Citation Nr: 1753090 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 10-01 628 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Fargo, North Dakota THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for right knee osteoarthritis. 2. Entitlement to an initial rating in excess of 20 percent for right knee laxity. 3. Entitlement to a higher initial rating for left knee osteoarthritis, rated at 10 percent prior to March 9, 2012 and at 30 percent beginning on May1, 2013. 4. Entitlement to an initial rating in excess of 20 percent for left knee laxity from February 3, 2009. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Baxter, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1970 to November 1971. This matter comes 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 Fargo, North Dakota, which, in pertinent part, granted service connection for left knee arthritis and assigned a 10 percent rating effective February 25, 2008, granted service connection for right knee osteoarthritis and assigned a 10 percent rating, effective February 25, 2008, and denied service connection for bilateral ankle disabilities and bilateral foot disabilities. A December 2009 rating decision granted a separate 10 percent rating for left knee laxity, effective March 12, 2009. In November 2010, the Veteran provided testimony at a video conference Board hearing before another Veterans Law Judge (VLJ). A transcript of the hearing is of record. In October 2017, the Veteran indicated that he did not want another hearing, provided an additional statement regarding the claim and requested that the case be considered on the evidence of record. When the case was before the Board in March 2012, the claims of entitlement to an initial rating in excess of 10 percent for right knee osteoarthritis, entitlement to an initial rating in excess of 10 percent for left knee osteoarthritis, entitlement to an initial rating in excess of 10 percent for left knee laxity, entitlement to service connection for a bilateral ankle disability and entitlement to service connection for a bilateral foot disability were remanded for additional development. In a May 2012 rating decision, a temporary evaluation of 100 percent for the left knee has been assigned effective March 9, 2012 based on surgical or other treatment necessitating convalescence. An evaluation of 100 percent is assigned from May 1, 2012. An evaluation of 30 percent is assigned from May 1, 2013. In December 2015, the Board remanded the claims of service connection for bilateral pes planus and left bunionectomy, as well as the claims for increased ratings for bilateral knee disorders, for additional development. Service connection for bilateral pes planus with left foot plantar fasciitis and residual left foot bunionectomy was granted by rating action in April 2016 and those issues are not in appellate status. In a rating decision in April 2016, the RO increased the Veteran's disability rating for left knee laxity to 20 percent effective February 3, 2016, and granted a separate 20 percent evaluation for laxity of the right knee also effective February 3, 2016. In November 2016, the Board remanded the claims for increased ratings for bilateral knee disorders, for additional development. In a rating decision in March 2017, the RO granted an earlier effective date as of February 2, 2009 for Veteran's disability rating for left knee laxity claim. To the extent that increased and separate ratings have been assigned for the bilateral knee disorders throughout the pendency of this appeal, because the increased ratings does not represent a grant of the maximum benefits allowable, the issues remain in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). The claims are now returned before the Board for appellate review. FINDINGS OF FACT 1. Throughout the period on appeal, the evidence of record shows that the Veteran's right knee disorder was manifested by pain, lost motion, and arthritis, but not flexion of the knee limited to at least 30 degrees or extension of the knee limited to at least 10 degrees even taking into account his complaints of pain and functional loss. 2. Throughout the period on appeal, the evidence of record shows that the Veteran's right knee disorder is manifested by moderate instability, but not severe instability, even when taking into account his complaints of pain and instability. 3. Prior to May 1, 2012, the evidence of record showed that the Veteran's left knee disorder is manifested by pain, lost motion, and arthritis, but not flexion of the knee limited to at least 30 degrees or extension of the knee limited to at least 10 degrees even taking into account his complaints of pain and functional loss. 4. For the period from May 1, 2013, forward the Veteran's total left knee replacement has been manifested by limitation of extension to 5 degrees, tenderness, grinding, aching, pain, lack of endurance, stiffness, weakness, swelling flare-ups and limitations on walking and standing; but not by ankylosis, malunion or nonunion of the tibia and fibula with marked knee disability, limitation of extension to 30 degrees or more, severe painful motion or weakness in the affected extremity. 5. The evidence of record shows that the Veteran's left knee disorder is manifested by moderate instability, but not severe instability, even when taking into account his complaints of pain and instability CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee osteoarthritis were not met any time during the appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5259-5003 (2016). 2. The criteria for an initial rating in excess of 20 percent for right knee instability are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 3.102, 3.159, 4.71a, Diagnostic Code 5257 (2016). 3. Prior to May 1, 2012, the criteria for an initial rating in excess of 10 percent for left knee osteoarthritis were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5259-5003 (2016). 4. Since May 1, 2013, the criteria for an initial rating greater than 30 percent for osteoarthritis of the left knee with status post left knee replacement are not met. 38 U.S.C.A. § 1155(West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5055 (2016). 5. The criteria for an initial in excess of 20 percent for left knee instability are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5257 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) Duties to Notify and Assist VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA) in June 2008 and January 2013letters. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 4.2 (2016). Concerning the duty to assist, the record reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran, including his service treatment records, post-service treatment records, private treatment records, and VA examination reports. The Veteran was provided a hearing before a VLJ in November 2010. As there is no allegation that either of the hearings provided to the Veteran were deficient in any way, further discussion of the adequacy of the hearing is not necessary. Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). These claims were remanded in November 2016 to obtain any relevant outstanding VA medical records and schedule the Veteran a new VA examination. In February 2017, records were obtained from Fargo VA Medical Center. Additionally, the Veteran was afforded a VA bilateral knee examination in February 2017. Accordingly, there has been substantial compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). II. Legal Criteria Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. When two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates such criteria. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function are expected in all instances. 38 C.F.R. § 4.21. In increased rating claims, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If the disability has undergone varying and distinct levels of severity throughout the entire time period that the increased rating claim has been pending, it is appropriate to apply staged ratings for each distinct time period. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses is to be avoided. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Although 38 C.F.R. §§ 4.1 and 4.2 stipulate that VA must view each disability "in relation to its history" to "accurately reflect the elements of disability present," a higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). For disabilities evaluated on the basis of limitation of motion, 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment, apply. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Range of motion ratings under 38 C.F.R. § 4.71a do not subsume 38 C.F.R. § 4.40, and 38 C.F.R. § 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use including during flare-ups. DeLuca, 8 Vet. App. at 205-06. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40 (2016)). Although Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991) held that painful motion is deemed limited motion warranting the minimum scheduler rating based on limited motion, even without actually limited motion, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011) it was held that pain throughout range of joint motion, which does not limit motion, does not warrant more than the minimum schedular rating. See Petitti v. McDonald, No. 13-3469, slip op. at 13 (U.S. Vet. App. October 28, 2015) (per curiam) (observing that Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) aptly stated that under 38 C.F.R. §§ 4.40 and 4.45 "pain in and of itself does not rise to the level of functional loss" and; rather, quoting 38 C.F.R. § 4.40 "pain may result in functional loss, but only if it limits the ability 'to perform the normal working movements of the body with normal excursion, strength, speed, coordination[,] or endurance.'"). The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran's left total knee arthroplasty is evaluated under DC 5055, knee replacement (prosthesis). Under DC 5055, for a prosthetic knee replacement, a 100 percent disability rating is assigned for one year following implantation of the prosthesis. The minimum rating that may be assigned thereafter is 30 percent. For chronic residuals consisting of severe, painful motion or weakness in the affected extremity, a 60 percent rating is assigned. Intermediate degrees of residual weakness, pain or limitation of motion are to be rated by analogy to DC 5256 (ankylosis of the knee), 5261 or 5262 (limitation of flexion or extension of the leg). 38 C.F.R. § 4.71a (2016). Under 38 C.F.R. § 4.71a DC 5010, traumatic arthritis, substantiated by X-ray findings, is rated on limitation of motion of affected parts, as degenerative arthritis under 38 C.F.R. § 4.71a, DC 5003. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate DCs, a 10 percent evaluation is assignable each such major joint or group of minor joints affected by limitation of motion, to be 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. 38 C.F.R. § 4.71a, DC 5003. A compensable rating for arthritis can be awarded on the basis of X-ray findings and painful motion under 38 C.F.R. § 4.59 even without motion being compensable limited under the rating schedule. VAOPGCPREC 9-98 (1998). Because DC 5003 requires that "satisfactory of evidence of pain" be "objectively confirmed," a Veteran's testimony, alone, is not enough. For the minimum compensable rating for motion which is painful but not actually limited to a compensable degree, a claimant's bare statement is not satisfactory evidence of painful motion. Petitti v. McDonald, No. 13-3469, slip op. (U.S. Vet. App. October 28, 2015) (per curiam) (holding that painful motion may be "objectively confirmed" by either a clinician, including a claimant's assertion of painful joints that is confirmed by a clinician's statement there is a history of "recurrent" joint pain or a layperson who witnessed the Veteran experience difficulty walking, standing, or sitting, or display a facial expression, such as wincing, indicative of pain). In other words, satisfactory lay evidence of painful motion also includes lay descriptions from other than the Veteran of painful motion; lay observations of witnesses of painful motion, lay statements of observed visible behavior or facial expressions during painful motion, as well as lay reports of difficulty walking, standing, sitting, or undertaking other activity. Petitti v. McDonald, No. 13-3469, slip op. (U.S. Vet. App. October 28, 2015) (per curiam). Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). 38 C.F.R. § 4.71a, DC 5256 provides for a 30 percent rating (and even higher ratings) for ankylosis of a knee in a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. Ankylosis is immobility and consolidation of a joint due to disease, injury, surgical procedure. Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). According to DC 5257, which rates impairment resulting from other impairment of the knee, to include recurrent subluxation or lateral instability, a 10 percent rating is assigned with evidence of slight recurrent subluxation or lateral instability of a knee; 20 percent rating is assigned with evidence of moderate recurrent subluxation or lateral instability; and 30 percent rating is assigned with evidence of severe recurrent subluxation or lateral instability. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain is inapplicable to ratings under DC 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). 38 C.F.R. § 4.71a , DC 5258 provides for a 20 percent rating for a dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the knee joint. 38 C.F.R. § 4.71a, DC 5259 provides for a 10 percent rating for symptomatic residuals of removal of a semilunar cartilage. Ratings under DC 5259 require consideration of 38 C.F.R. §§ 4.40 and 4.45 because removal of a semilunar cartilage may result in complications producing loss of motion. VAOGCPREC 9-98. The words "slight," "moderate." and "severe" as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. Thus, if there are symptoms as a residual of a meniscectomy (partial removal of semilunar cartilage in the knee) which are subluxation or instability, or limitation of motion, separate ratings for such manifestation may be assigned. However, 38 C.F.R. § 4.71a, DC 5258 provides for a 20 percent rating for a dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. A locked knee is "a condition in which the knee lacks full extension and flexion because of internal derangement, usually the result of a torn meniscus." http://medical-dictionary.thefreedictionary.com/locked+knee. Thus, locking encompasses limitation of motion such that assigning additional and separate rating for limited knee flexion or extension under, respectively, DCs 5260 or 5261 would constitute pyramiding under 38 C.F.R. § 4.14 and, as such, is prohibited. See VAOPGCPRECs 23-99 and 9-93. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a non-compensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. Under DC 5261, a non-compensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a, DC 5262 provides for evaluation of impairment of the tibia and fibula. With malunion and slight knee or ankle disability a 10 percent rating is warranted; with moderate knee or ankle disability a 20 percent rating is warranted; and with marked knee or ankle disability a 30 percent rating is warranted. For a 40 percent rating there must be nonunion of the tibia or fibula with loose motion, requiring a brace. 38 C.F.R. § 4.71a, DC 5263 provides for a 10 percent rating for genu recurvatum, when acquired, traumatic, with weakness and insecurity in weight-bearing which is objectively demonstrated. Separate disability 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. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Compensating a claimant for separate functional impairment under DC 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997) held that arthritis and instability of the same knee may be rated separately under DCs 5003 and 5257. Subsequently, VAOPGCPREC 9-98 further explained that if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also X-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. See also VAOPGCPREC 9-04 (holding that separate ratings under DC 5260 for limitation of flexion of the knee and DC 5261 for limitation of extension of the knee may be assigned). Factual Background A. Right Knee The Veteran was afforded a VA examination in November 2008. The Veteran reported that he had problems with his right knee. He indicated that his right knee would swell. He reported that he had gout and when the swelling occurred, he used coclchicines. The Veteran indicated that he was able to use a self-propelled lawnmower and was able to use a trimmer. The examiner indicated that the claims file was reviewed. The examiner noted that the Veteran was fully functional in all activities at his job. Upon evaluation, the examiner noted that the Veteran's right knee revealed no calor, rubor, or effusion. There was no instability of the collateral ligaments medial or lateral and any cruciate instability or insufficiency. The Veteran's gait was normal with no limping. The Veteran's right knee range of motion was extensions from 0 degrees and flexion to 120 degrees with painful motion. There was evidence of pain with exercise. However, there was no incoordination or fatigability with exercise. The right knee x-ray report revealed degenerative changes. The examiner noted that the x-ray showed evidence of osteoarthritis. A February 2009 VA orthopedic note indicated that the Veteran's right knee examination was normal. In March 2009, the Veteran was afforded another VA general medical examination. The examiner noted that there was no calor, rubor, or effusion of the right knee. There was no instability of the collateral ligaments medical or lateral and any cruciate instability or insufficiency. There was no swelling or tenderness of the pes anserine, superficial infrapatellar, or patellar. The Veteran's range of motion in his right knee was measured at 0 degrees of extension and 108 degrees of flexion, with pain but he could get to 111 degrees. There was no evidence of incoordination, excessive fatigability, or weakened movement. In May 2012, the Veteran was afforded a knee VA examination. Upon examination, the examiner indicated that the Veteran's right knee range of motion revealed a flexion to 105 degrees and an extension to 0 degrees. There was no objective evidence of pain. The examiner noted that there was no subluxation of his right knee and he had no lateral instability. The x-ray of the right knee showed arthritis. The examiner diagnosed the Veteran with DJD of the right knee. A January 2016 VA nursing note indicated that the Veteran had occasional gout in his right knee. In February 2016, the Veteran was afforded another VA knee examination. The Veteran reported that he exercised regularly to strengthen both of his knees. He indicated that he rode a stationary bike 30-60 minutes daily as well as exercised on an elliptical machine for 20 minutes 4-5 times a week. The Veteran did not report any flare-ups. The examiner noted that the claims file was reviewed. Upon examination, the examiner indicated that his left knee range of motion was measured at 0 degrees for extension and 105 degrees for flexion, with evidence of crepitus. There was no functional loss after repetition testing. There was no evidence of pain on weight bearing. There was no objective evidence of any localized tenderness or pain on palpation of the joint or associated soft tissue. There was no ankylosis, no recurrent subluxation, and no effusion. The examiner noted that the Veteran had moderate lateral instability. The Veteran's anterior, posterior, and lateral instability were normal. However, his medial instability was 2+ (5-10 millimeters). The examiner indicated that the Veteran did not use any assistive devices. In February 2017, the Veteran was afforded another knee examination. The Veteran reported that he was not confident in his right knee in stressful situations. The Veteran complained of recurring pain in his right knee on the lateral side. He indicated that the pain was brought on when his knee was in the bent position and was improved by being placed in a neutral position. He denied any locking of his knee. He reported that he had never collapsed but he felt it was unstable. He reported that his right knee condition affected his activities that required prolonged walks. Upon examination, the examiner measured his range of motion with repetitive motion at 0 degrees for extension and 90 degrees for flexion, without evidence of pain, incoordination, or fatigability. There was no evidence of pain on weight bearing. There was no objective evidence of any localized tenderness, or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. The examiner indicated that he was unable without mere speculation able to answer if pain, weakness, fatigability, or incoordination significantly limited the functional ability with repeated use over a period of time. There was no ankylosis, no recurrent subluxation, and no effusion. The examiner noted that the Veteran had moderate lateral instability. The Veteran's anterior, posterior, and lateral instability were normal. However, his medial instability was 2+ (5-10 millimeters). The examiner noted that the right knee pre-exercise stopped flexion at 90 degrees noting, "it is where it begins to cause pain." With considering that into functional loss, at 90 degrees flexion, the right knee pain would inhibit activities that require a seated position while bearing weight on the right knee. There was no further loss of function with the range of motion testing of the right knee. There were no suspected or observed additional losses of function due to flare-ups of the right knee condition. He further noted in regards to concerning non-weight bearing pain, there was no evidence of pain. In regards to, concerning weight-bearing pain evident by the Veteran's gait. However, he noted that the Veteran was limping post examination, but it was a result of a right ankle condition. Right Knee Osteoarthritis The Veteran contends that his right knee osteoarthritis should be rated at 20 percent disabling. Here, the 10 percent rating for the service-connected right knee disorder has been assigned on the basis traumatic arthritis, rated as degenerative arthritis, with functional impairment due to painful motion and limited motion under DC 5003/5010. After careful review of the record, the Board finds that the evidence of record does not support assigning an evaluation in excess of 10 percent for the right knee disability, pursuant to DCs 5003 and 5010, because no compensable degree of limitation of motion in extension or flexion has been demonstrated on objective testing from February 2008 to present. In other words, the board finds that the Veteran's right knee range of motion was never limited to a compensable degree in either extension (to 10 degrees) or flexion (45 degrees). Here, at worst the Veteran had a 0 to 90 degrees function with 90 to 0 degrees extension reported in the February 2017 VA examination report. Even considering the Veteran's report of pain with flexion and extension in the various VA examinations report, objective testing did not reveal evidence of functional loss as per DeLuca. As noted above, pain alone is not a sufficient basis to warrant an additional rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell, 25 Vet. App. at 38-43. As such, there is not a basis for a rating for a compensable rating based solely on limitation of extension pursuant to Diagnostic Code 5261. As such, a separate or higher rating under either DC 5260 or 5261 is not warranted for this time period. Further, the Veteran is not entitled to a 20 percent disability rating during this time period under DC 5003, as X-ray evidence of service-connected arthritis in two or more major joints of the right leg, and incapacitating exacerbations, have not been demonstrated. The Board has considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.10, 4.40, and 4.45 would warrant a higher rating. See Spurgeon v. Brown, 10 Vet. App. 194 (1997); and DeLuca. While evidence shows that the Veteran had symptoms, e.g., pain, during right knee motion, as well as other symptoms upon activity, there is a lack of objective medical evidence showing that the Veteran suffered any measurable functional loss and/or limitation of motion during flare-ups or with normal use. Here, the Veteran has been able to exercise regularly; he has reported that he is able to exercise 4-5 times a week. Accordingly, even with consideration of the doctrine of the favorable resolution of doubt, an initial rating in excess of 10 percent for the service-connected right knee disability is not warranted. Therefore, the Board finds that the preponderance of evidence is against assigning a rating in excess of 10 percent for osteoarthritis of the right knee is not warranted. See 38 C.F.R. § 4.71(a), Diagnostic Code 5003 (2016); see also 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Right Knee Laxity As to Diagnostic Code 5257, the February 2016 VA examination report indicates that the Veteran has moderate instability of his right knee with 2+ (5-10 millimeters) medical instability on testing. In this case, the Veteran receives 20 percent for right knee laxity, effective February 3, 2016. The lay evidence of record shows that the Veteran has complained of instability and lack of confidence in his right knee, which he is competent to report. Jandreau v, 492 F.3d 1372. However, the Veteran's statements do not address the frequency or severity of his instability during this period, instead simply establishing its presence as a symptom. The November 2008, March 2009, and March 2012 VA examiners note that there was no evidence of right knee moderate instability with 2+ (5-10 millimeters) medial instability on testing. There is no evidence that the VA examination reports are not competent or credible, and therefore they are entitled to significant probative weight as to the severity of the Veteran's right knee medial instability. There is no medical evidence of that the Veteran has severe instability or severe recurrent subluxation. Here, all VA examination reports indicate the Veteran does not have any recurrent subluxation. Therefore, entitlement to an evaluation in excess of 20 percent for right knee laxity is not warranted. Based on the lay and medical evidence of record, the Board finds that an increased rating in excess of 20 percent for right knee lateral instability is not warranted. While it is clear that the Veteran has experienced right knee instability during this period, the medical evidence has only indicated that the Veteran's instability, when noted to be present, is moderate in nature, which is consistent with the level of severity contemplated by a 20 percent rating for "moderate" instability. There is no indication in the medical or lay evidence that the Veteran's instability during this period was severe in nature. As such, the Board finds that the preponderance of the evidence is against an initial rating in excess of 20 percent for right knee medial instability. The Board further notes that symptomatic removal of semilunar cartilage has not been shown in the record. (Diagnostic Code 5259). Additionally, the medical evidence has not demonstrated any ankylosis (Diagnostic Code 5256), impairment of the tibia and fibula (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263). Therefore, these diagnostic codes are inapplicable in this case. The Board has considered whether there is any other basis for granting a higher rating for the right knee disability, either based upon the limitation of motion, or the instability, or for any other symptom of the disability, for any portion of the period on appeal, but has found none. The Veteran's claim for a rating increase, therefore, is denied. The preponderance of the evidence is also against an increased rating in excess of 20 percent under Diagnostic Code 5257. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. B. Left Knee A January 2008 statement from the Veteran's mother indicated that the Veteran did not suffer knee pain prior to service. She wrote that the Veteran's knee pain was so severe that it prevented him from working. She indicated that even standing for a couple of minutes had been a huge problem for the Veteran. A February 2008 VA primary care nursing note documented that the Veteran complained of arthritic pain in his knees. The Veteran described the pain in the left knee as continuous with dull and sharp arthropathy. The Veteran was afforded a VA examination in November 2008. The Veteran reported that he had problems with his left knee. He indicated that his left knee would swell. He reported that he had gout and when the swelling occurred, he used coclchicines. The Veteran indicated that he was able to use a self-propelled lawnmower and was able to use a trimmer. The examiner indicated that the claims file was reviewed. The examiner noted that the Veteran was fully functional in all activities at his job. Upon evaluation, the examiner noted tenderness and crepitation on his left knee on the lateral aspect of the patella, which likely indicated some plica synovialis. The examiner further noted that the cruciates, medial collateral ligaments, and lateral collateral ligaments appeared intact. The examiner indicated that there was no effusion, calor, or rubor. There were 3 scars on the medial aspect of the left knee, one 8 cm, one 6 cm, and one 4.5cm. All the Veteran's scars were healed, with no palpable tenderness, tissue loss, adherence, or any keloid formation. The examiner noted that the Veteran's gait was normal with no limping. The Veteran's left knee range of motion was from 4 degrees to 98 degrees after exercise. There was evidence of pain with exercise; however, there was no incoordination or fatigability with exercise. The left knee x-ray report revealed degenerative changes. The examiner diagnosed the Veteran with arthritis of the left knee, status post-surgery. A February 2009 VA orthopedic note indicated that the Veteran's left knee x-ray showed upper tibial osteotomy with plate and screw fixation with grade 2 out of 4 arthritis changed and mild to moderate narrowing of the medial side of the left knee. Notably, a VA orthopedic surgery consult note indicated that the Veteran had a mild to moderate positive Lachman's test. A September 2009 VA Orthopedic note indicated that the Veteran's left knee had a moderate positive Lachman's test. The examiner indicated that the Veteran had a grade 2 effusion and medial joint line pain with palpation A March 2009 private MRI report indicated that the Veteran had a torn ACL. The examiner noted that there was some ACL laxity in the Veteran's left knee. A March 2009 VA rheumatology report documented that Veteran rated his left knee pain at a level 7. In March 2009, the Veteran was afforded a VA general medical examination. The examiner noted that the Veteran's March 09, 2009 MRI showed a proximal to mid-portion ACL tear. The Veteran was given an ACL brace for his left knee, was referred to physical therapy, and no surgery was recommended. Upon examination, the examiner indicated that there was no effusion, calor, or rubor. There was no instability of the collateral ligaments, medical or lateral, and no cruciate instability or insufficiency. There was some tenderness on the lateral aspect of the patella. The medial and lateral collateral ligaments were tight. There was no swelling or tenderness of the pes anserine, superficial infrapatellar or prepatellar bursas. The Veteran's range of motion in his left knee was a flexion of 14 degrees with pain at 90 degrees and he could continue to 108 degrees before and after exercise. There was no evidence of incoordination, excessive fatigability, or weakened movement. A September 2009 VA rheumatology note indicated that the Veteran's left knee had a mechanical alignment problems which caused knee pain on weight bearing. A November 2009 nephrology-nursing note documented that Veteran just had knee surgery. The Veteran indicated that he was doing well. He reported that he went swimming for 3.5 miles each week as well as did strength training 2-3 times per week. A May 2010 VA primary care note documented that the Veteran's left knee showed an increased warmth relative to his right knee, with no crepitus appreciated. A June 2010 VA rheumatology note indicated the Veteran complained of pain in his left knee. The Veteran reported that at rest, his left knee pain was 8 out of 10 and with activity, his left knee pain was 10 out of 10. A November 2010 VA rheumatology note documented that Veteran reported knee pain. He reported left knee pain with no gout flare-ups. The Veteran rated his pain at a level five. A March 2012 private medical document indicated that the Veteran had his left knee replacement. In May 2012, the Veteran was afforded a knee VA examination. The Veteran reported that when he had flare-ups, his left knee would swell and had warmth in his knee since his recent surgery. Upon examination, the examiner indicated that the Veteran's left knee range of motion had a flexion of 105 degrees and an extension of 0 degrees. There was no objective evidence of pain. The Veteran was able to perform post-test ROM. The examiner noted that there was some recurrent subluxation of his left knee and he had some anterior instability and slight lateral instability. The examiner indicated that the Veteran occasionally used a cane. The x-ray of the left knee showed arthritis. The examiner diagnosed the Veteran with degenerative joint disease (DJD) of the left knee. In February 2016, the Veteran was afforded another VA knee examination. The Veteran reported that he exercises regularly to strengthen both of his knees. He indicated that he rode a stationary bike 30-60 minutes daily as well as exercised on an elliptical machine for 20 minutes 4-5 times a week. The Veteran did not report any flare-ups. The examiner noted that the claims file was reviewed. Upon examination, the examiner indicated that his right knee range of motion was from 0 degrees to 115 degrees for flexion and an extension of 115 degrees to 0 degrees. There was no additional functional loss after repetition testing. There was no evidence of pain on weight bearing. There was no objective evidence of any localized tenderness or pain on palpation of the joint or associated soft tissue. There was no ankylosis, no recurrent subluxation, and no effusion. The examiner noted that the Veteran had moderate lateral instability. The Veteran's anterior, posterior, and lateral instability were normal. However, his medial instability was 2+ (5-10 millimeters). The examiner indicated that the Veteran had a left total knee replacement in March 2012. He indicated that the residuals from the surgery included intermediate degree of residual weakness, pain, or limitation of motion. The examiner commented on the imaging studies of the Veteran's left knee. He commented that the current prosthetic elements remained in normal position and alignment and there were no significant joint effusion or soft tissue swelling. The examiner indicated that the Veteran did not use any assistive devices. In February 2017, the Veteran was afforded another VA knee examination. The Veteran reported that he was not taking any pain medication for his knee pain because he was status post renal transplant. When questioned specifically in regards to his left knee the Veteran stated that his knee is, "basically fine" with a little bit of pain on the lateral aspect of the joint. He indicated that when he was very active his knee felt fatigued. The Veteran reported that activities that required kneeling affected his knee. He denied locking or collapsing of his left knee. He also denied any current use of braces, splints, or prosthetic devices for his left knee condition. Upon examination, the examiner measured his range of motion with repetitive motion at 5 degrees for extension and 115 degrees for flexion, without evidence of pain, incoordination, or fatigability. There was no evidence of pain on weight bearing. There was no objective evidence of any localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. The examiner indicated that he was unable without mere speculation able to answer if pain, weakness, fatigability, or incoordination significantly limited the functional ability with repeated use over a period of time. There was no ankylosis, no recurrent subluxation, and no effusion. The examiner noted that the Veteran had moderate lateral instability. The Veteran's anterior, posterior, and lateral instability were normal. However, his medial instability was 2+ (5-10 millimeters). The examiner indicated that the Veteran had a left total knee replacement in March 2012. He indicated that the residuals from the surgery included intermediate degree of residual weakness, pain, or limitation of motion. The examiner further noted in an addendum note that the left knee was exercised by performing three repetitions of flexion/extension. There was no evidence of pain with the exercised the left knee. There was no evidence of excessive fatigability with the exercised left knee. There was no evidence of incoordination with the exercised left knee. There was no further loss and function with the exercised left knee. There were no suspected or observed additional losses of function due to flare-ups of the left knee condition. Left Knee Osteoarthritis Because the Veteran has been assigned temporary total disability ratings following left total knee replacement surgery of 100 percent for convalescence under 38 C.F.R. § 4.30 from May 1, 2012 to May 30, 2013, the schedular rating during that time period is not at issue in this appeal. Rather, the issues before the Board are entitlement to a rating in excess of 10 percent for the periods from February 25, 2008, to May 1, 2012, and a rating in excess of 30 percent from May 1, 2013, to present. The Veteran contends that his left knee should be rated at 40 percent disabling since 2008. Here, the 10 percent rating for the service-connected left knee disorder has been assigned on the basis traumatic arthritis, rated as degenerative arthritis, with functional impairment due to painful motion and limited motion under Diagnostic Codes 5003/5010 from February 25, 2008 to May 1, 2012 and 30 percent disabling from May 1, 2013 and thereafter. Ten percent from February 25, 2008, to May 1, 2012. After careful review of the record, the Board finds that the evidence of record does not support assigning an evaluation in excess of 10 percent for the left knee disability, because no compensable degree of limitation of motion in extension or flexion has been demonstrated on objective testing from February 25, 2008, to May 1, 2012. The Board finds that the Veteran's left knee range of motion was never limited to a compensable degree in either extension (to 10 degrees) or flexion (45 degrees). As such, a separate or higher rating under either DC 5260 or 5261 is not warranted for this time period. Further, the Veteran is not entitled to a 20 percent disability rating during this time period under DC 5003, as X-ray evidence of service-connected arthritis in two or more major joints of the left leg, and incapacitating exacerbations, have not been demonstrated. Moreover, there was no objective evidence of ankylosis, malunion or nonunion of the tibia or fibula, or genu recurvatum with weakness and insecurity on weight-bearing. Likewise, during this time period the Veteran had not had a meniscectomy. See 38 C.F.R. § 4.71a , DC 5259. Thirty percent since May 1, 2013 and thereafter To warrant the next higher schedular rating of 60 percent for the left knee replacement under DC 5055 there must be severe motion of the knee or weakness in the lower extremity. The weight of the evidence, including the recent VA examinations in February 2016 and 201, demonstrates that the Veteran does not have either severe painful left knee motion or weakness of the left leg. At the time of the February 2017 examination, the Veteran reported that his left knee was basically fine with a little bit of pain on the lateral aspect of the joint. To warrant a rating greater than the current 30 percent under DC 5256, ankylosis, there must be actual ankylosis in a position of flexion between 10 degrees and 20 degrees. While DC 5055 provides that such a rating is done analogously, the fact that the Veteran does not have any ankylosis leads to the conclusion that a rating in excess of 30 percent under DC 5256 is not warranted. To warrant a rating greater than the current 30 percent under DC 5261, limitation of extension, there must be actual extension, which is limited to 30 degrees. Again, while DC 5055 provides that such a rating be done analogously, the fact that the Veteran only has a limitation of extension to 5 degrees, which lead to the conclusion that a rating in excess of 30 percent under DC 5261 is not warranted. Similarly, to warrant a rating greater than the current 30 percent under DC 5262, impairment of the tibia and fibula, there must be more than findings indicating malunion; rather, the findings must analogously equate to nonunion with loose motion requiring a brace. Here, while the Veteran has occasionally used a brace the clinical findings do not approximate nonunion of either the tibia or the fibula. While he has had attacks of gout that have affected his left knee, he is not service-connected for gout. Thus, DC 5262 may not be considered for the purposes of a higher rating for tibial impairment. Also, the Veteran now has postoperative left knee scarring due to his multiple surgical procedures. If productive of disability, a separate rating is warranted for such scarring. See generally Esteban v. Brown, 6 Vet. App. 259, 261 (1994) ("[C]onditions are to be rated separately unless they constitute the 'same disability' or the 'same manifestation' under 38 C.F.R. § 4.14 (1994)"). The objective clinical evidence shows that the scarring is not painful or unstable and there is no evidence that it involves an area of less than 39 square centimeters, however. Moreover, the Veteran has never complained of any permanent residual symptoms relative to his scarring. Thus, the residual postoperative scarring does not warrant a separate compensable disability rating. See 38 C.F.R. § 4.115, DCs 7801-7805. Accordingly, even with consideration of the favorable resolution of reasonable doubt, a rating greater than 30 percent is not warranted since May 1, 2013. Left Knee Laxity As to Diagnostic Code 5257, a February 2009 VA orthopedic consult indicates that the Veteran had mild to moderate positive Lachman's test. Also, the February 2016 VA examination report indicates that the Veteran has moderate instability of his right knee with 2+ (5-10 millimeters) medical instability on testing. In this case, the Veteran receives 30 percent for left knee laxity, effective February 2, 2009. The lay evidence of record shows that the Veteran has complained of instability and lack of confidence in his left knee, which he is competent to report. Jandreau v, 492 F.3d 1372. However, the Veteran's statements do not address the frequency or severity of his instability during this period, instead simply establishing its presence as a symptom. The February 2009 VA orthopedic consult indicates that Veteran had mild to moderate positive Lachman's test and the February 2016 and February 2017 VA examiners noted that there was evidence of left knee moderate instability with 2+ (5-10 millimeters) medial instability on testing. There is no evidence that the VA examination reports are not competent or credible, and therefore they are entitled to significant probative weight as to the severity of the Veteran's left knee medial instability. There is no medical evidence of that the Veteran has severe instability or severe recurrent subluxation. Here, all VA examination reports indicate the Veteran does not have any recurrent subluxation. Therefore, entitlement to an evaluation in excess of 20 percent for left knee laxity is not warranted. The preponderance of the evidence is against an increased rating in excess of 20 percent for left knee laxity. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. ORDER Entitlement to an initial rating in excess of 10 percent for right knee osteoarthritis is denied. Entitlement to an initial rating in excess of 20 percent for right knee laxity is denied. Entitlement to a higher initial rating for left knee osteoarthritis rated at 10 percent prior to March 9, 2012 and 30 percent from May1, 2013 and thereafter is denied. Entitlement to an initial rating in excess of 20 percent for left knee laxity from February 3, 2009 is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs