Citation Nr: 1804403 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 12-20 833A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased rating for residuals of a right patella fracture with medial cruciate ligament tear, currently rated as 10 percent disabling. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Anderson, Counsel INTRODUCTION The Veteran served on active duty from June 1979 to April 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In March 2015, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding is of record. In September 2015, the case was remanded for additional development. FINDING OF FACT Throughout the pendency of the appeal, the preponderance of the probative evidence indicates that the Veteran's right knee disability was manifested by decreased motion, pain, intermittent crepitation, and subjective sensations of locking and giving away; it was not manifested by flexion limited to 60 degrees, extension limited to 10 degrees, recurrent subluxation, lateral instability, or dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. CONCLUSION OF LAW The criteria for a right knee disability rating in excess of 10 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5258, 5260, 5261 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran has raised no 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 a duty to assist argument). The Board also finds there has been substantial compliance with the prior remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In December 2016, VA requested that the Veteran identify any relevant recent private treatment providers. While partially completed VA Forms 21-4142 were received in May 2017, the Veteran had not identified any treatment provider. In July 2017, VA inquired whether the Veteran's Social Security Administration (SSA) disability benefits were related to his knee. In August 2017, the Veteran responded that his SSA benefits were not related to his right knee. The Veteran was afforded a VA knee examination in September 2017. Finally, additional treatment records have been obtained. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2017). Other applicable general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2017); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2017); where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2017); and evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2017). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2017); see also 38 C.F.R. §§ 4.45, 4.59 (2017). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2017). Under Diagnostic Code 5260, flexion that is limited to 60 degrees warrants a 0 percent rating; flexion that is limited to 45 degrees warrants a 10 percent rating; flexion that is limited to 30 degrees warrants a 20 percent rating; and flexion that is limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2017). Under Diagnostic Code 5261, extension that is limited to 5 degrees warrants a 0 percent rating; extension that is limited to 10 degrees warrants a 10 percent rating; and extension that is limited to 15 degrees warrants a 20 percent rating; extension that is limited to 20 degrees warrants a 30 percent rating; extension that is limited to 30 degrees warrants a 40 percent rating; and extension that is limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2017). Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2017). Under Diagnostic Code 5257, recurrent subluxation or lateral instability of the knee warrants a 10 percent rating when it is slight, a 20 percent rating when it is moderate, and a 30 percent rating when it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2017). Under Diagnostic Code 5258, a 20 percent rating is assigned for a knee with dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2017). The Veteran essentially contends that his service-connected right knee disability is worse than currently rated. In a November 2009 statement the Veteran stated that due to his right knee he had pain and problems walking distances. A December 2009 prescription from Dr. Gonzalez referred the Veteran for physical therapy because of brachial neuritis and right knee / lower extremity pain which resulted in difficulty walking. A December 2009 record from La Cardidad Home Health Corp indicates that the Veteran had functional limitations regarding contracture, endurance, and ambulation. However, it was noted that he was able to be up as tolerated and exercise as prescribed. In a January 2010 statement the Veteran reported that his knee had not been problematic until recently. However, he now had problems walking, pain, and would benefit from physical therapy. A January 2010 VA orthopedic record notes that the Veteran had pain and difficulty walking during cold weather. The Veteran was observed to have gait difficulties while walking secondary to pain. There was no evidence of swelling, and testing indicated that the Veteran's medial, lateral, anterior, and posterior cruciate ligaments were stable. The physicians noted that the Veteran was very apprehensive and reported pain throughout the examination. A cane was ordered for the Veteran as he reported difficulty walking. A February 2010 VA orthopedic note indicated that the Veteran endorsed knee pain and that a recent MRI showed a small tear, osteoarthritis, and chondromalacia. The physician noted that the Veteran was not a surgical candidate but could benefit from Ibuprofen and a knee brace to feel more comfortable. At a March 2010 VA knee examination the Veteran endorsed progressive knee pain, stiffness, and weakness. He denied any trauma, surgery, hospitalization, or steroid injection since his last evaluation. He reported pain, stiffness, weakness, giving way, decreased speed of joint motion, impeded motion, effusion, and daily flare-ups of knee symptoms. He stated that walking, standing, squats, stairs, jogging, jumping, lifting, and carrying aggravated his knee, while rest and activity modification provided partial relief. He denied deformity, instability, incoordination, episodes of dislocation or subluxation, episodes of locking, or inflammation. The Veteran reported that he could stand for five minutes and walk half a block with use of a cane and knee brace. Upon physical examination, there was evidence of crepitation, patellar abnormality in the form of sub-patellar tenderness, and meniscus abnormality in the form of evidence of a tear and joint line tenderness. There was no evidence of a mass behind the knee, clicks or snaps, grinding, instability, locking, effusion, dislocation, ankylosis, surgically absent meniscus, abnormal tendons or bursae, or other knee abnormality. The Veteran had right knee flexion to 100 degrees and extension to zero degrees. There was evidence of pain following repetitive motion but there was no additional reduction in range of motion. The examiner noted that the Veteran was uncooperative throughout range of motion examination, but indicated that the Veteran was observed to have active flexion to at least 100 degrees while ambulating and sitting. X-ray studies conducted in conjunction with the examination were normal except for evidence of a lateral meniscal tear and mild abnormal signal at the medial joint compartment. There was no significant joint effusion or bursal collection. The impression was high suspicions of a small horizontal tear involving the lateral meniscus, degenerative changes around the posterior horn of the medial meniscus, and low grade medial chondromalacia. With regard to functional impairment, the examiner noted that the Veteran was unemployed due to a comorbidity of medical and musculoskeletal problems. The examiner opined that the Veteran's service-connected right knee condition would have significant effects on the Veteran's prior warehouse and detailing work. Specifically, the Veteran would have problems with lifting and carrying, decreased stamina, weakness or fatigue, decreased strength, and pain. The examiner opined that the Veteran's knee disability prevented sports and exercise; had severe effects on chores, shopping, recreation, and driving; moderate effects on traveling; mild effects on bathing, dressing, toileting, and grooming; and no effects on feeding. At an April 2010 VA appointment, the Veteran endorsed knee pain. Upon examination, the Veteran's extremities were free from edema, joint swelling, and warmth. Full range of motion of the right knee was observed. A June 2010 orthopedic note indicates that the Veteran had right knee pain that was aggravated by flexion. The Veteran was noted to use a cane, which he alternated between his right and left hand, sometimes limping on his right leg and at other times limping on his left side. Upon examination, the Veteran's knee was inconsistently tender; there was no evidence of swelling or crepitus. Range of motion testing revealed "good, strong full, extension" but voluntary flexion was limited to 30 degrees. The orthopedist noted that radiographs and MRI studies from December 2009 and January 2010 were normal, without any evidence of a healed fracture, or any patella deformity. The Veteran was assessed with knee pain unexplained by examination and imaging. A nursing note from the same day indicated that the Veteran reported that his knee disability had progressively worsened. He was observed to ambulate with a cane for stability. With regard to his pain he described it as an aching, heavy, nagging, and popping pain. He stated that assistive devices, a knee brace, and lying down alleviated the pain, while changing positions, sitting, standing, walking, and weather aggravated his pain. A July 2010 record from La Cardidad Home Health Corp noted that the Veteran had gait dysfunction secondary to knee pain. Upon examination, the Veteran's right knee muscle strength was assessed as 3-/5; he had flexion to 80 degrees, and flexion to 4 degrees. At an August 2010 appointment, the Veteran was noted to have gait dysfunction secondary to his right knee disability. Upon assessment, the Veteran's bilateral lower extremity strength was rated as 4/5 and he was estimated to have 80 percent of normal range of motion. He rated his current knee pain was 1 out of 10. A November 2010 record from La Cardidad Home Health Corp indicates that the Veteran had lumbar pain that radiated into his lower extremities, intermittent dull aching pain in his bilateral knees, decreased range of motion and muscle strength in both knee joints, and was at a moderate risk of falling. Upon examination, the Veteran's right knee muscle strength and range of motion were assessed as 2+/5. The physical therapy goals pertaining to the Veteran's low back and knees were to increase his bilateral knee lateral bend to 90 degrees, extension to 4 degrees, and increase muscle strength to 4/5. A December 7, 2010 treatment record indicates that the Veteran had muscle strength of 4/5, flexion to 90 degrees, and extension to 5 degrees. It was also noted that the Veteran could ambulate 92 feet. Records from December 9, 2010 and December 11, 2010 record indicate that the Veteran had a dysfunctional gait secondary to lumbar spine and right knee pain. He was noted to have muscle strength of 4/5, flexion to 90 degrees, and extension to 4 degrees. It was also noted that the Veteran could ambulate 102 feet and 120 feet. VA treatment records from January 2011 and February 2011 note that the Veteran complained about right knee arthritis. However, specific complaints were not noted and he denied any stiffness. Examination of the Veteran's extremities was noted to be unremarkable. VA treatment records within this period repeatedly indicate that the Veteran was moving all extremities within normal limits and that lower extremity examination did not reveal any tenderness. A March 2011 VA treatment record noted that musculoskeletal assessment was within normal limits, and that the Veteran did not have any mobility limitations or evidence of gait dysfunction. A March 15, 2011 record from La Caridad Home Health Corp notes that the Veteran's bilateral leg pain interfered with movement, ambulation, and activities of daily living. The Veteran's right knee muscle strength was assessed as 3-/5 and his right knee motion was noted to be reduced by approximately 50 percent. A March 26, 2011 treatment record indicates the Veteran's right knee muscle strength was 3+/5 and that he had approximately 70 percent of normal knee motion. A March 31, 2011 record notes that the Veteran's right knee motion was within full limits, that his muscle strength was 4/5, and that he was able to ambulate 100 feet. A March 2011 VA treatment record indicates that the Veteran reported ongoing knee pain and requested an orthopedic consultation. It was noted that there was a misunderstanding by the Veteran that the only option available for his service-connected right knee disability was surgical intervention. The Veteran was instead referred for physical therapy. Upon examination, there was no evidence of right knee swelling or effusion. A November 2011 VA treatment record indicates that musculoskeletal assessment was within normal limits. No gait dysfunction was observed. A February 2012 treatment record notes that the Veteran had full range of motion in all extremities and ambulated without any assistive devices other than a knee brace. In June 2012 statements, the Veteran reported that his right knee was so bad that there was nothing else his private treatment provider could do absent surgery. The Veteran also noted that his knee cracked when it rained, and that he had a hard time walking and bending his knee, and that he used a cane and knee brace. A November 2012 record from AMR - Dade County indicates that physical examination of the Veteran's extremities was normal. Likewise a VA treatment record from the same date indicates that musculoskeletal examination was normal and that the Veteran was ambulatory. Treatment records dated later in November 2012 indicate that the Veteran had some difficulty ambulating; however, that difficulty was attributed to a condition other than the Veteran's knee. VA treatment records from January 26, 2013, January 27, 2013, January 28, 2013, January 29, 2013, and January 30, 2013 indicate that the Veteran had full range of motion in all extremities. A March 2013 VA treatment record indicates that the Veteran had full range of motion of all extremities, but ambulated with an unsteady gait. The record notes that Veteran had been admitted recently for dizziness secondary to drug and alcohol use and was currently being treated for infected condylomas. The Veteran's unsteadiness was not attributed to his knee disability. A March 6, 2013 treatment record indicates that the Veteran was able to ambulate without any difficulties. VA treatment records dated in May 2013 indicate that the Veteran denied any pain or discomfort, was ambulatory, and was provided a knee brace. VA treatment records dated in June 2013 indicate that the Veteran denied any musculoskeletal weakness, pain, or stiffness. The Veteran was noted to ambulate with a normal gait without any assistance. Muscle strength and muscle tone were also noted to be normal. A September 2013 VA treatment record again noted that the Veteran's gait was normal. An October 2013 VA treatment record indicated that the Veteran reported right knee pain. Upon examination, he had limited range of motion of the right knee, but there was no evidence of crepitus, warmth, tenderness, or swelling. A March 2014 VA treatment record indicates that the Veteran was prescribed a right knee neoprene-hinged brace to provide collateral ligament support. He was observed to ambulate without any assistance. A March 2014 VA treatment record indicates that the Veteran was prescribed a right knee neoprene-hinged brace to provide collateral ligament support. He was observed to ambulate without any assistance. A September 2014 treatment record indicates that the Veteran ambulated without any assistance and that examination revealed no lower extremity deformities. A VA primary care note approximately one week later indicates that the Veteran reported increasing knee pain that impacted his ability to walk. The Veteran was observed to wear a right knee brace and ambulate with a cane. Upon examination there was no evidence of edema. A treatment record from the next day notes that the Veteran ambulated with a good gait. X-rays dated in September 2014 indicate that the Veteran's right knee joint was preserved with no evidence of narrowing or joint effusion. A November 2014 VA orthopedic note indicates that the Veteran reported knee discomfort that was partially alleviated with ibuprofen and use of a cane. The orthopedist noted that the Veteran resisted attempts to examine the stability and range of motion of his knees, reacting as if he was uncomfortable. The orthopedist noted that the Veteran's line discomfort could not be adequately evaluated because the Veteran jumped whenever his knee was touched. The orthopedist opined that the Veteran's knee was completely stable and that there was no indication for any surgery or further testing. He further noted that a more accurate opinion could be rendered if the Veteran tolerated attempts to examine the knee but that seemed unlikely in light of the Veteran's pending disability rating appeal. VA treatment records from December 2014 note that the Veteran ambulated independently without assistance and that there was no deformity or edema evident in the Veteran's extremities. At his March 2015 hearing the Veteran testified that he had been issued a metal knee brace that prevented him from doing a lot of things he would normally like to do. He noted that the brace prevented him from fully bending his knee and that his knee popped and slipped. He indicated that his knee slipped when he played basketball, rode his bike, sat, and occasionally when he ascended stairs. With regard to flare-ups, the Veteran stated that he had pain that ran down the back of his leg and that sometimes his leg froze like it was jammed up. He denied any knee swelling, but noted sometimes it was a little puffy. He stated that he always used a knee brace and a cane and noted that his knee locked, popped, froze, and felt as if it would give out. VA treatment records from April 2015 note that the Veteran denied any arthralgia, weakness, or joint swelling. However, he was noted to have impaired bilateral lower extremity movement secondary to his multiple skin lesions. A June 2015 VA treatment record indicates that the Veteran denied joint arthralgia, weakness, or swelling. VA treatment records from September 2015 indicate that the Veteran denied joint pain, joint weakness, joint swelling, and decreased joint motion. However, he was noted to have minimal bilateral lower extremity strength secondary to pain and wound healing related to his extensive condylomas. A February 24, 2016 record indicates that the Veteran denied joint pain, muscle pain, muscle weakness, muscle tenderness, or joint swelling. Upon examination there was no evidence of joint erythema, swelling, or tenderness. A February 25, 2016 treatment record indicates that the Veteran had limited range of motion and stiffness in his legs due to pain and scar tissue related to his condylomas. The Veteran denied any arthralgia or joint swelling. Treatment records from March 2016 indicate that the Veteran was able to move all extremities without any deficits and that he denied any musculoskeletal complaints. VA treatment records from April 2016 indicate that the Veteran had active range of motion of the knee within functional limits or within full limits. It was noted that he had difficulty ambulating, used a cane or walker, and had lower extremity weakness and pain related to his previously infected condylomas that were healing. VA treatment records from September 2016 indicate that the Veteran's right knee pain was unimproved by his knee brace. He was noted to have gait problems and ambulate with a cane secondary to right knee pain. Upon examination, there was no evidence of swelling, tenderness, or decreased range of motion. An October 2016 treatment record notes that the Veteran was unsatisfied with his knee brace because it did not allow him to get a clothing allowance. He requested an orthopedic consultation so he could obtain a clothing allowance. At a November 2016 VA appointment the Veteran endorsed right knee pain. Examination revealed no evidence of swelling, tenderness, or decreased motion. However, he was observed to walk with a cane secondary to his right knee pain. A December 2016 orthopedic note indicates that the Veteran had limited motion of the right knee and used a cane and knee brace. The Veteran reported right knee pain and giving out. It was noted that the Veteran was argumentative and refused examination of the right knee, which prevented proper evaluation the Veteran's symptomatology. The clinician opined that there was no evidence of effusion or instability or indication for any need for bracing, injections, or surgery. The Veteran was encouraged to engage in muscle strengthening either on his own or through physical therapy. A January 2017 VA treatment record notes that the Veteran had a history of right knee pain that was controlled with Diclofenac. A record later that month indicates that musculoskeletal examination revealed no joint pain or abnormalities. A February 2017 VA treatment record indicates that musculoskeletal examination was negative for any evidence of muscle or joint pain. It was noted that the Veteran reported he stayed active by walking. However, he also reported that his walking on stairs or uneven ground was limited secondary to knee pain. A March 2017 VA treatment record indicates that the Veteran ambulated with a steady gait and moved all extremities without any deficits. At a subsequent March 2017 appointment it was noted that the Veteran endorsed limited flexion secondary to wound pain and tightness following his condyloma excision. VA treatment records from May 2017, July 2017, and August 2017 indicate that the Veteran ambulated without any assistance and that he reported he walked in the park for recreation. A September 7, 2017 VA podiatry record indicates that the Veteran presented to the clinic ambulating without any assistance. Gait examination revealed no gross deformities. At his VA knee examination later the same day, the Veteran reported for the examination in a wheelchair with a cane in his lap. He stated his use of the assistive devices was occasional, and noted that he used a walker at home. He transferred to the examination table independently and exhibited a steady gait. He reported that his knee hurt very badly and was always achy, weak, and very sensitive to touch. He reported that he was unable to walk more than 15 feet. He stated that he treated his knee pain with over-the-counter medication. He denied experiencing any flare-ups of knee symptomatology, but endorsed functional loss in the form of tenderness and an inability to move his knee. The examination report indicates that the examiner removed the Veteran's knee brace without any problems, including when the examiner held the right leg. However, the examiner noted that once physical examination started the Veteran stated he was unable to move his knee because it was very tender. The Veteran agreed to perform passive range of motion testing but then withdrew his leg stating it hurt when the examiner touched the Veteran's lower leg. The examiner noted that it was impossible to perform range of motion or stability testing due to the Veteran's reports of pain throughout the lower extremity even with soft touch. The examiner further noted that the Veteran stated his knee was swollen, but the examiner did not see or feel any swelling. The examiner opined that there was no evidence of ankylosis, crepitus, or pain with weight bearing, but the Veteran endorsed pain, tenderness, and guarding in both knees. Muscle strength testing for extension and flexion was normal and there was no evidence of muscle atrophy or reduced muscle strength. It was noted that muscle strength testing was limited to observation of the Veteran's ability to stand and transfer to the examination table during which time the Veteran's ambulation appeared normal and steady. The examiner noted that the Veteran's assertion that he was unable to move his legs was "quite controversial as he is able to stand and sit." With regard to joint stability testing, the examiner again indicated that such testing was not able to be performed because the Veteran displayed "[s]evere voluntary guarding of his knees during the examination" and was withdrawing his legs with even a simple touch. The examiner opined that the Veteran had a semilunar cartilage condition and endorsed frequent episodes of chronic joint pain. The examiner noted that visual inspection of the Veteran's knee revealed no swelling or deformity. It was further noted that the Veteran cooperated with measuring his knees, which evidenced no deformity or atrophy. The Veteran's knees were symmetrical and there was no evidence of valgus or varus deformity. The examiner noted that the Veteran was unemployed and on SSA disability secondary to medical problems other than his right knee. In the remarks section, the examiner opined that the Veteran's reported symptoms were worse than the clinical picture, objective evidence, and previous orthopedic examinations. The examiner explained that prior podiatry notes, including one approximately 30 minutes prior to the knee examination, indicate that the Veteran ambulated without any assistive device. Nevertheless, the Veteran presented to the examination in a wheelchair stating that he was unable to walk. A September 22, 2017 VA treatment record indicates that musculoskeletal examination was negative and that the Veteran's range of motion was intact in all joints. A September 29, 2017 indicates that the Veteran ambulated independently and denied any pain at present. Likewise an October 17, 2017 treatment record indicates that the Veteran reported that he walked frequently and no mobility impairments were noted. However, at a subsequent appointment from the same day the Veteran endorsed arthralgia and was observed to walk with a cane. Upon review of the evidence, the Board finds that the criteria for a rating in excess of 10 percent have not been met. The preponderance of the evidence demonstrates that throughout the appeal period, the Veteran has reported symptoms included pain, intermittent limitation of motion, trouble ambulating, and subjective sensations of giving way and locking. However, the Board does not find the Veteran's reports as to the symptomatology and severity of his knee disability to be credible. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995) As shown above, the medical evidence throughout the appeal period reflects inconsistent reports and findings, as well as the Veteran being uncooperative on examination on multiple occasions, despite being observed to not have such limitations at other points during the examinations. (See e.g. March 2010 VA knee examination, June 2010 orthopedic evaluation, December 2016 orthopedic note, September 2017 VA examination). The most significant instance of this is evidenced by the September 2017 examination report. At that time he reported for the examination in a wheelchair asserting that he was unable to move his knee or walk. Nevertheless, a podiatry note from an appointment just hours prior indicated that the Veteran presented to the clinic in no apparent distress and ambulated without any assistance. His assertions regarding the severity of his knee disability are further undermined by the examiner's observation that the Veteran was able to stand and transfer independently from the wheelchair to the examining table with normal weight bearing and a steady gait. While the Veteran requested that the examiner remove his knee brace for him and allowed him to do so without any reports of pain, the Veteran later refused to perform range of motion testing by withdrawing his leg and reporting he was in too much pain when the examiner softly touched either leg. As the Veteran's presentation and reports regarding his symptomatology are inconsistent with the examiners' observations during examination and with the other medical evidence in proximity to the examinations, the Board finds the Veteran's assertions as to the severity of symptomatology and his asserted functional impairment to lack credibility. Id. Moreover, despite private treatment notes and some VA records reflect decreased range of motion and strength as well as gait disturbance, numerous VA treatment records reveal no such impairment. Indeed, the Veteran was noted to have range of motion within normal limits in April 2010, January 2011, February 2011, March 2011, and November 2011 when he was noted to have no mobility limitations or gait dysfunction. He also had full range of motion in February 2012, January 2013 and March 2013. In June 2013 he denied musculoskeletal weakness or pain, was able to ambulate with a normal gait without assistance and muscle strength was normal. Similar findings were noted at VA medical visits in 2015 and 2016. Indeed, a February 24, 2016 record indicates that the Veteran denied joint pain, muscle pain, muscle weakness, muscle tenderness, or joint swelling. In a February 2017 visit there was no evidence of muscle or joint pain and the Veteran reported that he stayed active by walking. During 2015 to 2017 lower extremity and gait limitations were noted to be due to infected and surgically treated skin lesions. (See e.g. September 2015, February 2016, April 2016, March 2017 VA treatment records). In sum, the Veteran's presentation to treatment clinics when not specifically for a knee evaluation reflect significantly less impairment than when presenting for visits that pertained to his disability for which he was seeking increased compensation. This conclusion is further bolstered by the November 2014 orthopedic clinician's noting the Veteran refused to cooperate with the evaluation and that the Veteran's actions appear to be motivated by his pending disability appeal, as well at the October 2017 VA treatment record noting the Veteran's request for a different knee brace because the one he had been given did not qualify him for the monetary clothing allowance benefit and he wanted one that did. Thus, the Board finds the Veteran's reports to treatment providers in conjunction with his claim reflect an exaggeration of symptoms and are not credible. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a Veteran's testimony simply because the Veteran is an interested party; personal interest may, however, affect the credibility of the evidence). In light of the inconsistent reporting and the lack of cooperation during examinations, any medical examination or evaluation based upon this unreliable reporting is not persuasive or probative. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Thus, the weight of the credible and probative evidence indicates that the right knee disability was not manifested by flexion limited to 45 degrees, extension limited to 10 degrees, recurrent subluxation or lateral instability, or dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. With regard to limitation of motion, the weight of probative evidence indicates that the Veteran's right knee disability was not manifested by flexion limited to 45 degrees or extension limited to 10 degrees. The Board acknowledges that a June 14, 2010 treatment record indicates that the Veteran voluntarily limited his flexion to 30 degrees. However, as noted above, the Veteran was frequently uncooperative, resisted attempts to adequately examine his right knee, and exaggerated the functional limitations related to his right knee; thus, the Board does not find the voluntary limitation to be credible. Additionally, the Veteran's flexion at that appointment is vastly different than other range of motion findings in close proximity. See March 2010 VA Joints Examination Report noting right knee flexion to 100 degrees; May 30, 2010 VA treatment record noting full range of motion; and July 29, 2010 record from La Caridad Home Health Corp noting flexion to 80 degrees. The Board also considered the Veteran's report at the September 2017 examination that he was unable to perform range of motion testing, but for the reasons noted above, the Board does not find such assertion credible. In sum, there is no competent and credible evidence supporting a finding of limitation of flexion to 45 degrees or worse or extension limited to 10 degrees or worse. The Board also considered whether the Veteran's knee pain resulted in a level of functional loss greater than that already contemplated by the assigned rating. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45 (2017). However, as noted above the Veteran has been uncooperative and resisted attempts to examine his right knee throughout the pendency of the appeal and his assertions as to the extent and severity of his functional limitations has been found to lack credibility. Accordingly, the Board finds that the bulk of medical records and documented observations by medical professionals indicate that the Veteran's right knee range of motion was within functional limits did not more nearly approximate the criteria for a higher rating under Diagnostic Codes 5260 and / or 5261. 38 C.F.R. § 4.71a (2017). The Board also considered whether the Veteran is entitled to an increased rating under Diagnostic Code 5257 for recurrent subluxation or lateral instability. With regard to the Veteran's use of a knee brace, the evidence of record indicates that the Veteran used it for pain relief. The Board acknowledges that a March 7, 2014 prosthetics note indicates that the brace was appropriate to provide collateral ligament support. Nevertheless, the March 2010 VA examiner indicated that the Veteran did not have episodes of instability or subluxation and noted the Veteran's knee appeared stable. The November 3, 2014 and December 29, 2016 orthopedists also opined that the Veteran's right knee appeared stable. Moreover, VA treatment records from February 4, 2010, June 14, 2010, and September 29, 2016 suggest that the brace was for pain relief. Accordingly, the weight of probative evidence indicates that a rating under Diagnostic Code 5257 is not warranted. The Board also considered whether the Veteran is entitled to an increased rating under Diagnostic Code 5258 for dislocated semilunar cartilage. While the March 2010 VA examiner noted that the Veteran had patellar and meniscal abnormality in the form of tenderness, she nevertheless found that the Veteran did not have recurrent semilunar cartilage dislocation or locking. Likewise, the September 2017 examiner indicated that the Veteran did not have recurrent patellar dislocation and noted that the only symptom of the Veteran's meniscal condition was the Veteran's reports of frequent episodes of chronic pain. Accordingly, the Board finds that the notation regarding patellar and meniscal tenderness does not more nearly approximate the criteria specified under Diagnostic Code 5258, which requires "dislocation with frequent episodes of locking, pain, and effusion." 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2017). In summary, the preponderance of the competent, credible, and probative evidence is against assigning a rating in excess of 10 percent for the Veteran's right knee disability, and the appeal is denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to a rating in excess of 10 percent for a right knee disability is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs