Citation Nr: 1801455 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 09-37 268A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for left knee instability status postoperative arthroscopy with meniscectomy (hereinafter instability). 2. Entitlement to an initial rating in excess of 10 percent for limitation of flexion of the left knee. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD T. Henry, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1981 to August 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge at the St. Petersburg, Florida, RO. In March 2012, the Board remanded the instability claim for further development. In September 2016 and May 2017, the Board remanded both claims for further development. FINDINGS OF FACT 1. For all periods relevant to this appeal, the Veteran has had slight left knee lateral instability. 2. The Veteran's left knee disability has been manifested primarily by pain, swelling, weakness, and instability that required the use of a knee brace, decreased flexion no less than 80 degrees, and full extension to zero degrees. 3. The evidence shows left knee meniscal tears with pain, locking, swelling, weakness, and stiffness. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2017). 2. The criteria for a disability rating in excess of 10 percent for limitation of flexion of the left knee have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5260 and 5261 (2017). 3. The criteria for a separate rating of 20 percent rating for episodes of left knee cartilage "locking," pain, and joint effusion have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by a letter dated May 2008. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA also has a duty to assist a Veteran in the development of the claim. That duty includes assisting the Veteran in the procurement of service treatment records (STR) and other pertinent records, and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board notes that in her December 2017 Appellate Brief, the Veteran questioned the adequacy of the July 2017 VA examination. The Veteran stated that the examiner did not elicit her complete history, which was contrary to the Board's instructions. The Board notes that it is clear from the report that the VA examiner reviewed the record and accurately noted the Veteran's history. The Board notes that in an increased rating claim, the Veteran's current severity is at issue. Here, the examiner's findings reflect the current severity of the disability, so any error the examiner committed in not fully complying with the Board's instructions amounts to harmless error. The Veteran also stated that the examiner did not address the Veteran's flare-ups but instead noted that addressing the issue would be mere speculation. The Board notes that the examiner reported the same information on flare-ups as the Veteran herself reported. The Board also notes that the information provided provides sufficient information to render a decision. Thus, the Board finds that all necessary development as to the issues decided herein has been accomplished, and therefore, appellate review may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). II. Stegall Compliance The Board finds there has been substantial compliance with its March 2012, September 2016, and 2017 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand.) Increased Rating Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes (DC). Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. Under Diagnostic Code 5010, arthritis due to trauma substantiated by X-ray findings is rated under Diagnostic Code 5003 as degenerative arthritis. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. Diagnostic Code 5257 is used to evaluate recurrent subluxation or lateral instability of the knee. Severe symptoms warrant a 30 percent rating; moderate symptoms warrant a 20 percent rating; and slight symptoms warrant a 10 percent rating. See 38 C.F.R. §§ 4.71a, Diagnostic Code 5257. The terms "slight," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Diagnostic Code 5260 is used to denote the rating criteria for the limitation of flexion of the leg. 38 C.F.R. § 4.71a. Limitation of flexion is rated as follows: flexion limited to 60 degrees warrants a noncompensable rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 evaluates limitation of extension as follows: extension limited to 5 degrees warrants a noncompensable rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate evaluations may be assigned for limitation of flexion and extension of the same joint. See VAOPGCPREC 09-04 (September 17, 2004). Specifically, when a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. The normal range of motion of the knee is 0 degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.7, Plate II. Under Diagnostic Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2017). VA's General Counsel has additionally concluded that arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257; evaluation of knee dysfunction under both codes does not amount to pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCPREC 09-98 (August 14, 1998). Therefore, arthritis and instability of the knee may be rated separately, provided that any separate rating must be based upon additional disability. See also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). In June and July 2008, the Veteran was seen at the Pahrump CBOC: Primary Care Outpatient Note. See Medical Treatment Record-Government Facility entered in Caseflow Reader in April 2010, p. 37. The Veteran stated that she experienced left knee pain, giving out, and crepitus. She stated that her knee was always popping. See id. at 37, 39. In August 2008, the stated that her knee continued to give out which resulted in falls. See id. at 39. In November 2008, the Veteran was afforded a VA examination to determine the nature and etiology of her left knee condition. The examiner performed an in-person examination. The Veteran stated that she noticed left knee pain with stiffness and swelling. In 1982, the Veteran underwent arthroscopic surgery requiring debridement and repair of a torn meniscus. In 1985, the Veteran required a secondary arthroscopy with lateral release; in 1987, a third arthroscopy debridement with meniscectomy; and in 2003, arthroscopy of the left knee partial meniscectomy. During the VA examination, the Veteran complained of pain, weakness, stiffness, and swelling. The Veteran took acetaminophen and iced and elevated her knee. The Veteran wore a knee brace at all times. Without the brace, the Veteran reported falling. The Veteran denied any dislocations or subluxations of the knee, and the examiner did not find constitutional symptoms of inflammatory or systemic arthritis. Regarding the Veteran's activities of daily living, the Veteran washed and dressed herself without any assistance. However, she reported difficulty when she performed light housekeeping due to the turning and twisting activities. Regarding functional impairment, the left knee precluded and limited the Veteran's ability to squat, kneel, and crawl. She was able to walk up a maximum of one flight of stairs. Due to the concomitant knee and back conditions, she could no longer run or jump, and play contact or physical sports. The Veteran was able to sit and stand for a maximum of one hour. On flat and level land, she was able to ambulate one-quarter of a mile. The Veteran's flexion was to 120 degrees and full extension to zero degrees. The Veteran experienced crepitans of the knee joint during active and passive movements. The Veteran had a mild degree of pain and discomfort throughout the entire arc of movement, but the pain increased at the end arc of motion. The examiner noted well-healed multiple surgical portal wounds from prior arthroscopies. The examiner noted guarding of a mild degree increasing with repetitive movement of the knee joint; however, there was no loss of range of motion after repetitive usage. The Veteran did not experience ankylosis, instability, excessive looseness or laxity or effusion of the knee joint. There was no noticeable loss of strength, motor strength was normal, and motor tone was satisfactory. The Veteran did not use prosthesis. Collateral ligaments were stress in varus and valgus at neutral and 30 degrees of flexion and there was no excessive movement of the ligaments or capsule. The examiner diagnosed the Veteran with status postoperative arthroscopy with meniscectomy of the left knee with residuals. In July 2009, the Veteran was seen at the Tallahassee VAMC. The examiner noted that since the Veteran's 2003 surgery, the Veteran has experienced knee pain and instability. See Medical Treatment Record-Government Facility entered in Caseflow Reader in April 2010, p. 21. However, upon examination, the examiner did not find instability and negative ballottement and McMurray. The Veteran had crepitations. Id. at 23. An examiner also noted that the Veteran had left knee with recurvatum. The Veteran ordered a customized knee brace. See id. at 2. In September 2011, the Veteran testified at a Board hearing. The Veteran stated that she was authorized a knee brace which prevented frequent episodes of locking; however, her knee gave out and buckled, and she would fall. Because of her knee, she was unable to squat, stand, and climb stairs. She stated that she was on anti-arthritic medication for her knee. The Veteran stated that her November 2008 VA examiner did not adequately evaluate her knee. She stated that in 2008 or 2009, a VA orthopedic surgeon told her that she needed a knee replacement. She felt that her knee had gotten worse since then. In November 2012, the Veteran was afforded another VA examination to determine the severity of her left knee condition. The examiner reviewed the Veteran claims file and performed an in-person examination. The Veteran stated that since her 2003 left knee surgery meniscus repair, she has had pain and some instability in the knee. She used a knee brace, but she developed a rash in response to the vinyl on the brace. The Veteran reported flare ups which impacted the functioning of her knee. She stated that her knee pain was 2/10 flaring to 6/10 after ascending or descending stairs. The examiner noted that the Veteran's right knee flexion was to 120 degrees with objective painful motion beginning at zero degrees. Extension ended at 0 degrees with no objective evidence of painful motion. Left knee flexion was to 90 degrees with objective painful motion at 70 degrees. Extension ended at zero degrees, and there was no objective evidence of painful motion. The Veteran was unable to perform repetitive use testing after three repetitions due to the severe pain from her lumbar spine and left knee conditions. However, after repetitive use, the Veteran experienced functional loss and/or functional impairment of the knee. The Veteran experienced less movement than normal and excess fatigability in both knees with weakened movement, pain on movement, deformity, disturbance of locomotion, pain on palpation, and interference with sitting, standing and weight-bearing in the left knee. The Veteran muscle strength was 4/5 and 3/5 in the right and left knee, respectively. The Veteran instability tests were normal. There was no evidence of patellar subluxation or dislocation. The examiner noted that in 1984 and 1993, the Veteran experienced stress fractures in both knees. Additionally, the Veteran had left knee meniscal tear and frequent episodes of joint locking, pain, and effusion. Due to the meniscectomy, the Veteran also experienced grinding, popping, locking, and medial and lateral instability at 2+. The Veteran had a scar that was not greater than 39 square cm. She used a knee brace as a normal mode of locomotion and could not climb stairs, ladders or stand on her feet sufficient lengths of time to construct furniture, stoop, or squat. However, the examiner noted that the Veteran could perform clerical and sedentary occupations. There was no evidence of patellar subluxation. Diagnostic testing showed degenerative or traumatic arthritis in the left knee. The examiner confirmed the Veteran's lateral facet patellar and meniscal degenerative joint disease of left knee requiring surgeries including finally a meniscectomy. In November 2016, the Veteran was afforded a VA examination to determine the severity of her left knee condition. The examiner reviewed the Veteran's VA e-folder and performed an in-person examination. The Veteran stated that her left knee was weak and unstable and hyperextended. She stated that she often fell, collapsed, and the knee would locked. The Veteran stated that there was a loose piece in the knee that would catch. The Veteran did not report flare-ups or functional loss or impairment. The examiner note the Veteran's right knee flexion was to 125 and 125 to zero. The Veteran's left knee had flexion to 130 degrees and from 130 degrees to zero. The Veteran's range of motion (ROM) did not contribute to functional loss nor was there evidence of pain with weight-bearing for either knee. However, there was localized tenderness or pain on palpation of the joint or associated soft tissue, and there was objective evidence of crepitus for the right knee but none for the left. After three repetitive testings, there was no functional loss or ROM. The Veteran's records noted genu recurvatum with hyperextension to 10 degrees. However, the examiner stated that the Veteran's genu recurvatum was a congenital condition and was not due to the Veteran's service connected condition. During the examination, the examiner did not find ACL laxity or genu recurvatum. The Veteran had normal muscle strength with no muscle atrophy. She did not experience ankylosis, instability, or recurrent effusion. The Veteran experienced recurrent patellar dislocation. She used a knee brace, crutches, cane, wheelchair, and sometimes a walker. The examiner noted that there was no functional impairment of an extremity such that no effective function remains other than that which would equally well served by an amputation with prosthesis. The examiner confirmed the Veteran's degenerative arthritis in both knees. In May 2017, the Board remanded the claims for further development. The previous examinations did not indicate whether range of motion testing of the left knee was performed in passive motion and in weight-bearing and nonweight-bearing. Therefore, the Board remanded the claim to determine the current severity of the Veteran's left knee disability. In July 2017, the Veteran was afforded a VA examination to determine the severity of her left knee condition. The examiner reviewed the Veteran's VA e-folder and performed an in-person examination. The Veteran stated that humidity caused flare-ups. She reported functional loss or functional limitation and could not walk for over 10-15 minutes, bend, stoop, or lift any objects. The examiner noted the Veteran's right knee flexion and extension to be from zero to 110 and 110 to zero, respectively. Left knee flexion and extension were from zero to 80 and 80 to zero, respectively. There was no localized tenderness or pain on palpation of the joint or associated soft tissue for either knee. The Veteran experienced pain on weight bearing and crepitus in both knees. The examiner noted that there was no functional loss in either knee after repetitive use. The Veteran was not tested after repetitive use over time or during flare-ups. There were no additional factors contributing to disability. The Veteran had normal muscle strength in the right knee with no reduction in muscle strength. The left knee's muscle strength was 4/5 with reduction in muscle strength. The Veteran did not experience muscle atrophy, ankylosis, or instability in either knee. The Veteran did not have or never had recurrent patellar dislocation or a history of recurrent effusion. The Veteran did not have any visible scars related to any conditions related to her left knee condition. She sometimes used a wheelchair, brace, or crutches as a normal mode of locomotion. There was no functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis. There was no objective evidence of pain in non-weight bearing for either knee. The Veteran's ROM was the same as for weight bearing and non-weight bearing. The examiner diagnosed the Veteran with left knee stability, status postoperative arthroscopy with meniscectomy and painful motion of the left knee. i. Left Knee Instability Status Postoperative Arthroscopy with Meniscectomy The Veteran contends that the left knee instability is worse than contemplated by the 10 percent initial rating. See Statement in Support of Claim entered in Caseflow Reader in January 2009. After a review of all the evidence of record, lay and medical, the Board finds that a rating in excess of 10 percent for left knee instability is not warranted. In the November 2008 VA examination, the Veteran reported that if she did not wear her knee brace, she would fall. Upon objective testing, the VA examiner indicated that the Veteran did not experience instability, excessive looseness or laxity or effusion of the knee joint. There was no noticeable loss of strength, motor strength was normal, and motor tone was satisfactory. In a July 2009 VA treatment record, the Veteran complained of knee pain and instability. However, the treating physician did not find instability. In a November 2012 VA examination report, the VA examiner noted the Veteran's subjective complaint of left knee instability in which she used a knee brace for support. However, the VA examiner noted that instability tests were normal, and there was no evidence of patellar subluxation or dislocation. However, the examiner noted lateral instability, 2+. The Veteran muscle strength was 3/5. Additionally, the Veteran's VA treatment records noted that the Veteran wore a knee brace and had left knee instability. During her November 2016 VA examination, the Veteran stated that her left knee was weak, unstable, and hyperextended. However, the VA examiner did not find ACL laxity or genu recurvatum. The Veteran had normal muscle strength with no muscle atrophy. She did not experience instability or recurrent effusion. In a July 2017 VA examination, the examiner noted that the Veteran's left knee's strength was 4/5 with reduction in muscle strength. The Veteran did not experience muscle atrophy or instability in the left knee. As noted above, a rating in excess of 10 percent (20 percent) under Diagnostic Code 5257 requires "moderate" symptoms of instability. Throughout the vast majority of the rating period on appeal, multiple VA examiners found no instability upon objective testing. Indeed, when instability (anterior, posterior, and medial-lateral) was objectively measured, all tests were "normal" except for the November 2012 VA examiner who found moderate lateral instability. The Board also notes that a VA treatment record also indicated moderate left knee instability. As such, the Board concludes that the greater weight of the evidence is against finding that the knee disability manifested by symptomatology or findings more nearly approximating the criteria for an initial rating excess of 10 percent under Diagnostic Code 5257. Because the preponderance of the evidence is against the appeal, the benefit of the doubt doctrine is not for application, and the appeal must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board notes that VA's General Counsel has concluded that arthritis and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257; evaluation of knee dysfunction under both codes does not amount to pyramiding under 38 C.F.R. § 4.14. See VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCPREC 09-98 (August 14, 1998). Therefore, arthritis and instability of the knee may be rated separately, provided that any separate rating must be based upon additional disability. See also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). During the November 2012 VA examination, the examiner noted diagnostic testing showed degenerative or traumatic arthritis in the Veteran's knee as well as some limitation of motion caused by painful motion. The November 2016 examiner confirmed the arthritis. The Board notes that the Veteran has already received a compensable rating under the appropriate Diagnostic Code. Assigning a separate rating under Diagnostic Code 5003 would constitute pyramiding, as these diagnostic codes rate based on limitation of motion, including limitation of motion caused by pain, including arthritic pain. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Further, the rating criteria under Diagnostic Code 5003 specifically directs that degenerative arthritis be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a DC 5003. In sum, the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for left knee instability with degenerative changes. 38 U.S.C. § 5107; see Gilbert, 1 Vet. App. at 53. The benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ii. Painful motion of the left knee Effective February 8, 2013, the Veteran was granted a separate 10 percent disability rating for painful motion, pursuant to the criteria under 38 C.F.R. § 4.71a, DC 5260. Overall, the evidence reported above shows that the Veteran's left knee disability has been marked primarily by pain, stiffness, popping, giving out, weakness, and instability that required the use of a knee brace, cane, wheelchair, and sometimes a walker. At worse, the Veteran's flexion has been no less than 80 degrees with normal extension. Given that the record shows left knee flexion to no less than 80 degrees, the criteria for a disability rating higher than 10 percent under DC 5260 are not met. The Board recognizes that, under DeLuca v. Brown, 8 Vet. App. 202 (1995), VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the Diagnostic Codes. "Functional loss" may occur as a result of weakness or pain on motion. Here, the evidence shows that pain has been a constant and predominant symptom in her left knee. Additionally, the November 2012 examiner noted weakened movement, pain on movement, deformity, disturbance of locomotion, pain on palpation, and interference with sitting, standing, and weight bearing. Nonetheless, given the extent of left knee motion and the extent of functional and occupational impairment indicated in the record, there is no evidence of a disability picture that is commensurate to a limitation of left knee flexion to the extent necessary to establish entitlement to a higher disability rating, even after taking her reported pain into full consideration. See DeLuca, 8 Vet. App. at 204 -07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Codes 5260 and 5261. In this regard, the Board emphasizes that a 10 percent disability rating under DC 5260 already contemplates an otherwise non-compensable degree of limitation of motion verified by objective evidence of symptoms such as painful motion. The Board also notes that the Veteran has normal extension; therefore, a separate rating under 5261 is not warranted. Further, the Board has considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board notes that other criteria for rating knee disabilities are provided under DCs 5256 (for ankylosis), 5262 (for impairment of the tibia and fibula), and 5263 (for genu recurvatum). The evidence does not show that the Veteran's left knee manifestations have included ankylosis, or impairment of the tibia and fibula. In the absence of such manifestations, those DCs are inapplicable in this case. Regarding 5263, a VA physician noted that the Veteran had genu recurvatum. However, the November 2016 VA examiner noted that genu recurvatum is a congenital condition, and it was not found on the examination. Therefore, a rating under 5263 is not warranted. Rating criteria for knee disabilities are also provided under DC 5258 (for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion) and 5259 (for symptomatic removal of the semilunar cartilage). See Lyles v. Shulkin, No. 16-0994, --- Vet. App. --- (November 29, 2017) (concluding that an evaluation of a knee disability under DC 5257 does to preclude, as a matter of law, separate evaluation of a meniscal disability of the same knee under DC 5258 or 5259.) In Lyles, the Court stated that where a certain manifestation of a disability has not been compensated via an assigned evaluation under a particular DC, evaluation of that manifestation under another DC would not constitute pyramiding. See id.; see also Fanning v. Brown, 4 Vet. App. 225 (1993). Further, a manifestation of a disability has not been compensated by an assigned evaluation if the manifestation is "distinct and separate" from the manifestations that form the basis of the assigned evaluation. See Lyles, No. 16-0994 (quoting Murray v. Shinseki, 24 Vet. App. 420, 423 (2011)). The Court concluded by stating that where manifestations of a musculoskeletal disability causing additional functional limitation have not resulted in elevation pursuant to Deluca, those manifestations have not yet been compensated for separate evaluation and pyramiding purposes. The Board notes that the Veteran's swelling, weakness, effusion, and stiffness have not been compensated for under Deluca or any other DC; therefore, evaluating these manifestations under DC 5258 or 5259 does not amount to pyramiding. See Lyles, No. 16-0994. Diagnostic Code 5258 relates to knee problems including cartilage, semilunar, dislocated with frequent episodes of "locking," pain, and effusion into the joint. To meet the criteria for a 20 percent rating under DC 5258, the symptoms must include "frequent episodes of 'locking', pain, and effusion into the joint." A finding of "locking" alone would not meet the criteria, rather pain and effusion must be present as well to meet the criteria. See Camacho v. Nicholson, 21 Vet. App. 360, 366 (2007) (use of conjunctive "and" indicates all criteria must be met). The November 2012 VA examiner noted that the Veteran had episodes of joint locking, pain, and effusion in her left knee. The November 2016 VA examiner did not note effusion at the time, but did note pain and locking. Having resolved doubt in favor of the Veteran, the Board assigns DC 5258 and the corresponding 20 percent disability rating. ORDER Entitlement to an initial rating in excess of 10 percent for left knee instability status postoperative arthroscopy with meniscectomy is denied. Entitlement to a rating in excess of 10 percent for painful motion of the left knee is denied. Entitlement to a separate 20 percent rating for left knee cartilage, semilunar, dislocated with frequent episodes of "locking," pain, and effusion under Diagnostic Code 5258 is granted. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs