Citation Nr: 1626879 Decision Date: 07/06/16 Archive Date: 07/14/16 DOCKET NO. 10-17 571 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to an increased rating for right knee osteoarthritis, currently rated as 10 percent disabling. 2. Entitlement to a separate compensable disability rating for right knee lateral instability effective June 16, 2008. 3. Entitlement to an increased rating for left knee osteoarthritis, currently rated as 10 percent disabling. 4. Entitlement to a separate compensable disability rating for left knee lateral instability effective November 11, 2015. REPRESENTATION The Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Cherry, Counsel INTRODUCTION The Veteran served on active duty from March 1969 to March 1999. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. Jurisdiction of the claims file has been transferred to the VA RO in Manila, the Republic of the Philippines. In June 2010, the Veteran testified at a hearing held at the VA RO in San Diego, California, before a Decision Review Officer. A transcript of the hearing has been associated with the Veteran's electronic claims file. In October 2013, the Board remanded the claims for further development. In June 2016, the Veteran's representative waived initial consideration by the agency of original jurisdiction (AOJ) of additional evidence received since an April 2014 supplemental statement of the case. 38 C.F.R. § 20.1304(c) (2015). FINDINGS OF FACT 1. The weight of evidence shows that the right knee osteoarthritis is not manifested by flexion limited to 60 degrees or extension limited to 15 degrees. 2. The evidence is in equipoise as to whether since June 16, 2008, the Veteran has had slight lateral instability in the right knee. 3. The weight of evidence shows that the left knee osteoarthritis is not manifested by flexion limited to 60 degrees or extension limited to 15 degrees. 4. The weight of the evidence shows that prior to November 11, 2015, the Veteran had no lateral instability or recurrent subluxation in the left knee and that since November 11, 2015, the Veteran has had slight lateral instability in the left knee. CONCLUSIONS OF LAW 1. The service-connected right knee osteoarthritis does not meet the criteria for an evaluation in excess of 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261 (2015). 2. Resolving doubt in the Veteran's favor, right knee lateral instability has met the criteria for a separate evaluation of 10 percent effective June 16, 2008. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.71a, Diagnostic Code 5257 (2015). 3. The service-connected left knee osteoarthritis does not meet the criteria for an evaluation in excess of 10 percent. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.71a, Diagnostic Codes 5003, 5010, 5260, 5261. 4. Left knee lateral instability has met the criteria for a separate evaluation of 10 percent effective November 11, 2015. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The requirements of the 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in June 2008, February 2010, and November 2013 (pursuant to the October 2013 remand) of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by him, and notice of what part VA will attempt to obtain. In the June 2008 letter, VA notified the Veteran of how VA determines the disability rating and effective date. The claims were most recently readjudicated in the April 2014 supplemental statement of the case. VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording a VA examination. The RO obtained service and VA treatment records, to include VA treatment records obtained pursuant to the October 2013 remand. The Veteran was afforded four VA examinations, to include one in April 2014 pursuant to the October 2013 remand. The Board notes that the VA examinations provided sufficient clinical findings so as to allow the Board to evaluate the severity of his service-connected disabilities. Therefore, the Board finds that these examinations are adequate on which to base a decision. In light of the above and the readjudication of the claims in the April 2014 supplemental statement of the case, VA complied with the directives of the October 2013 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998). Governing law and regulations Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (2015). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2015). Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2015). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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. If the limitation of motion of the joint involved is noncompensable, a rating of 10 percent is applicable. 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, but with X-ray evidence of involvement of two or more major joints or two or more minor joint groups and occasional incapacitating exacerbations, a 20 percent evaluation is assigned. With X-ray evidence of involvement of two or more major joints or two or more minor joint groups, a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2015). With any form of arthritis, painful motion is an important factor. It is the intent of the rating schedule to recognize actually painful, unstable or mal-aligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. A compensable evaluation under Diagnostic Code 5003 and 38 C.F.R. § 4.59 (for painful motion) is in order where arthritis is established by X-ray findings and no compensable limitation of motion of the affected joint is demonstrated. See Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991); see also VAOPCGPREC 9-98 (Aug. 14, 1998). Where a compensable limitation of motion is demonstrated in the joint, the Lichtenfels rule is not applicable. For the purpose of rating disability due to arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2015). Leg flexion limited to 60, 45, 30, and 15 degrees warrant noncompensable, 10 percent, 20 percent, and 30 percent evaluations, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Leg extension limited to 5 degrees warrants a noncompensable evaluation, and extension limited to 10 degrees warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5261. VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59,990 (2004). The basis for the opinion is that the knee has separate planes of movement, each of which is potentially compensable. Id. Under the criteria for impairment of the knee other than ankylosis, 10, 20, and 30 percent evaluations are assigned for slight, moderate, and severe recurrent subluxation or instability, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Ankylosis is not shown in this case given that the Veteran is able to move both of his knees in all possible planes of movement. See 38 C.F.R. § 4.71a, Diagnostic Code 5256 (2015). Arthritis manifested by limitation of motion and instability of the knee are two separate disabilities, and a veteran may be rated separately for these symptoms. See VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997) (when a claimant has arthritis and is rated under instability of the knee, those two disabilities may be rated separately under 38 C.F.R. § 4.71a, Diagnostic Codes 5003 or 5010 and Diagnostic Code 5257). Under Diagnostic Code 5258, a 20 percent rating is warranted for a dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2015). Pursuant to Hart v. Mansfield, 21 Vet. App. 505 (2007), the Board must consider the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Analysis Right knee In a May 2000 rating decision, a RO granted service connection for right patellofemoral pain syndrome and assigned a 10 percent disability rating under Diagnostic Code 5010-5260. On June 16, 2008, the Veteran filed a claim for an increased rating. In the December 2008 rating decision, the RO reclassified the disability as osteoarthritis. A November 2015 private treatment record reflects that a right total knee replacement was recommended. While the Veteran may undergo a knee replacement in the future, the disability rating is based on the present level of disability and not a future level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Therefore, consideration under Diagnostic Code 5055 (knee replacement (prosthetic)) is not warranted. A July 2008 VA examination report reveals that the active range of motion in the right knee was flexion to 115 degrees and extension to five degrees. A February 2010 VA examination report reflects that the range of motion in the right knee was flexion to 120 degrees and extension to zero degrees. A January 2012 VA examination report shows that the range of motion in the right knee was flexion to 120 degrees and extension to zero degrees. An April 2014 VA examination report indicates that the range of motion in the right knee was flexion to 100 degrees and extension to five degrees. A November 2015 private treatment record reveals that flexion in the right knee was to 115 degrees. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The evidence shows that there is limitation of extension to a noncompensable degree (five degrees) on one examination whereas limitation of flexion is not the recognized noncompensable degree (60 degrees) on any examination. Therefore, the Board finds that the right knee osteoarthritis is more appropriately rated under Diagnostic Code 5261 (limitation of extension) than Diagnostic Code 5260 (limitation of flexion). As limitation of flexion is not to a compensable degree, the Veteran cannot be separately rated under both Diagnostic Code 5260 and Diagnostic Code 5261. The various VA examination reports do not reveal that there was limitation of extension on active-range-of-motion testing to 15 degrees. Thus, a rating in excess of 10 percent under limitation of extension is not warranted. The February 2010 VA examination report reveals that a June 2003 magnetic resonating imaging (MRI) scan of the right knee showed a horizontal tear of the posterior horn of the medial meniscus with osteochondral changes in the medial femoral condyle. The weight of the evidence, however, does not show a dislocated medial meniscus with frequent episodes of "locking," pain, and effusion into the joint. VA examination reports indicate that there are complaints of pain. As for effusion, however, the July 2008 VA examination report shows no effusion on physical examination. Similarly, at the February 2010 VA examination, there was no swelling noted and the McMurray test was negative. The November 2011 and April 2014 VA examination reports show no swelling after repetitive-motion testing. An November 2011 private treatment record reveals that the McMurray test was negative. Furthermore, there are no complaints of locking or swelling. Therefore, even though there is evidence of pain and a meniscus tear, Diagnostic Code 5258 is not applicable to the right knee claim in the absence of evidence of locking and effusion. Turning to whether a separate rating is warranted for recurrent subluxation or lateral instability under Diagnostic Code 5257, the July 2008 VA examination report reflects that there was pain in the right knee with both valgus and varus stresses and that there was + 1 laxity of the medial collateral ligament to valgus stress. The drawer sign was negative. At the February 2010 VA examination, the right knee was stable to stress testing with intact cruciate and collateral ligaments. The November 2011 and April 2014 VA examination reports reveal that there was no history of recurrent patellar subluxation or dislocation. The tests for anterior instability (Lachman test), posterior instability (posterior drawer test), and medial-lateral instability (valgus/varus pressure) were all normal. A private treatment record dated November 11, 2015, indicates that there was 1 + laxity in the right knee and tenderness to valgus and varus stress tests. Given the conflicting medical evidence on the presence of laxity, the evidence is in equipoise as to whether since June 16, 2008, the Veteran has had slight lateral instability in the right knee. As noted above, the limited medical evidence showing laxity does not reveal that there is 2 + or higher laxity in the right knee. Accordingly, a rating in excess of 10 percent under Diagnostic Code 5257 is not warranted. There is no evidence showing that the lateral instability began during the one-year period prior to June 16, 2008, the date of claim. Therefore, the lateral instability did not undergo an increase in disability during the one-year period prior to June 16, 2008. As to the holding in DeLuca v. Brown, 8 Vet. App. 202 (1995) and 38 C.F.R. §§ 4.40, 4.45, and 4.59, at the July 2008 VA examination there was moderate pain in the right knee with flexion beyond 60 degrees. The Veteran described increased pain, fatigue, and lack of endurance with repetitive motion of the right knee. The February 2010 VA examination report reflects that the Veteran had pain with prolonged walking but that there was no additional impairment due to flare-ups. He had normal strength, coordination, and endurance on repeated testing with no fatigability. At the January 2012 VA examination, the Veteran reported that during flare-ups his abilities to walk, to bend, to lift, to stand, and to climb and descend stairs are affected. Painful motion began at 115 degrees of flexion and flexion was limited to 115 degrees after repetitive-motion testing. The functional losses after repetitive use were less movement than normal and pain on movement. The April 2014 VA examination report reveals that painful motion began at 100 degrees of flexion. After repetitive-motion testing, flexion was limited to 100 degrees and extension was limited to five degrees. The functional losses after repetitive use were less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, and interference with sitting, standing, and weight-bearing. The examiner remarked that pain significantly limits functional ability during flare-ups or when the joint is used repeatedly over a period of time. The examiner added that the Veteran has very limited ambulation during flare-ups and that the range of motion in the right knee during flare-ups is flexion to 90 degrees and extension to 10 degrees. In light of the evidence showing that extension was not limited to more than 10 degrees during flare-ups, the Veteran's painful motion and other functional limitations are insufficient to warrant a rating in excess of 10 percent for right knee painful extension or separate compensable rating for painful flexion pursuant to DeLuca and 38 C.F.R. §§ 4.40, 4.45, and 4.59. As to a higher rating under Diagnostic Code 5257 under 38 C.F.R. §§ 4.40 and 4.45, the United States Court of Appeals for Veterans Claims (the Court) has held that where a diagnostic code is not predicated on a limited range of motion alone, such as with Diagnostic Code 5257, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Left knee In a May 2000 rating decision, a RO granted service connection for left patellofemoral pain syndrome and assigned a 10 percent disability rating under Diagnostic Code 5010-5260. On June 16, 2008, the Veteran filed a claim for an increased rating. In the December 2008 rating decision, the RO reclassified the disability as osteoarthritis. A November 2015 private treatment record reflects that a left total knee replacement was recommended. While the Veteran may undergo a knee replacement in the future, the disability rating is based on the present level of disability and not a future level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Thus, consideration under Diagnostic Code 5055 (knee replacement (prosthetic)) is not warranted. Moreover, unlike the right knee, there is no evidence of a meniscus tear and Diagnostic Code 5258 is not applicable. The July 2008 VA examination report reveals that the active range of motion in the left knee was flexion to 135 degrees and extension to five degrees. The February 2010 VA examination report reflects that the range of motion in the left knee was flexion to 120 degrees and extension to zero degrees. The January 2012 VA examination report shows that the range of motion in the left knee was flexion to 120 degrees and extension to zero degrees. The April 2014 VA examination report indicates that the range of motion in the left knee was flexion to 95 degrees and extension to five degrees. A November 2015 private treatment record reveals that flexion in the left knee was to 115 degrees. The evidence shows that there is limitation of extension to a noncompensable degree (five degrees) on one examination whereas limitation of flexion is not the recognized noncompensable degree (60 degrees) on any examination. Therefore, the Board finds that the left knee osteoarthritis is more appropriately rated under Diagnostic Code 5261 (limitation of extension) than Diagnostic Code 5260 (limitation of flexion). As limitation of flexion is not to a compensable degree, the Veteran cannot be separately rated under both Diagnostic Code 5260 and Diagnostic Code 5261. The various VA examination reports do not reveal that there was limitation of extension on active-range-of-motion testing to 15 degrees. Thus, a rating in excess of 10 percent under limitation of extension is not warranted. Turning to whether a separate rating is warranted for recurrent subluxation or lateral instability under Diagnostic Code 5257, the July 2008 VA examination report reflects that there was pain in the left knee with both valgus and varus stresses but that there was no ligament laxity. The drawer sign was negative. At the February 2010 VA examination, the left knee was stable to stress testing with intact cruciate and collateral ligaments. The November 2011 and April 2014 VA examination reports reveal that there was no history of recurrent patellar subluxation or dislocation. The tests for anterior instability (Lachman test), posterior instability (posterior drawer test), and medial-lateral instability (valgus/varus pressure) were all normal. A private treatment record dated November 11, 2015, indicates that there was 1 + laxity in the left knee and tenderness to valgus and varus stress tests. The weight of evidence shows that since November 11, 2015, the Veteran has had slight lateral instability in the left knee. The medical evidence prior to November 11, 2015, does not show any lateral instability. As noted above, the November 11, 2015, treatment record showing laxity does not reveal that there is 2 + or higher laxity in the left knee. Accordingly, a rating in excess of 10 percent under Diagnostic Code 5257 since November 11, 2015, is not warranted. As to the holding in DeLuca and 38 C.F.R. §§ 4.40, 4.45, and 4.59, at the July 2008 VA examination there was moderate pain in the left knee at flexion from 120 to 135 degrees. The Veteran described increased pain, fatigue, and lack of endurance with repetitive motion of the left knee. The February 2010 VA examination report reflects that the Veteran had pain with prolonged walking but that there was no additional impairment due to flare-ups. He had normal strength, coordination, and endurance on repeated testing with no fatigability. At the January 2012 VA examination, the Veteran reported that during flare-ups his abilities to walk, to bend, to lift, to stand, and to climb and descend stairs are affected. Painful motion began at 115 degrees of flexion and flexion was limited to 115 degrees after repetitive-motion testing. The functional losses after repetitive use were less movement than normal and pain on movement. The April 2014 VA examination report reveals that painful motion began at 100 degrees of flexion. After repetitive-motion testing, flexion was limited to 95 degrees and extension was limited to five degrees. The functional losses after repetitive use were less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, and interference with sitting, standing, and weight-bearing. The examiner remarked that pain significantly limits functional ability during flare-ups or when the joint is used repeatedly over a period of time. The examiner added that the Veteran has very limited ambulation during flare-ups and that the range of motion in the right knee during flare-ups is flexion to 90 degrees and extension to 10 degrees. In light of the evidence showing that extension was not limited to more than 10 degrees during flare-ups, the Veteran's painful motion and other functional limitations are insufficient to warrant a rating in excess of 10 percent for left knee painful extension or separate compensable rating for painful flexion pursuant to DeLuca and 38 C.F.R. §§ 4.40, 4.45, and 4.59. As to a higher rating under Diagnostic Code 5257 under 38 C.F.R. §§ 4.40 and 4.45, the Court has held that where a diagnostic code is not predicated on a limited range of motion alone, such as with Diagnostic Code 5257, the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not apply. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Extraschedular consideration The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate a veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether a veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected bilateral knee disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disabilities - painful limitation of flexion, painful limitation of extension, a right medial meniscus tear without locking and effusion, and bilateral lateral instability - with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. There is no evidence in the medical records of an exceptional or unusual clinical picture. The January 2012 VA examiner noted that the knee pains moderately affect the performance of manual work and that bending, lifting, and prolonged standing and ambulation are limited when a flare-up is present. The April 2014 VA examiner noted that the Veteran cannot tolerate jobs that would require prolonged walking, standing, and heavy weightlifting. While the bilateral knee disabilities resulted in some employment impairment, a high rating is recognition that the impairment makes it difficult to obtain or keep employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. TDIU considerations In denying the Veteran's claim for an increased rating, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the evidence of record does not show, and the Veteran has not asserted, that his knee disabilities rendered him unable to maintain substantially gainful employment. It appears that the Veteran is currently retired and neither he nor his representative has asserted that he had to retire because of the knee disabilities. Furthermore, in unappealed July 2012 and April 2015 rating decisions, the RO denied a claim of entitlement to TDIU. Accordingly, the Board concludes that the issue of TDIU has not been raised in this case. ORDER Entitlement to a disability rating in excess of 10 percent for right knee osteoarthritis is denied. A separate 10 percent disability rating, but not higher, since June 16, 2008, is granted for right knee lateral instability, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 10 percent for left knee osteoarthritis is denied. A separate 10 percent disability rating, but not higher, since November 11, 2015, is granted for left knee lateral instability, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs