Citation Nr: 1802888 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 10-09 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for left knee degenerative joint disease. 2. Entitlement to an evaluation in excess of 30 percent for status post total right knee replacement. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Underwood, Associate Counsel INTRODUCTION The Veteran served in the National Guard with periods of active duty for training from April to August 1970 and from June to July 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This case has a somewhat complicated procedural history. In June 2011, the Board issued a remand so that the Veteran could be afforded a Board hearing, per his request. In November 2011, the Veteran testified before the undersigned via live videoconference. A transcript of that hearing has been prepared and is associated with the Veteran's electronic claims file. In September 2012, the Board issued a decision which, in pertinent part, denied the Veteran's increased rating claims for his service-connected back and right and left knee. The Board also remanded his claim for TDIU to the RO for further development. Thereafter, the Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In September 2013, the Court granted a Joint Motion for Partial Remand (JMR), filed by VA's General Counsel and the Veteran, which remanded the denied increased rating claims for the Veteran's back and left and right knee disabilities. In response to that JMR, in March 2014, the Board issued a remand of all of the issues that were on appeal so that the Veteran could be afforded a new VA examination, and be provided the opportunity to provide additional information in support of his TDIU claim. In January 2016, the Veteran presented for the requested VA examination, and the matters were returned to the Board for further appellate review. In September 2016, the Board granted entitlement to TDIU and a separate 20 percent rating for radiculopathy of the lower left extremity, associated with degenerative joint disease of the lumbar spine. The Board denied entitlement to a rating increase in excess of 40 percent for degenerative joint disease of the lumbar spine, which has not been appealed by the Veteran. The Board also issued a remand for the matters currently on appeal for an addendum examination to evaluate his service-connected right and left knees. In February 2017 and June 2017, the requested VA addendum examinations were performed. A supplemental statement of the case denying the issues currently on appeal was issued by the AOJ in August 2017. FINDINGS OF FACT 1. The Veteran is currently in receipt of the maximum 30 percent rating under Diagnostic Code 5257 for lateral instability of the knee. 2. Upon examination on January 22, 2016, left knee extension was to 10 degrees with repetitive movement; subsequent examination on February 16, 2017 showed left knee extension to be no worse than 5 degrees. 3. The evidence of record shows evidence of chronic residuals consisting of severe painful motion or weakness in the right knee. CONCLUSIONS OF LAW 1. For the entirety of the rating period, the criteria for a rating in excess of 30 percent for left knee lateral instability/degenerative joint disease have not been met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.1, 4.45, 4.71a, Diagnostic Codes 5010-5257 (West 2017). 2. From January 22, 2016 to February 16, 2017, the criteria for a separate rating in of 10 percent for limitation of left knee extension have been met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.1, 4.45, 4.71a, Diagnostic Codes 5010-5257 (West 2017). 3. For the entirety of the rating period, the criteria for a rating in excess of 60 percent, but not higher, for status post total right knee replacement have been met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.1, 4.45, 4.71a, Diagnostic Code 5055 (West 2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Procedural Duties VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C. §§ 5103, 5103A (West 2012) and 38 C.F.R. § 3.159 (2017). Here, the duty to notify was satisfied by way of a letter sent in October 2008. VA also has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished and all available evidence pertaining to the matter decided herein has been obtained. The September 2016 Board remand instructed that VA afford the Veteran with a new bilateral knee examination to include range of motion testing in active motion and passive motion, as well as weight bearing and non-weight bearing motion, pursuant to requirements set forth by the Court. See Correia v. McDonald, 28 Vet. App. 158 (2016). VA examinations were conducted in February 2017 and an addendum opinion was provided in June 2017. Accordingly, the Board finds that the remand directives have been substantially complied with. Stegall v. West, 11 Vet. App. 268 (1998). See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008). II. Rating Analysis The Veteran asserts that his knee disabilities warrant ratings in excess of those assigned by the RO. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of another. 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran is competent to provide evidence of symptoms observable by his senses. However, he is not competent to measure functional limitation and instability of the knee as this requires specialized testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds the Veteran credible to report his symptoms, as his statements are detailed and consistent. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional loss-of-motion due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59. Standard motion of a knee joint is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of leg motion is governed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 (DC) concerns limitation of leg flexion. A zero, non-compensable rating is warranted where flexion is limited to 60 degrees and a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under Diagnostic Code 5261, limitation of extension to 15 degrees warrants a 20 percent evaluation, and limitation of extension to 20 degrees warrants a 30 percent evaluation. Limitation of extension of the knee to 30 degrees warrants a 40 percent evaluation and limitation of extension of the knee to 45 degrees warrants a 50 percent evaluation, the highest schedular evaluation under this diagnostic code. 38 C.F.R. § 4.71a. A veteran who had both limitation of flexion and limitation of extension of the same leg may be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. However, separate ratings require separate compensable symptomatology. VAOPGCPREC 9-2004 (2004), 69 Fed. Reg. 59,990 (2004). Under Diagnostic Code 5055, a knee replacement (prosthesis) will be assigned a 100 percent rating for one year following the implantation of the prosthesis and a minimum rating of 30 percent thereafter. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5055. A 60 percent rating is warranted where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. Under Diagnostic Code 5257 (other impairment of the knee), a 10 percent evaluation requires a slight recurrent subluxation or lateral instability. A 20 percent evaluation requires moderate recurrent subluxation or lateral instability. A maximum 30 percent evaluation requires severe recurrent subluxation or lateral instability. Under Diagnostic Code 5258, a 20 percent rating is warranted where there is evidence of dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the knee joint. 38 C.F.R. § 4.71a, DC 5258. Under Diagnostic code 5259, symptomatic removal of semilunar cartilage in the knee warrants a 10 percent rating. 38 C.F.R. § 4.71a, DC 5259. Under Diagnostic Code 5262, 20, 30, and 40 percent ratings are warranted for malunion of the tibia and fibula with moderate knee or ankle disability, marked knee or ankle disability, and nonunion of the tibia and fibula. 38 C.F.R. § 4.71a, DC 5262. A claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. However, separate ratings require separate compensable symptomatology. VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56,704 (1998); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997). Additionally, evaluation of a knee disability under DCs 5257 or 5261 or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under DC 5258 or 5259, and vice versa. The Court further holds that entitlement to a separate evaluation in a given case depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different DC. In the context of evaluating musculoskeletal disabilities based on limitation of motion, a manifestation of disability has not been compensated, for separate evaluation and pyramiding purposes, if that manifestation did not result in an elevation of the evaluation under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the principles set forth in DeLuca v. Brown, 8 Vet. App. 202 (1995). See Lyles v. Shulkin, No. 16-0994 (Argued August 17, 2017, Decided November 29, 2017). Intermediate degrees of residual weakness, pain, or limitation of motion will be rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). Standard motion of a knee joint is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Under DC 5003, degenerative arthritis, when 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 the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate DCs, a rating of 10 percent is for application for 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. III. Factual Background In October 2008, the Veteran filed a claim for an increased rating for left and right knee disabilities. He has continued to report severe knee pain and various knee problems throughout the claims period. Private treatment records show that the Veteran underwent a right total knee arthroplasty in February 2007, more than one year prior to the date he filed his current claim for an increased evaluation. At the October 2008 VA examination, the Veteran reported constant bilateral knee pain. His right knee could swell and give way. Symptoms were precipitated by standing too long and stair climbing, with the severity rated as 7 out of 10. Symptoms were relieved by rest and Advil. He reported no use of assistive devices, but did wear support when needed. Again, he was able to perform activities of daily living, including driving. His ability to engage in recreational activities was the same as with his back, indicated previously. He asserted that he had lost many hours from work due to his knee problems and reported no flare-ups as symptoms were constant. On objective examination, the knees were asymmetrical. There was a bony enlargement deformity bilaterally. There was no swelling, crepitus, erythema or effusion. Range of motion on the right was zero degrees extension to 130 degrees flexion. There was pain with this activity. On the left, he extended to zero degrees and flexed to 125 degrees. His motor was 5 over 5 including quadriceps. He had decreased sensation to light touch on the right lateral knee. Varus and valgus testing was negative. Both knees were stable. Again, deep tendon reflexes on the right were absent. On repetitive use testing, he performed 15 out of 15 knee flexions with a two pound weight on his ankle. While he had pain throughout, there was no weakness, fatigue or lack of endurance. The pain he had was on the left knee. X-ray of the right knee noted evidence of right total knee replacement with cemented femoral, tibial and patellar polyethylene components. Alignment was maintained without hardware loosening and a small joint effusion was noted. The diagnosis was right knee arthroplasty with mild effusion. At a November 2011 Board hearing, the Veteran testified that he had chronic pain in both of his knees rating at a 5/10, which elevated during rainy weather. Although he lived in a two story house, he had a bedroom and bathroom installed on the first floor due to his leg problems. He stated that he did not feel comfortable going down a flight of stairs, due to his knee instability. He noted that he used a whirlpool and ice on his knees approximately 5 to 6 times per month. He noted knee instability and that his left knee gave out at least twice a year. He sometimes had to use a cane, e.g., when running errands. He also reported difficulty sleeping due to pain. (11/02/2011, Hearing Testimony.) In January 2016, VA was contacted by a private orthopedic physician, R.B., who treated the Veteran's left knee for advanced, end-stage degenerative osteoarthritis. He noted that the Veteran was status post multiple injuries to his left knee, including an open reduction internal fixation of the patella. As a result of severe arthritis, a realignment osteotomy of his tibia was performed to reduce the weight-bearing pressure on the inside of his knee. R.B. further noted that over the years, the Veteran's arthritis progressively worsened to the point where he had severe difficulties performing activities of everyday life and required the use of a cane. He noted that the Veteran had significant effusion in his left knee with restricted range of motion to only about 100 degrees of flexion with full extension. The large effusion was symptomatic and caused severe pain. The physician opined that conservative treatment had failed and that the Veteran was a candidate for left knee replacement surgery. (01/08/2016, Third Party Correspondence.) During a January 2016 VA examination, the Veteran reported constant bilateral knee pain that was worsening since his last examination. He reported that his left knee condition was worse than his right knee. Right knee flexion measured 0 to 100 degrees (0 to 90 after repetitive use testing) and extension measured 140 to 0 (which remained unchanged after repetitive use testing). Left knee flexion measured 0 to 90 degrees (0 to 85 after repetitive use testing) and extension measured 140 to 10 (which went unchanged after repetitive use testing). Pain was present with weight bearing for both knees and both knees showed evidence of crepitus. He continued to have bilateral degenerative arthritis, left knee recurrent subluxation, and slight left knee instability. The Veteran's bilateral knee residuals and left knee instability were found to functionally impact his ability to do work that required prolonged sitting, standing, and/or walking; going up and down stairs; and heavy lifting and carrying. Bilateral flare ups were reported. The examiner provided an opinion regarding repeated use over time, finding that bilateral functional loss had occurred. Ankylosis was not found in either knee. The Veteran experienced recurrent effusion, with the latest episode of effusion drainage about 6 months before the examination. As a result of 2007 right knee total joint replacement surgery, he had intermediate degrees of residual weakness, pain or limitation of motion. As a result of left knee patella surgery, he had residual signs or symptoms of chronic pain, weakness, instability, and fatigue. Muscle strength was measured at 3/5 for left and right forward flexion and extension, with a finding of reduced muscle strength bilaterally, due to the claimed conditions. (01/22/2016, C&P Exam.) In August 2016, a private chiropractor, D.F., noted a number of the Veteran's health conditions that impacted his ability to work, to include his left knee injury. 09/02/2016, Medical Treatment Record - Non-Government Facility at 2. In September 2016, the Board remanded the matters on appeal for a new examination, pursuant the Court's holding in Correia. The Board found that a new examination was necessary to include range of motion testing for the right knee in active motion and passive motion, as well as weight bearing and nonweight bearing motion. The Board noted the right knee could render a higher rating if extension was limited in either nonweight-bearing or passive movement. The remand acknowledged that left knee extension measured to a compensable 10 degrees; however, it found that the Board could not accurately evaluate the examination results because the testing did not specify if the examiner administered passive movement or weight bearing versus nonweight-bearing testing. At a February 2017 VA examination, the Veteran continued to report pain and decreased range of motion of both knees. Bilateral degenerative arthritis continued. Although the Veteran underwent extensive physical therapy, he continued to walk with a limp and utilized knee braces, shoe lifts, and occasionally a cane for support when walking. He used ice frequently along with daily use of Tylenol and Aleve. Daily bilateral flare ups were reported with right knee pain at 5/10 and left knee pain at 6/10. Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), active motion, passive motion, weight-bearing, and opposite joint range were tested on both knees. Right knee flexion measured 5 to 110 degrees (5 to 90 after repetitive use testing) and extension measured 110 to 5 degrees (90 to 5 after repetitive use testing). Left knee flexion measured 5 to 110 degrees (5 to 100 after repetitive use testing) and extension measured 110 to 5 degrees (which went unchanged after repetitive use testing). The examiner found that the Veteran was not being examined immediately after repetitive use over time. Bilaterally, ankylosis and instability were not found. The Veteran walked with antalgic gait. Regarding the effects of surgical procedures, the 2006 total right knee replacement had chronic residuals of severe painful motion or weakness. A 2001 left knee osteotomy surgical procedure caused residual symptoms of pain and decreased range of motion. Functional loss for the left and right knee included pain, weakness, and lack of endurance. Contrary to the January 2016 VA examination report, the examiner found that providing an opinion regarding whether the pain, weakness, fatigability, or incoordination significantly limited the Veteran's functional ability with repeated use over a period of time would be speculative. Functional impact was noted, to include bending; however, it was not so diminished that amputation with prosthesis would equally serve the Veteran. Muscle strength measured at 3/5 for right and left knee flexion and extension, with a reduction in muscle strength due to the claimed conditions. Finally, the examiner checked off a box indicating that the Veteran's scars were painful, unstable, 6 inches or greater, or located on the head, face, or neck. She referred the reader to her scars examination form for further details. (02/16/17, VA Examination.) On the same date as the February 2017 knee examination, the same VA examiner also completed a VA Scars/Disfigurement form. She found that there were not any complications related to the scars and that the scars did not impact his functional ability. She answered "no" to questions of the presence of painful scars and unstable scars. (See 02/16/2017, C&P Exam at 2.) The scar sizes measured 19 x 0.5 cm on the right knee and 11 x 0.1 cm/9 x 1.2 cm on the left knee. (Id.) In May 2017 and June 2017, the AOJ followed up with the February 2017 examiner, requesting an addendum opinion to clarify whether she found the Veteran had painful or unstable scars. (05/25/2017, Deferred Rating; 06/02/2017, Request for Physical Examination.) The examiner responded by providing a June 2017 addendum opinion, which stated that the Veteran's scars were neither painful nor unstable. (06/06/2017, VA Examination.) In October 2017, the Veteran's representative filed an appellate brief, which asserted that the June 2017 addendum opinion was inadequate because it included an unsupported opposing opinion regarding the Veteran's painful scars when compared to the February 2017 favorable opinion. (10/11/2017, Appellate Brief.) IV. Legal Analysis Left Knee The Veteran is currently rated for left knee degenerative joint disease at a 30 percent evaluation under DC 5010-5257. A rating in excess of 30 percent is not applicable under Diagnostic Code 5257, because 30 percent is the maximum rating available from recurrent subluxation or lateral instability. Under DC 5257, a 30 percent rating is warranted for severe impairment from recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. During the January 2016 VA examination, the Veteran showed evidence of slight left knee instability. (See e.g., 01/22/2016, C&P Exam at 6, 8, 12.) The February 2017 VA examination did not find any evidence of left knee instability. (See 02/16/2017, VA Examination at 11.) Although the RO found that the most recent examination warranted a 10 percent rating, "sustained improvement [had] not been definitively established;" therefore it continued the maximum 30 percent rating pursuant to DC 5257. Regarding range of motion, left knee extension was to 10 degrees following repetitive testing in January 2016. This is consistent with a 10 percent evaluation under Diagnostic Code 5261 and thus such evaluation is warranted here. However, a noncompensable rating applies effective February 16, 2017, at which time examination showed left knee extension to 5 degrees. Overall, the Board has taken into consideration evidence provided in the record of functional loss due to limitation of flexion and extension pursuant to Deluca. The February 2017 VA examiner found that despite complaints and findings of pain, such have not been shown to cause functional limitation commensurate with the next-higher evaluation in this case. Tibia and fibula impairments are governed by DC 5262. A 40 percent rating is afforded if there is nonunion with loose motion, requiring a brace; a 30 percent rating requires malunion with marked knee or ankle disability; a 20 percent rating requires malunion with moderate knee or ankle disability, and a 10 percent rating is afforded for malunion with slight knee or ankle disability. Here, while the Board notes that the Veteran's private physician, R.B., reported that a realignment osteotomy of his tibia was performed to reduce the weight-bearing pressure on the inside of his knee, evidence of the required malunion is absent. Moreover, the symptomatology at issue here has already been contemplated under other diagnostic codes and thus assignment of a separate rating under Diagnostic Code 5262 would constitute impermissible pyramiding in this case. The record reflects evidence of effusion and pain in the right knee joint. However, a rating under DC 5258 is not warranted because the record fails to show dislocated semilunar cartilage in the knee and locking. (See 02/16/2017, VA Examination at 12.) Likewise, there is no showing of removal of semilunar cartilage, pursuant to DC 5259. Ratings are also available for a knee disability under DC 5256 (ankylosis), DC 5259 (symptomatic removal of semilunar cartilage or meniscus) and DC 5263 (genu recurvatum). See 38 C.F.R. § 4.71a. The Veteran's treatment records do not show evidence of any of these conditions. The Board also notes that because the Veteran is already receiving the minimum compensable rating for pain, 38 C.F.R. § 4.59 is not applicable. Right Knee The Veteran's right knee status post total right knee replacement is currently rated at a 30 percent evaluation under DC 5055. A rating in excess of 30 percent for the right knee is applicable under DC 5055 because the February 2017 VA examiner provided evidence that the Veteran had chronic residuals consisting of severe painful motion or weakness. As noted above, under DC 5055, a minimum rating of 30 percent contemplates any total knee replacement residuals such as pain, limitation of motion, or weakness; 60 percent is afforded when there are chronic residuals consisting of severe painful motion or weakness in the affected extremity; and 100 percent is afforded for one year following the implantation of the prosthesis. Here, a 60 percent rating is warranted as evidence of chronic residuals consisting of severe painful motion or weakness in the affected extremity has been provided. The Veteran reported having chronic, daily, bilateral knee pain, flare ups, and the use of knee support products such as braces. The Board finds particularly probative the February 2017 VA examination, which found that residuals of the Veteran's total right knee joint replacement surgery constituted "chronic residuals consisting of severe painful motion or weakness." (See 02/16/2017, C&P Exam at 12.) The Board agrees that these residuals are, in fact, severe in nature, pursuant to DC 5055. Accordingly, for the period on appeal, the Board finds that the Veteran's right knee disability should be rated as 60 percent disabling based on residuals of his prosthetic knee replacement. The record also reflects evidence of effusion and pain in the right knee joint. However, a rating under DC 5258 is not warranted because the record fails to establish the additional requirements of dislocated semilunar cartilage in the knee and locking. (See 02/16/2017, VA Examination at 12.) Likewise, the Veteran lacks evidence of removal of semilunar cartilage, pursuant to DC 5259. Furthermore, there is no evidence of recurrent subluxation or lateral instability of the joint itself found for the right knee. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. Neither is there any evidence of right knee ankylosis; impairment of the tibia and fibula; nor acquired genu recurvatum. See Diagnostic Codes 5256, 5262, 5263. The Board also notes that because the Veteran is already receiving the minimum compensable rating for pain, 38 C.F.R. § 4.59 is not applicable. Finally, the right knee symptoms have been generally consistent during the period on appeal such that additional staged ratings are not appropriate. Fenderson, 12 Vet. App. at 126-27. Additional Matter - Scars As noted above, in October 2017, the Veteran's representative filed an appellate brief, which asserted that the June 2017 addendum opinion was inadequate because it included an unsupported opposing opinion regarding the Veteran's painful scars when compared to the February 2017 favorable opinion. (10/11/2017, Appellate Brief.) The Board finds that the evidence does not show a need for the examiner to clarify her opinion regarding painful and/or unstable scars. The Board acknowledges that on the February 2017 knee VA examination report, the examiner incorrectly checked off a box that affirmed the Veteran had evidence of scars that were either painful, unstable, had total area greater than or equal to 39 square cm, or were located on the head, face, or neck. However, she commented under the incorrectly checked box to "[p]lease see scars exam." (See 02/16/2017, VA Examination at 13.) Indeed, on the same date as the knee examination, the examiner filled out a VA Scars/Disfigurement form, which provided further details about his scars. On the Scars/Disfigurement form, the examiner stated "[n]o" as an answer to whether the scars were painful or unstable. (See 02/16/2017, C&P Exam at 2.) Moreover, the RO already contacted the examiner in May 2017 and June 2017 requesting that she clarify this discrepancy. (See 05/25/2017, Deferred Rating; 06/02/2017, Request for Physical Examination.) The examiner responded by again stating that none of the Veteran's scars were painful or unstable. (See 06/06/2017, VA Examination.) The Board therefore finds that the VA examiner provided sufficient clarification regarding her conflicting opinions on painful or unstable scars through the February 2017 Scars/Disfigurement report and the June 2017 addendum opinion. Further remand regarding this opinion would merely delay the matter for the same outcome. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (stating that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). ORDER For the entirety of the rating period, entitlement to an evaluation in excess of 30 percent for left knee degenerative joint disease is denied. From January 22, 2016 to February 16, 2017, assignment of a separate 10 percent rating for limitation of extension of the left knee is granted. For the entirety of the rating period, entitlement to an evaluation in excess of 30 percent for status post total right knee replacement is granted. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs