Citation Nr: 1803760 Decision Date: 01/19/18 Archive Date: 01/29/18 DOCKET NO. 12-30 866 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUE Entitlement to an initial rating in excess of 10 percent for a left knee degenerative joint disease. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. Mine, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1982 to November 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran requested a hearing in November 2012, but later withdrew her request. The Board remanded the issues on appeal for additional development in March 2015 and again in June 2017. FINDING OF FACT The Veteran's left knee disability has been manifested by limitation of flexion from 100 to 130 degrees with pain on motion, and normal extension. There is no indication of left knee ankylosis; recurrent subluxation or lateral instability; dislocated, semilunar cartilage; or tibial or fibular impairment. CONCLUSION OF LAW The criteria for an increased rating in excess of 10 percent for the Veteran's left knee disability have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5003-5260 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist 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). Regarding the duty to notify, once a claim of service connection has been granted, the filing of a notice of disagreement with the RO's rating of a disability does not trigger additional 38 U.S.C. § 5103(a) notice. See 38 C.F.R. § 3.159(b)(3). Therefore, further notice is not applicable in the Veteran's claim for a higher initial rating for a left knee disability. See id.; see also, e.g., Dunlap v. Nicholson, 21 Vet. App. 112, 116-117 (2007); Goodwin v. Peake, 22 Vet. App. 128, 136 (2008). In a November 2014 statement, the Veteran's representative argued that the November 2012 VA examination was inadequate because, while the Veteran had asserted that she experienced flare-ups that caused additional lost range of motion, the examination was not conducted during a flare-up. The Court of Appeals for Veteran's Claims (Court) has recently held that if a Veteran is not experiencing a flare up at the time of the examination, the examiner must ascertain the severity, frequency, duration, or functional loss manifestations related to flare ups by alternative means, including, but not limited to, asking the Veteran to provide a full description. Sharp v. Shulkin, 29 Vet. App. 26 (2017). While in this case the Veteran has not been examined while she was experiencing a flare-up at any point during the period on appeal, as discussed in detail below, the Veteran has otherwise provided an adequate description of the frequency, severity, duration, and additional functional loss that she experiences during flare-ups. Thus the Board finds that remand is not necessary to comply with the holding in Sharp as there is adequate evidence to base a determination. In an April 2017 brief, the Veteran's representative asserted that the May 2015 VA examiner provided an inadequate basis for the opinion, arguing that the examiner ignored the Veteran's ongoing complaints. However, the Board notes that the examination report documents the Veteran's complaints of constant knee pain and her description of symptoms. Additionally, the Veteran was afforded an additional VA examination in June 2017 during which the examiner referred to the Veteran's complaints of pain and functional loss. Therefore the Board concludes that there is adequate information on which to base a determination. Neither the Veteran nor her representative has raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Accordingly, the Board will address the merits of the claim. II. Increased Rating for a Left Knee Disability Legal Criteria Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, 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 Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Pursuant to VAOPGPREC 9-98 (August 14, 1998), a separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. In the absence of limitation of motion, a 10 percent rating is assigned where there is x-ray evidence of involvement of two or more major joints, or two or more minor joint groups; and a 20 percent evaluation is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability due to arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability of the knee warrants a 10 percent evaluation. A 20 percent evaluation requires moderate recurrent subluxation or lateral instability, while a 30 percent evaluation requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. The normal range of motion for the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Leg flexion limited to 60, 45, 30, and 15 degrees warrants noncompensable, 10 percent, 20 percent, and 30 percent evaluations, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Leg extension limited to 5, 10, and 15 degrees warrants noncompensable, 10 percent, and 20 percent evaluations, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59,990 (2004). The basis for the opinion is that the knee has separate planes of movement, each of which is potentially compensable. Id. Arthritis manifested by limitation of motion and instability of the knee are two separate disabilities, and a veteran may be rated separately for these symptoms. See VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997) (when a claimant has arthritis and is rated under instability of the knee, those two disabilities may be rated separately under 38 C.F.R. § 4.71a, Diagnostic Code 5003 and Diagnostic Code 5257). Facts and Analysis An April 2011 x-ray conducted by the Veteran's private physician showed no fracture or dislocation. There was a small amount of early spurring in the lateral patellar facet. There was no significant bony or articular abnormality. The soft tissue appeared unremarkable. The Veteran's coworker, W.M., in a July 2011 statement, reported that he had worked with the Veteran for three years, and reported that over the prior two years the Veteran had complained of pain in her knees, lower back, and ankle constantly. According to the statement, the Veteran had to use sick leave because pain interfered with her ability to complete her work. The Veteran was first afforded a VA examination in July 2011, during which she described her symptoms as instability, pain, stiffness, weakness, incoordination, tenderness. The Veteran reported experiencing flare-ups, which were precipitated by kneeling, squatting, and weather. The flare-ups were described as severe, occurring weekly and lasting hours. She reported no constitutional symptoms of arthritis and no incapacitating episodes of arthritis. The Veteran reported that she was able to stand for more than one hour but less than three hours. She stated she was able to walk more than a quarter of a mile, but less than one mile. On physical examination, the examiner noted an antalgic gait but no other evidence of abnormal weight bearing. There was no loss of bone and no inflammatory arthritis. The examiner noted tenderness and grinding, but no bumps consistent with Osgood-Schlatter's disease, no crepitation, no mass behind the knee, no clicks or snaps, no instability, no patellar abnormality, and no meniscus abnormality. Range of motion testing showed flexion from 0 to 120 degrees with pain on motion. Extension was normal. After repetitive motion testing, the Veteran had decreased flexion from 0 to 110 degrees. The examiner noted that pain contributed to the additional loss of range of motion. There was no loss of range of motion in extension. X-rays showed mild degenerative changes. The examiner described the impact on the Veteran's occupational activities as decreased mobility, problems with lifting and carrying, weakness or fatigue, and pain. The effects on the Veteran's daily activities included mild interference with chores, shopping, exercise, recreation, traveling, and driving, as well as severe interference with sports. In an April 2012 VA treatment record, a VA nurse reported that an MRI showed patellar chondrosis, areas of full-thickness cartilage loss and subchondral marrow edema, a 7 x 4 millimeter intra-articular loose body within the PCL recess, and trace joint effusion and trace Baker's cyst. In an October 2012 VA treatment record the Veteran reported pain mainly going up and down stairs, with occasional pain after prolonged standing. She reported occasional locking, but denied any tingling, numbness, or weakness. On examination, the Veteran's knee was without deformity, swelling, erythema, or effusion. There was evidence of crepitus, but no laxity or tenderness. Range of motion testing showed flexion from 0 to 110 degrees. Varus/valgus draw test, McMurray test, and pinch testing were all negative. A later October 2012 VA treatment record showed that the Veteran's knee pain was localized to her knee cap and was worse when going up and down stairs. On physical examination, the Veteran's knee had slight effusion, her knee was stable to varus/valgus testing and anterior/posterior drawer, and her patella was stable. In an October 2012 statement a coworker of the Veteran, M.K., reported that the Veteran was in significant pain on multiple occasions, to the point that the coworker had volunteered to take the Veteran to the hospital. The Veteran, in an October 2012 statement, reported that her knee had locked approximately six times over the prior year, causing her to fall up or down stairs. She stated that her knee pain was a problem when going up stairs. She also stated that she had left work due to pain on occasion. The Veteran reported that she had numbness and would lose feeling after sitting for long periods of time. She also indicated that her knee would lock after getting up, which caused pain and made it difficult to walk. Finally, she asserted that her knee condition had caused her to miss days of work due to pain. A November 2012 VA treatment record showed that the Veteran's active range of motion was within normal limits and strength was normal. The Veteran was afforded a VA examination in November 2012. The Veteran reported that her left knee locked and she would fall going up stairs. She wore a brace for increased stability and to decreased pain and falling. She rated her pain as seven out of 10 and described it as sharp and throbbing in nature that was particularly painful with stair climbing. The Veteran reported that she experienced flare-ups when going up stairs after prolonged sitting, which she described as numbness. Range of motion testing showed flexion to 110 degrees with pain beginning at 100 degrees, and extension to 0 with no objective evidence of pain. The Veteran was able to perform repetitive use testing with a minimum of three repetitions, after which the Veteran was limited to 100 degrees of flexion. Extension did not show any additional loss of range of motion. The examiner opined that repetitive use was productive of less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. The Veteran's knee was tender to palpation. Strength testing showed active movement against some resistance on both flexion and extension. Joint stability testing was normal. The examiner noted no history of patellar subluxation or dislocation, nor any history of a meniscal condition. The Veteran was wearing a brace constantly. During a December 2012 VA orthopedic outpatient examination the Veteran's knee did not have any deformity, swelling, erythema, effusion, laxity or tenderness, and the Veteran had a stable gait. There was some crepitus. Range of motion testing showed flexion from 0 to 110 degrees. Varus/valgus draw test, McMurray test, and pinch testing were all negative. A March 2013 VA orthopedic surgery note shows that the Veteran's knee caused pain when walking up and down steps and after sitting for a long period of time. Her knee was stable to Lachman, posterior drawer, and varus/valgus stress testing. The patella was tender to palpation with pressure. A May 2013 VA orthopedic surgery note shows that the Veteran's knee caused pain when walking up and down steps and after sitting for a long period of time. Her knee was stable to Lachman, posterior drawer, and varus/valgus stress testing. The patella was tender to palpation with pressure. During a March 2015 physical therapy consultation, the Veteran had left knee strength of four out of five. Varus stress testing was positive, with medical knee gapping. Lachman's test and the anterior drawer test were negative. The Veteran underwent a VA examination for her left knee in May 2015. During the examination the Veteran reported that she was in constant pain, which she described as cracking and locking, as well as a sharp pain when descending stairs. She reported that she had to use a handrail to descend stairs. According to her account, when she walked for more than 30 minutes she could not stand the next day due to her ankle and knee pain. Her knee pain disrupted her sleep. At the time of the examination, she stated that she had not been able to work for the prior four days due to her knees, ankles, and hips. She did not report experiencing flare-ups. The Veteran described her functional loss as pain, weakness, limited range of motion, and feelings of instability. Range of motion testing showed flexion from 0 to 100 degrees, and extension from 100 to 0 degrees. The examiner noted that the lost range of motion did not itself contribute to functional loss. The examiner further stated that pain was noted on flexion, which did cause functional loss. There was evidence of pain on weight bearing and objective evidence of crepitus, but no localized tenderness or pain on palpation. The Veteran was able to perform repetitive use with at least three repetitions without any additional functional loss or lost range of motion. The Veteran was not examined immediately after repetitive use, and the examiner stated that the examination was neither consistent nor inconsistent with the Veteran's description of functional loss. However, the examiner opined that it was impossible to say without mere speculation whether there would be any additional lost range of motion, compared to the VA examination findings, during a flare-up or over a period of time. The examiner found that the Veteran's left knee disability resulted in a disturbance of locomotion and interference with standing. Muscle strength testing showed active movement against some resistance, or four out of a possible five. The Veteran's knee was not ankylosed. The examiner noted that the Veteran did not have a history of recurrent subluxation, lateral instability, or effusion. Joint stability testing was normal. The examiner also noted no history of recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. Nor did the examiner find any history of a meniscus condition. The Veteran was wearing a knee brace on a constant basis. The examiner described the impact of the Veteran's condition on employment as pain and limited range of motion. In November 2015, a VA physician reviewed an MRI conducted in 2012, which showed patellar chondrosis, areas of full-thickness cartilage loss, subchondral marrow edema, an intraarticular loose body, trace joint effusion, and trace Baker's cyst. The Veteran was afforded a VA examination for her right knee in October 2016. While the examination focused on the right knee, the examiner also examined the Veteran left knee. Range of motion testing showed flexion from 0 to 130 degrees, and extension from 0 to 140 degrees. No pain was noted on the examination. There was no evidence of pain on weight bearing, no tenderness on or pain on palpation, and no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without any additional functional loss. The Veteran was examined immediately after repetitive use over time. The examiner opined that it would be impossible to indicate any additional loss or range of motion, pain, weakness, or fatigability compared to the VA examination findings, during a flare-up or over a period of time without resorting to mere speculation. Muscle strength testing was normal, and the examiner noted no muscle atrophy. There was no ankylosis documented. The examiner noted no history of recurrent subluxation, instability, or effusion. Stability testing was normal. The Veteran was again afforded a VA examination in June 2017. During the examination the Veteran reported left knee pain when she knelt and squatted. She also reported occasional locking. She described her symptoms as worse when she was going down stairs, and had to hold the rail and had fallen. The Veteran stated that she had intentionally lost 50 pounds in about the past year. She went to gym most days and used a bike and elliptical. She used biofreeze, motrin, and rest when her knee hurt. The Veteran reported that she experienced flare-ups with overuse, which she described as pain. She stated that after over-use she had additional functional loss including an inability to do yard work, as well as difficulty getting in and out of vehicles, up and down stairs, and out of chairs. Range of motion testing of her left knee showed flexion from 0 to 120 degrees and extension from 140 to 0 degrees. The examiner noted that the Veteran experienced pain on flexion, which led to the functional loss. There was evidence of pain on weight bearing, evidence of tenderness or pain on palpation on the top of her patella, but no evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without any additional functional loss. The Veteran was not examined during a flare-up, but was examined immediately after repetitive use over time. The examiner opined that it would be impossible to indicate any additional loss or range of motion, pain, weakness, or fatigability compared to the VA examination findings, during a flare-up or over a period of time without resorting to mere speculation. Muscle strength testing was normal, and the examiner noted no muscle atrophy. There was no ankylosis documented. The examiner noted no history of recurrent subluxation, instability, or effusion. Stability testing was normal. The examiner also noted no history of recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The Veteran regularly used a brace. Arthritis was confirmed by x-rays dated in July 2011. The examiner opined that the Veteran would be unable to do heavy physical labor, including lifting and carrying more than 30 pounds, as well as any occupations that require long periods of standing, walking and going up and down stairs or that required kneeling, bending, squatting. However, the examiner found that the Veteran would be able to do sedentary work. The examiner also examined the Veteran's right knee joint, and noted no pain on non-weight-bearing or passive range of motion testing during the examination, but the Board notes that the Veteran is service connected for right knee degenerative arthritis as well, thus there is no uninjured contralateral joint. The Veteran's left knee disability is rated under Diagnostic Code 5003. As mentioned above, degenerative arthritis that results in limitation of motion that is non-compensable under another diagnostic code can be rated under 5003. Under Diagnostic Code 5003 such limitation of motion of a major joint is given a 10 percent rating. When considering limitation of motion of the Veteran's left knee joint, the Board finds that the evidence of record weighs against assigning a rating in excess of 10 percent at any time during the course of the appeal. Specifically, the evidence of record does not support a finding that the Veteran's left knee disability has resulted in, or more nearly approximated, flexion limited to 30 degrees or less, or extension limited to 15 degrees or more, at any time during the pendency of the appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. On the contrary, a careful review of the Veteran's VA examination reports and medical treatment records reflects throughout the course of the appeal, her left knee disability has been manifested by flexion ranging between 100 and 130 degrees, and extension no worse than 0 degrees, which only warrants a noncompensable rating under Diagnostic Code 5260 or 5261. See 38 C.F.R. § 4.71a, Diagnostic Code 5260-61. Thus, the degenerative arthritis in the Veteran's knee qualifies for a no greater than the 10 percent rating for non-compensable limitation of motion under Diagnostic Code 5003. There is also no basis for assigning a rating higher than 10 percent based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7. As demonstrated by the competent medical evidence of record, the assigned 10 percent rating properly compensates the Veteran for the extent of functional loss resulting from factors such as functional loss due to pain, weakness, fatigue, repetitive use over time, and flare-ups. The July 2011 VA examiner reported that after repetitive use testing, the Veteran's range of motion on flexion decreased from 120 degrees to 110 degrees. The examiner also noted pain on motion, and opined that the Veteran's disability resulted in decreased mobility, problems with lifting and carrying, weakness or fatigue, and pain. The November 2012 VA examination report indicated that the Veteran had flexion to 110 degrees, with pain beginning at 100 degrees. After repetitive use testing the examiner opined that repetitive use was productive of less movement than normal, weakened movement, excess fatigability, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing, and weight-bearing; however, the Veteran still had flexion to 100 degrees. The May 2015 VA examiner reported flexion to 100 degrees, but opined the lost range of motion did not itself contribute to functional loss. The examiner further stated that pain was noted on flexion, which did cause functional loss. The Veteran was able to perform repetitive use with at least three repetitions without any additional functional loss or lost range of motion. During the June 2017 VA examination, the Veteran had flexion to 120 degrees, with pain on flexion that led to functional loss; however, she was able to perform repetitive use testing with at least three repetitions without any additional functional loss. The Veteran stated that after over-use she experienced additional functional loss including an inability to do yard work, as well as difficulty getting in and out of vehicles, up and down stairs, and out of chairs. As for flare-ups, the Veteran has reported flare-ups which are precipitated by going up stairs, prolonged sitting, kneeling, squatting, and weather. She described the flare-ups as severe, occurring weekly and lasting hours. In addition to the above-noted objective findings, the Board finds significant that when addressing functional limitations posed by the Veteran's left knee disability, the July 2011 examiner opined that the Veteran's knee condition included mild interference with chores, shopping, exercise, recreation, traveling, and driving, as well as severe interference with sports. The May 2015 VA examiner found that the Veteran's left knee disability resulted in a disturbance of locomotion and interference with standing. Finally, the June 2017 examiner opined that the Veteran would be unable to do heavy physical labor, including lifting and carrying more than 30 pounds, as well as any occupations that require long periods of standing, walking and going up and down stairs or that required kneeling, bending, squatting. The Veteran reported that she went to gym most days and used a bike and elliptical. Based on these findings and assessments regarding the Veteran's ROM and the functional impact of her left knee disability on the ability to perform daily activities and/or occupational tasks, the Board finds that the evidence of record is against a finding that the Veteran's disability picture has more nearly approximated the criteria for a 20 percent rating based on limitation of flexion, or for a separate rating based on limitation of extension. Even when considering functional loss due to factors such as pain, the examination reports suggest that pain primarily limits the Veteran's functional ability to walk, stand for prolonged periods of time, kneel, bend, squat, and go up and down stairs without pain, but they do not suggest that the Veteran's pain or flare-ups result in additional loss of ROM so as to warrant a higher or separate rating. Specifically, the evidence does not suggest that functional loss on account of pain or flare-ups has resulted in the Veteran's disability picture generally approximating flexion limited to 30 degrees or less, or extension limited to 15 degrees or more at any time during the course of the appeal. As noted above, when rating knee disabilities, VA may assign separate ratings for limitation of motion and for recurrent lateral instability or subluxation. The Veteran reported feelings of instability during the July 2011 and May 2015 VA examinations. While the Veteran is competent to report observable symptoms such as feelings of instability, these reports appear to be isolated and there is no objective or subjective evidence of record that tends to suggest recurrent left knee instability. Similarly, while a March 2015 VA treatment record showed positive varus stress testing, Lachman's test and anterior drawer testing were normal, and the remainder of the medical evidence of record shows normal stability testing. See VA treatment records dated in October 2012 and December 2012; VA examination reports dated in July 2011, November 2012, May 2015, October 2016, and June 2017. Moreover, VA examination reports dated in July 2011, November 2012, May 2015, October 2016, and June 2017 indicate that the Veteran did not have a history of recurrent instability. Further, there is no indication in the evidence of record that the Veteran has experienced any recurrent subluxation. Thus, when considering factors such as frequency of complaints and objective medical evidence, the preponderance of the evidence is against a finding of recurrent lateral instability or subluxation to warrant a separate rating of 10 percent or more. Further, the Veteran is not entitled to a higher rating under diagnostic code 5258 (cartilage, semilunar, dislocated, with frequent episodes of "locking," pain and effusion into the joint). In addition to pain, there is evidence that the Veteran has complained of frequent episodes of "locking." See, e.g., October 2012 Veteran statement; November 2012 VA examination report; May 2015 VA examination report; and June 2017 VA examination report. However, while there is some evidence of trace joint effusion in VA treatment records dated in April and October 2012, there is no evidence of frequent episodes of effusion into the joint. Moreover, there is no evidence showing a history of any meniscal dislocation or other meniscal condition. The Board has also considered whether an additional or higher rating would be available under other diagnostic codes pertaining to the knee. There is no indication of left knee ankylosis; and no impairment of the tibia or fibula. As such, there is no basis for evaluating the Veteran's disability under Diagnostic Codes 5256 (ankylosis), or 5262 (impairment of tibia and/or fibula). See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262. Finally, the Board has considered the Veteran and her co-workers' lay statements describing the Veteran's pain and discomfort, as well as the impact that her left knee disability has had on her work and activities of daily living. As reflected above, the Veteran has reported that on account of her left knee disability, she experiences constant pain in her left knee, has difficulty with activities such as prolonged standing and walking, and avoids activities such as climbing stairs, squatting, and kneeling. According to both the Veteran and her co-workers, she has had to leave work on occasion due to pain, although it is unclear from these statements whether this was due to pain in her knee, or a combination of factors. She also wears a left knee brace for support. However, the Board finds that after considering all the medical and lay evidence, the objective findings do not support a rating higher than 10 percent for limited range of motion at any time during the appeal period. Accordingly, the preponderance of the evidence is against assigning a rating in excess of 10 percent at any time during the course of the appeal. ORDER Entitlement to a disability rating in excess of 10 percent for a left knee disability is denied. ____________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs