative March 2007 VA examination report shows that the Veteran had limitation of motion of the left knee (70 degrees flexion and full extension) and the right knee (90 degrees flexion and full extension) that would be rated noncompensable under the regular schedular criteria for knee disabilities (DCs 5260 and 5261). As this limitation of motion is shown to be the result of arthritis and neither the Veteran nor the evidence of record indicates occasional incapacitating exacerbations due to the left knee and right knee disabilities, a rating in excess of the currently-assigned 10 percent disability ratings are not warranted under DC 5010 for the left knee for any period and for the right knee prior to December 17, 2009. Most recently and pursuant to the May 2013 Board remand instructions, the Veteran underwent a VA Disability Benefits Questionnaire (DBQ) examination of knee and lower leg conditions in June 2013. On physical examination, he exhibited left and right flexion limited to 45 degrees with pain and full extension to 0 degrees with no changes after repetitive-use testing, providing more evidence against this claim. With regard to the left knee, the competent and probative June 2013 VA DBQ examination report shows that the Veteran had limitation of flexion to 45 degrees, which meets the criteria for a compensable 10 percent rating under the regular schedular criteria for knee disabilities, specifically DC 5260. Thus, a separate 10 percent disability rating is warranted for limitation of flexion of the left knee. As limitation of flexion of the left knee is not shown to 30 degrees or below, a rating in excess of the currently-assigned 10 percent disability rating is not warranted under DC 5260 at any period. With regard to the right knee, as of December 17, 2009, the Veteran is assigned the maximum rating of 30 percent for limitation of flexion under DC 5260. The Board also finds that the competent and probative June 2013 VA DBQ examination report documents that limitation of extension is not shown to 30 degrees or higher, thus a rating in excess of the currently-assigned 30 percent disability rating is not warranted under 5261 as of December 17, 2009. With regard to both claims on appeal, the Board acknowledges the Veteran's reported history of symptomatology regarding his knees and that he is competent to report such symptoms because this requires only personal knowledge as it comes through ones senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board finds the Veteran's lay evidence is also credible as he provided consistent reports of symptomatology regarding the service-connected disabilities, which has provided the basis for the evaluations provided. The Veteran is not entitled to a rating in excess of 10 percent under 5010 for left knee disability at any time or right knee disability prior to December 17, 2009. He is already receiving at least the minimum compensable rating for the left knee and right knee based on painful motion due to arthritis during the respective appeal periods. See 38 C.F.R. §§ 4.59, 4.71a, DC 5010; VAOPGCPREC 9-98. Thus, to assign a higher rating based on arthritis under 5010, would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. The Board also considers whether a rating in excess of 10 percent for limitation of flexion of the left knee at any time and in excess of 30 percent for limitation of flexion of the right knee as of December 17, 2009 is warranted for additional functional impairment beyond the actual level of compensable limitation of flexion. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 205; Mitchell, 25 Vet. App. at 32. After a review of the evidentiary record, the Board finds that the Veteran's lay evidence, alone, is insufficient to support an increased rating in excess of the currently assigned evaluations for the respective periods. That is because his statements as to the symptoms he experiences are outweighed by the fact that such symptomatology has not resulted in additional impaired functioning. The Board acknowledges the Veteran's complaints of pain, aching, and stiffness at the June 2013 examination and the examiner's functional impairment of the Veteran's knees include less movement than normal, pain on movement, and disturbance of locomotion. Nonetheless, the Veteran remains able to use the knees in a somewhat normal manner and that examination report documents there is no evidence of impaired strength testing and no decrease in range of motion following repetitive motion testing. As such, there is no basis for a rating in excess of the 10 percent rating for the left knee at any time and of the 30 percent rating for the right knee as of December 17, 2009 for additional functional impairment. The problems the Veteran has have been considered within the evaluations provided. The Board has considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, with respect to the claims on appeal as required by the United States Court of Appeals for Veterans Claims (Court). See Schafrath, 1 Vet. App. at 594. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign a rating higher than the currently assigned disability ratings for the service-connected disabilities for any period on appeal. Specifically, the evidentiary record does not demonstrate findings of left or right knee joint ankylosis or impairment of the tibia and fibula. Thus, a higher rating for either knee disability is not warranted under DCs 5256 or 5262. See 38 C.F.R. § 4.71a. The record also does not show semilunar dislocated cartilage of the left knee to warrant a higher rating for the left knee under DC 5258. Id. In addition, the evidence, during any period, does not show disabilities resulting from the lower extremities, so another, separate, disability rating is not appropriate. The Board further acknowledges that review of the evidentiary record shows the Veteran was awarded Disability Insurance Benefits by the Social Security Administration (SSA) in March 2009. The Veteran was found not to have engaged in substantial gainful activity since September 2009 and the Veteran is unable to perform any past relevant work. The medical evidence established he had the following "severe" impairments: major depression, posttraumatic stress disorder (PTSD), and arthritis affecting the knees. While the determination of the SSA is probative evidence in favor of the Veteran's claims, SSA regulations and administrative decisions, including its factual conclusions regarding the date on which he became unable to work, are not necessarily binding on VA or the Board. See Colliet v. Derwinski, 1 Vet. App. 413, 417 (1991). The evidence of record raised the issue of a total disability rating based on individual unemployability (TDIU) and the RO denied entitlement to TDIU in March 2007 and June 2008 rating decisions, to include consideration of the service-connected knee disabilities. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Moreover, the Veteran informed the March 2007 VA examiner that he "quit his job at a childcare center primarily due to the side effects of the medications he takes for his PTSD." This statement would tend to provide evidence that it was not his knee that caused the problem. An extra-schedular rating may be provided in exceptional cases. 38 C.F.R. § 3.321 (2013). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. In this case, the schedular rating criteria contemplate the symptoms and impairment caused by the service-connected disabilities on appeal. The schedular rating criteria specifically provide for ratings based on the Veteran's reported left and right knee symptomatology, to include pain, aching, stiffness, and limitation of motion. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 5010-5260; see also DeLuca. There is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, referral for extra-schedular consideration for the service-connected disabilities on appeal is not required. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the 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). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. The Board finds that the VCAA notice requirements have been satisfied by December 2006 and February 2007 letters. In these letters, VA informed the Veteran that in order to substantiate a claim for an increased evaluation for his service-connected knee arthritis disabilities, the evidence must show that such disabilities have gotten worse. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed the Veteran it had to obtain any records held by any federal agency. These letters also informed the Veteran that on his behalf VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the letter told the Veteran that he could obtain private records himself and submit them to VA. The VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the December 2006 and February 2007 letters included the type of evidence necessary to establish a disability rating and effective date. Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the claims on appeal, the evidence of record includes VA outpatient treatment records, January 2009 private pain evaluation report, SSA records, statements from the Veteran, and VA examination reports dated March 2007, December 2009, and June 2013. The March 2007 and June 2013 VA examiners reviewed the Veteran's medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that these VA examination reports are probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As discussed above, the range of motion findings in the December 2009 VA examination report are inadequate, according to the examiner, thus the report lacks probative value. In November 2010, the Veteran testified at a video conference hearing held before the undersigned Veterans Law Judge. Any deficiencies in development were addressed in the subsequent Board remands, as discussed below. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding that the Veterans Law Judge who conducts a hearing fulfill the duty to fully explain the issues and the duty to suggest the submission of evidence that may have been overlooked). Pursuant to the Board's February 2011 remand instructions, the RO obtained and associated with the record outstanding SSA records and readjudicated the claims on appeal in a May 2012 Supplemental Statement of the Case (SSOC). Pursuant to the Board's May 2013 remand instructions, the RO was instructed to readjudicate the claims on appeal, to include an initial review of all the most recently associated evidence of record since April 2012 on the "Virtual VA" system. See 38 C.F.R. § 20.1304(c) (2013). Specifically, such evidence consisted of VA outpatient treatment records from January 2011 to January 2012. As noted above, these records document symptomatology, pain, aching, and stiffness, already contemplated in the currently assigned disability ratings. The RO also arranged for a VA examination in June 2013. That examination report reflects the examiner considered the evidence of record and the reported history of the Veteran, conducted a thorough examination of the Veteran, noting all findings necessary for proper adjudication of the matter, and explained the rationale for the opinion offered. The Board concludes that the June 2013 examination was adequate and substantially complied with the May 2013 remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). Thus, the Board finds there was substantial compliance with the May 2013 remand instructions and adjudication of the claims on appeal may proceed. See also Dyment v. West, 13 Vet. App. 141 (1999) (a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there is substantial compliance with the Board's remand instructions). For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims on appeal. The evidence of record provides sufficient information to adequately evaluate the claims, all obtainable evidence identified by the Veteran relative to the claims has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER An increased rating for left knee disability, currently rated as 10 percent disabling, is denied. A separate 10 percent disability rating, and no higher, for limitation of flexion of the left knee is granted, subject to the criteria applicable to the payment of monetary benefits. An increased rating for right knee disability, currently rated as 10 percent disabling prior to December 17, 2009 and as 30 percent disabling thereafter, is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs