Citation Nr: 18141736 Decision Date: 10/11/18 Archive Date: 10/11/18 DOCKET NO. 12-31 179A DATE: October 11, 2018 ORDER Entitlement to service connection for bilateral pes planus is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an increased rating greater than 10 percent for service-connected right knee degenerative joint disease is denied. Entitlement to an increased rating greater than 10 percent for traumatic arthritis of the left knee is denied. Entitlement to an increased rating greater than 20 percent for service-connected left knee anterior cruciate ligament insufficiency with subluxation, status post reconstructive surgery, is denied. Entitlement to an initial rating of 10 percent for left knee removal of the semilunar cartilage, symptomatic, effective February 26, 2010, is granted, subject to the rules and regulations governing monetary awards. Entitlement to an initial compensable rating for service-connected left leg discrepancy is denied. Entitlement to an initial compensable rating for service-connected left knee scars is denied. REMANDED Entitlement to service connection for asthma is remanded. FINDINGS OF FACT 1. The Veteran’s pes planus was noted on his service entrance examination and did not increase in severity during service. 2. The Veteran’s current tinnitus was not incurred in and is not otherwise etiologically related to his active service, to include conceded acoustic trauma. 3. For the entire period on appeal, the Veteran’s right knee degenerative joint disease has been manifested by degenerative joint disease noted on x-ray, extension to 0 degrees and flexion to 120 degrees with pain, but no ankylosis, subluxation, meniscus disabilities, or lateral instability. 4. For the entire period on appeal, the Veteran’s left knee traumatic arthritis has been manifested by degenerative joint disease noted on x-ray, extension to 0 degrees and flexion to 120 degrees with pain, but no ankylosis. 5. For the entire period on appeal, the Veteran’s left knee anterior cruciate ligament insufficiency with subluxation, status post reconstructive surgery, manifested as, at most, a level I Lachman’s test with firm endpoint, and no other evidence of lateral instability or recurrent subluxation. 6. For the entire period on appeal, the Veteran’s left knee disability manifested as removal of the semilunar cartilage that remained symptomatic with symptoms of recurrent effusion and locking pain. 7. During the entire period on appeal, evidence demonstrates that the Veteran’s left leg length discrepancy was no more than two centimeters. 8. The Veteran’s service-connected left knee scars consist of four linear superficial scars that are neither painful or unstable. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral pes planus have not been met. 38 U.S.C. §§1101, 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2017). 2. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). 3. The criteria for entitlement to an increased rating greater than 10 percent for service-connected right knee degenerative joint disease have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (2017). 4. The criteria for entitlement to an increased rating greater than 10 percent for traumatic arthritis of the left knee have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010 (2017). 5. The criteria for entitlement to an increased rating greater than 20 percent for service-connected left knee anterior cruciate ligament insufficiency with subluxation, status post reconstructive surgery, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257 (2017). 6. The criteria for entitlement to a separate compensable rating for symptomatic removal of the semilunar cartilage of the left knee have been met effective February 26, 2010. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5259 (2017). 7. The criteria for entitlement to an initial compensable rating for service-connected left leg discrepancy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5275 (2017). 8. The criteria for entitlement to an initial compensable rating for service-connected left knee scars have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.14, 4.27, 4.118, Diagnostic Codes 7804, 7805 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1994 through January 1999. The Veteran presented sworn testimony before the undersigned Veterans Law Judge during a June 2014 videoconference hearing. A transcript has been associated with the claims file. In October 2017, the Board remanded the above-listed issues for further development. The requested actions having been completed to the extent possible, and the claims having been readjudicated by the Regional Office (RO) in a March 2018 Supplemental Statement of the Case (SSOC), the matter has properly been returned to the Board for appellate consideration. See Stegall v. West, 11 Vet App. 268 (1998). In October 2017, the Board also remanded the issues of entitlement to service connection for diabetes mellitus, entitlement to service connection for obstructive sleep apnea, entitlement to an initial compensable rating for pseudofolliculitis barbae, and entitlement to an initial compensable rating for allergic rhinitis to provide the Veteran a Statement of the Case. The Veteran then filed timely substantive appeals for these issues in January 2018 and April 2018, requesting videoconference hearings, which have not yet been afforded to him. Accordingly, these issues are not before the Board at this time, as they are pending a hearing, which will be scheduled in accordance with the fact that his requests were received in 2018. In reviewing the Veteran’s appeal for increased ratings, the Board has not overlooked the holding of Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the United States Court of Appeals for Veterans Claims (Court) held that a claim for a total disability rating based on individual unemployability (TDIU) can be inferred as part of the original claim for an increased rating in certain circumstances. In this case, however, the Veteran has not asserted that he is unemployable, and the evidence in the claims file reflects he maintained employment as a correction officer. As such, the Board finds that Rice is not applicable to this appeal and the current decision need not consider whether the Veteran meets the criteria for entitlement to a TDIU. Several pieces of medical evidence have been added to the claims file since the March 2018 SSOC. However, in the August 2018 appellate brief, the Veteran’s representative waived Agency of Original Jurisdiction (AOJ) review of all evidence received since the last SSOC. Accordingly, the Board may proceed with appellate adjudication. Duty to Notify and Assist The Veteran has expressed discontent with the September 2010 QTC examination of his right knee degenerative joint disease, left knee traumatic arthritis, left knee anterior cruciate ligament insufficiency with subluxation, status post reconstructive surgery, left leg discrepancy, and left knee scars. The Veteran contends that the VA examiner did not receive supporting medical information from the VA hospital, and the information that was not viewed was the history and foundation of his claims. A presumption of regularity is applied to all manner of VA processes and procedures. Miley v. Principi, 366 F.3d 1343, 1346-47 (Fed. Cir. 2004) (“The presumption of regularity provides that, in the absence of clear evidence to the contrary, the court will presume that public officers have properly discharged their official duties.”); Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2008) (applying the presumption of regularity to VA examination). Clear evidence is required to rebut the presumption of regularity. Miley, 366 F.3d at 1347. Here, the Board finds the presumption of regularity has not been rebutted. First, the VA examination reports require the examiner to indicate where range of motion ends and where objective painful motion begins. The Veteran’s arguments do not demonstrate that the VA examiner’s report was inadequate in this regard, as it is unclear how a history and foundation of his various knee disabilities would inform the results of his range of motion testing or other physical evaluation of his knees to determine the most appropriate disability rating. Second, the Veteran was granted entitlement to service connection for his left leg discrepancy and his left knee scars based on the results of the September 2010 QTC examination, so any prejudice caused by the examiner not reviewing the medical records for the Veteran’s history is harmless error. Although evidence of the Veteran’s injuries and treatment for his right knee degenerative joint disease, left knee traumatic arthritis, left knee anterior cruciate ligament insufficiency with subluxation, status post reconstructive surgery, left leg discrepancy, and left knee scars is certainly relevant to his history, it is not necessarily relevant to the ratings to be assigned since service connection was granted. Neither the Veteran nor his representative has raised any other issues with the duty to notify, the duty to assist, or the conduct of his Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). 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 or Bryant hearing deficiency argument). Thus, the Board need not discuss any potential issues in this regard. Service Connection 1. Entitlement to service connection for bilateral pes planus The Veteran claims service connection for pes planus. Specifically, he asserts that his pes planus was the result of running in boots during service. Service treatment records reflect the Veteran had mild, asymptomatic pes planus noted on his April 1994 enlistment examination. The pes planus therefore preexisted service and the evidence must show that there was an increase in the disability during service to trigger the presumption of aggravation. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. See 38 C.F.R. § 3.306. Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare-ups is not evidence of an increase in disability). The Board finds that the Veteran’s preexisting pes planus did not increase in severity during service sufficient to trigger the presumption of aggravation. Service records, which appear to be complete, show that the Veteran did not report any foot trouble while on active duty service. Although he reported experiencing shin splints in December 1998, he reported no foot pain and no foot pain was noted in the clinical note. He was ordered to light duty and instructed to run only in running shoes, but the treatment was specifically to treat shin splints, not any foot trouble. During his May 1998 medical board evaluation, the Veteran specifically marked “no” when asked if he had any foot trouble on his report of medical history. Although the Veteran did not indicate whether he had foot trouble on his December 1998 report of medical history for his separation examination, no foot trouble, to include pes planus, was noted during the clinical evaluation. The Veteran was afforded a VA examination to determine the severity of his service connected knee disabilities in September 2010. During that examination, the examiner also conducted an examination of the Veteran’s feet. Although he reported he wore shoe inserts, the inserts were specifically to relieve his knee pain and were not associated with any foot trouble. The examiner found no evidence of abnormal weight bearing, breakdown, callosities, or any unusual shoe wear pattern. There were no reports of foot pain during examination. Post-service treatment records are silent for any complaints of foot pain or treatment until January 2012. A January 2012 VA treatment record noted the Veteran needed insoles; however, the insoles were for treatment of his knee pain, and there were no noted foot complaints. In May 2012, it was noted the Veteran needed new inserts for his flat feet. A November 2015 VA treatment record noted the Veteran needed new custom fit orthotics due to general plantar surface pain, and was diagnosed with flat foot and diabetes mellitus. The Veteran was afforded a VA examination to determine whether his bilateral pes planus was aggravated by his active duty service in April 2015. He did not report any foot pain, flare-ups, or functional loss due to his pes planus. Physical examination reflected no pain on manipulation, no swelling, no callouses, no tenderness to the plantar surfaces, no decreased longitudinal arch height on weight bearing, no objective evidence of marked deformity, no marked pronation, no inward bowing to the Achilles tendon, no inward displacement and severe spasm of the Achilles with manipulation, and his weight bearing line did not fall over or medial to the great toes. The examiner opined that the Veteran did not experience symptomatic pes planus, but he did have symptomatic diabetic neuropathy. In December 2017, the RO obtained a VA medical addendum opinion to determine whether the Veteran’s pes planus had been aggravated by his active duty service. The examiner noted that the Veteran’s claims file had been reviewed, and opined that his pes planus was not aggravated by his active duty service because he had asymptomatic pes planus, and therefore there could be no aggravation. The examiner noted that the Veteran’s current symptoms were due to diabetic neuropathy and most likely peripheral vascular disease. During his June 2014 Board hearing the Veteran reported that he had been prescribed inserts for his bilateral pes planus and that the pain was brought on during five mile runs in boots and carrying heavy packs. He also reported that the pain got worse over time through service. There is simply no competent evidence the Veteran’s bilateral pes planus was aggravated by his active duty service. Accordingly, service connection is not warranted. He raised no complaints concerning his feet during service. The first noted treatment for pes planus following the Veteran’s active duty service was in May 2012, approximately 14 years after his separation from active duty, when it was noted he needed new inserts for his flat feet. Physical evaluation of the Veteran’s feet conducted during his April 2015 VA examination revealed no symptoms of pes planus, including no tenderness or other deformity. The examiner opined in the December 2017 VA medical addendum opinion that his pes planus was not aggravated by his active duty service because he was currently asymptomatic, and his symptoms were most likely caused by diabetic neuropathy and peripheral vascular disease. Although the Veteran testified during his June 2014 Board hearing that he reported foot pain in service, his service treatment records are completely silent for any complaints of foot pain or disability. The Veteran denied any type of foot pain during his May 1998 medical board evaluation, and there was no notation of any foot trouble during his December 1998 clinical separation examination. The Board finds that the contemporaneous, in-service medical evidence documenting no foot problems in service is more probative than the Veteran’s testimony made over 15 years after separation from active duty. The Court has determined the Board may properly assign more probative value to lay statements in contemporaneous medical records than subsequent statements made for compensation purposes. Harvey v. Brown, 6 Vet. App. 390, 394 (1994). In this case, the Board finds the lack of history in the Veteran’s medical records more probative than his lay statements of ongoing pain made in the process of a compensation claim. Accordingly, his lay statements, although competent, are not credible. There is simply no evidence that the Veteran’s preexisting pes planus was aggravated by his active duty service. Davis, 273 F.3d at 1345; see Jensen, 4 Vet. App. at 306- 307; Hunt, 1 Vet. App. 292. The Veteran’s service and post-service medical records, are silent for any complaints of plantar pain or other symptoms associated with pes planus until many years after service. Moreover, the Veteran’s pes planus was noted to be asymptomatic during the April 2015 VA examination, and the examiner opined in the December 2017 VA medical addendum opinion that there could be no aggravation because the Veteran did not experience any symptoms related to his preexisting pes planus. In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection for pes planus and there is no doubt to be otherwise resolved. As such, the appeal is denied. 2. Entitlement to service connection for tinnitus The Veteran claims entitlement to service connection for tinnitus, which, he asserts is due to in-service noise exposure. Specifically, he reported that he noticed the onset of his tinnitus approximately one week after his separation from active duty, and believed it was due to his work as a communicator and exposure to explosions during operations. See Hearing Transcript at Page 4. Service treatment records are silent for any complaints of tinnitus. During his May 1998 medical board evaluation, the Veteran reported no hearing loss or ear, nose, or throat trouble. His December 1998 report of medical history similarly indicated no ear trouble, and clinical evaluation noted no ear disabilities. The first report of tinnitus contained in the claims file is the Veteran’s February 2010 claim for compensation, in which he reported he began experiencing tinnitus in boot camp, which worsened throughout his career. Post service private treatment records reflect that on an April 2005 patient questionnaire, the Veteran specifically did not circle “ringing in ears” when asked to circle all the symptoms he was experiencing. A July 2011 VA treatment record noted the Veteran reported no tinnitus. The Veteran was afforded a VA examination to determine the etiology of his tinnitus in July 2012. He reported bilateral continuous tinnitus with onset approximately one week after discharge. The examiner noted that the Veteran had normal hearing in his right ear through 8000 Hertz, and normal hearing in his left ear through 6000 Hertz, with very mild hearing loss at 8000 Hertz only. However, the examiner also noted that the Veteran demonstrated serious interest discrepancies in responses to threshold level stimuli – speech vs. puretones. The Veteran’s puretone threshold in the right ear was 26 decibels greater than his speech threshold, but the two values should have been within seven to eight decibels of each other. The examiner needed to repeat the instructions several times before the Veteran’s responses to puretone stimuli fell within acceptable agreement to the speech thresholds. The examiner then opined that, as the Veteran had normal hearing at separation from active duty, any reports of tinnitus were not a symptom of hearing loss caused by military noise exposure. The examiner then turned to whether the Veteran’s tinnitus was directly related to his active duty service. The examiner noted his service treatment records were silent for any complains of tinnitus, the Veteran had not reported any tinnitus to either his primary care physician or his neurologist since he began treatment in March 2000, and had specifically denied any tinnitus in July 2011 when asked by his primary care physician. For those reasons, the examiner opined the Veteran’s tinnitus was not related to his active duty service, to include noise exposure. There is no persuasive evidence the Veteran’s tinnitus is etiologically related to his active duty service. Although tinnitus is a type of disorder associated with symptoms capable of lay observation, the Board does not find the Veteran credible to report his symptoms for several reasons. First, the Veteran’s reports regarding the onset of his tinnitus have been inconsistent throughout the appeals process. In his initial claim for compensation in February 2010, the Veteran reported his tinnitus had onset while in boot camp and worsened throughout his time in service. However, at his July 2012 VA examination and June 2014 Board hearing, the Veteran reported his tinnitus had onset approximately one week after separation from active duty. The extreme discrepancy of the reported onset of his tinnitus weighs heavily against his credibility. Second, the Veteran expressly denied any symptoms of tinnitus after service in April 2005 and July 2011, and only reported tinnitus in connection with his claim for compensation. At no point has the Veteran reported symptoms of tinnitus to his VA or private physicians. The Court has determined the Board may properly assign more probative value to lay statements in contemporaneous medical records than subsequent statements made for compensation purposes. Harvey v. Brown, 6 Vet. App. 390, 394 (1994). Finally, the July 2012 VA examiner noted that the Veteran demonstrated serious interest discrepancies in responses to threshold level stimuli, and required reinstruction several times, indicating he was not accurately responding to the audiological testing conducted. The Board finds the July 2012 VA examination highly probative because the conclusion is supported by medical rationale and is consistent with the verifiable facts regarding the Veteran’s contentions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). After conducting a full hearing test and reviewing the Veteran’s service treatment records, the examiner opined that the Veteran’s tinnitus was not related to any hearing loss associated with his active duty service, because he had normal hearing at separation and demonstrated normal hearing for VA purposes during the examination. The examiner then went on to note that the Veteran had not reported any tinnitus to either his primary physician or his neurologist and had expressly denied tinnitus in July 2011 and opined that the Veteran’s tinnitus was less likely than not related to military noise exposure. The elements for service connection for tinnitus have not been met. Accordingly, service connection for the claimed disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against these claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53. Increased Rating 3. Entitlement to an increased rating greater than 10 percent for service-connected right knee degenerative joint disease The Veteran asserts that his service-connected right knee degenerative joint disease warrants a rating greater than 10 percent. His right knee disability is rated as 10 percent disabling under Diagnostic Code 5003, applying to degenerative arthritis. After a full review of the claims file, in conjunction with the applicable laws and regulations, the Board finds that entitlement to an increased rating greater than 10 percent for right knee degenerative joint disease is not warranted. The Veteran was afforded a VA examination to evaluate the severity of his right knee degenerative joint disease in September 2010. He did not report any specific symptoms with regards to his right knee, but reported flare ups of pain once per day precipitated by activity that manifested as difficulty walking long distances, standing long periods of time, and limitation of motion of the joint. Physical evaluation of the right knee revealed tenderness, crepitus, and locking pain. There was no evidence of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding, malalignment, drainage, subluxation or ankylosis. Range of motion testing revealed the following results: flexion to 140 degrees with pain at 140 degrees, and extension to zero degrees with pain at zero degrees. There was no further limitation of motion after repetitive use testing, and the examiner noted that the Veteran’s joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. All stability testing of the ligaments of the right knee was within normal limits. The Veteran’s peripheral pulses and neurological testing were normal. VA treatment records dated June 2012 reflected the Veteran’s right knee had no tenderness to palpation, no pain with patellar grind, no tenderness to palpation along the medial collateral ligament, negative Apley test, negative McMurray test, no effusion, negative anterior drawer test, negative Lachman’s test, and range of motion from zero to 120 degrees. A VA treatment record dated July 2012 noted the Veteran’s range of motion was intact. Records from March 2013 continued to note the Veteran had intact range of motion and no effusion. The Veteran was afforded a VA examination in April 2015 to evaluate the severity of his right knee disability. He reported chronic pain and periodic swelling, but no instability or locking. Range of motion testing reflected the Veteran had normal flexion and extension without pain. The examiner noted the Veteran did not experience pain, weakness, fatigability, or incoordination that significantly limited his functional ability with repeated use over time. Interference with standing was noted as an additional contributing factor of his disability, and no response was provided when asked about flare ups. All muscle strength and neurological testing was normal. There was no evidence of ankylosis, recurrent subluxation, or instability. There was evidence of effusion, as the Veteran reported periodic swelling of the right knee. VA treatment records from March 2016, August 2016, and February 2017 noted the Veteran’s right knee demonstrated full range of motion with no evidence of effusion. The Veteran was afforded a final VA examination to evaluate the severity of his right knee disability in December 2017. The Veteran reported that his knee was weak. Range of motion testing reflected the Veteran’s right knee had full range of motion with flexion and extension with pain. There was no evidence of localized tenderness or pain on palpation of the joint or associated tissue or pain with weight bearing. The examiner observed objective evidence of pain with non-weight bearing. There was evidence of crepitus. Repetitive use testing and passive range of motion testing resulted in no additional limitation of motion or functional loss. The examiner could not provide an opinion as to whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time or during flare ups because the examination was not being conducted immediately after repetitive use over time or during a flare up. The examiner noted symptoms of weakened movement due to muscle injury or peripheral nerves injury, deformity, enlarged knee, and pain of the joint with daily use causing a weaker joint. Muscle strength testing reflected reduced strength of 4/5, but the examiner noted the reduced strength was not entirely due to the claimed condition. There was no evidence of ankylosis, instability, recurrent subluxation, or recurrent effusion. No meniscal conditions were noted for the right knee. In consideration of the medical and lay evidence, the Board finds that a rating in excess of 10 percent under Diagnostic Code 5003 is not warranted. The Veteran’s right knee disability manifested as x-ray evidence of degenerative joint disease, but no additional limitation of motion. Note One to Diagnostic Code 5003 states that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. The Board has considered whether the Veteran’s right knee disability would best be compensated based on painful limitation of flexion and/or extension under diagnostic codes 5260 and 5261, applying to limitation of flexion and extension, respectively. The evidence throughout the entire period on appeal does not show compensable limitation of motion, or flexion limited to 45 degrees. The vast majority of VA treatment records noted the Veteran’s right knee range of motion was full or intact, and he demonstrated flexion and extension from zero to 140 degrees at his September 2010, April 2015, and December 2017 VA examinations. The only record indicating any limitation with range of motion is a single June 2012 VA treatment record noting his range of motion was from zero to 120 degrees. Therefore, the evidence shows that his flexion was, at worst, limited to 120 degrees with pain. As the Veteran is already in receipt of a 10 percent rating based on x-ray findings of degenerative joint disease of the right knee, a rating for limitation of flexion under Diagnostic Code 5260 is not warranted. Moreover, the Veteran has had normal extension throughout the period on appeal; therefore, a rating based on limitation of extension is not warranted. The Board has considered whether the Veteran would be entitled to a rating in excess of 10 percent under any other diagnostic code applying to the knees. Diagnostic Codes 5258 and 5259 are not applicable as the Veteran does not have any meniscus disabilities of the right knee. Diagnostic Code 5257 is not applicable because the Veteran has not reported any episodes of “giving way” and ligamentous testing throughout the period on appeal has shown no objective evidence of lateral instability or subluxation of the right knee. Finally, Diagnostic Code 5256 is not applicable as there is no evidence the Veteran’s right knee disability manifests as ankylosis, or that his symptoms are severe enough to be analogous to ankylosis. The Board additionally considered whether the Veteran is entitled to a higher rating due to functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). In making this determination, the Board considered the Veteran’s statements regarding his symptoms, VA examination reports, and VA treatment records. While the record shows knee pain, swelling, and reported limitation of motion during flare ups, the evidence does not show that his symptoms and flare ups produce functional loss that is manifested by adequate evidence of disabling pathology for higher ratings. See 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Indeed, the Veteran did not experience additional limitation of motion after repetitive use testing and his disability rating is already based on the extent to which his symptoms reduce range of motion due to arthritis. Moreover, his many VA treatment records consistently noted his range of motion was full or intact. Entitlement to an increased rating greater than 10 percent for service-connected right knee degenerative joint disease is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); Gilbert, 1 Vet. App. at 49. 4. Entitlement to an increased rating greater than 10 percent for traumatic arthritis of the left knee 5. Entitlement to an increased rating greater than 20 percent for service-connected left knee anterior cruciate ligament insufficiency with subluxation, status post reconstructive surgery 6. Entitlement to a separate compensable rating for limitation of extension and locking of the left knee The Veteran asserts that his left knee disability warrants increased disability ratings. He is currently in receipt of a 20 percent disability rating for left knee anterior cruciate ligament insufficiency with subluxation rated under Diagnostic Codes 5010-5257, applying to recurrent subluxation or lateral instability, and a 10 percent disability rating for traumatic arthritis of the left knee, rated under Diagnostic Code 5010, applying to traumatic arthritis with either painful motion or noncompensable limitations of motion. The Veteran has also asserted he is entitled to separate compensable ratings for limitation of extension and cartilage removal with locking. The Board will certainly consider all applicable diagnostic codes in its evaluation. The Veteran was afforded a VA examination to determine the severity of his left knee traumatic arthritis and anterior cruciate ligament insufficiency with subluxation (left knee disabilities) in September 2010. He reported symptoms of weakness, stiffness, swelling, heat, giving way, lack of endurance, locking, fatigability, deformity, tenderness, subluxation, and pain. He denied symptoms of redness, drainage, effusion, or dislocation. He reported flare ups of pain once per day precipitated by activity that manifested as difficulty walking long distances, standing long periods of time, and limitation of motion of the joint. He also reported that his upper leg would slide forward and the knee would sometimes lock when walking or going up and down stairs. Physical examination of the Veteran’s left knee revealed evidence of tenderness and locking pain, but no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, subluxation, ankylosis, genu recurvatum, or crepitus. Range of motion testing reflected the Veteran had full range of motion in his left knee, with pain beginning at 140 degrees with flexion and zero degrees with extension. The examiner noted the Veteran’s joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. All ligamentous and meniscus stability tests were normal for the left knee. Motor function, sensory, and neurological testing were normal for the left lower extremity. VA treatment records reflect the Veteran experienced left knee pain, mild limitation of flexion, and effusion. A June 2012 VA treatment record noted the Veteran had range of motion from zero to 120 degrees with evidence of a grade I Lachman’s test with firm end point. There was no pain with patellar grind, stable varus/valgus, no effusion, negative Apley and McMurray’s tests, and a stable anterior drawer test. A MRI report dated later in June 2012 reflected the Veteran’s left knee had small effusions. A July 2012 VA treatment record noted the Veteran’s left knee had mild swelling, but his range of motion was intact. VA treatment records from July 2013 and March 2014 noted the Veteran’s knee had no effusion, edema, or erythema and his range of motion was intact. A July 2014 VA radiology report noted no joint effusion was demonstrated in the Veteran’s left knee. The Veteran was afforded a VA examination to evaluate his left knee disabilities in April 2015. He reported daily swelling and chronic pain with rest and ambulation, no true instability or locking, but periodic buckling. Range of motion testing reflected normal range of motion from zero to 120 degrees with no evidence of pain with weightbearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or any crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions without any additional limitation of motion. Pain, weakness, fatigability, and incoordination did not significantly limit his functional ability after repeated use over time. No response was provided when asked about flare ups. Muscle strength and neurological testing were all normal. There was no evidence of ankylosis, recurrent subluxation, or muscle atrophy. The examiner did note a history of recurrent effusion with evidence of left knee swelling during the examination. All joint and ligament stability testing was normal. VA treatment records from 2016 continued to demonstrate full range of motion and effusion of the left knee. A March 2016 record noted the Veteran’s left knee showed no evidence of erythema, edema, or effusion, but there was moderate tenderness to palpation of the medial joint ligament and crepitus with flexion and extension. He had full range of motion. Treatment records dated August 2016 and February 2017 noted the Veteran’s knee had full active range of motion, mild effusion, and crepitus. In June 2017, the Veteran’s left knee range of motion was noted to be zero to 120 degrees with no effusion, heat, redness, or tenderness to palpation. The Veteran was afforded a final VA examination to evaluate the severity of his left knee disabilities in December 2017. He reported that both of his knees were weak. Range of motion testing reflected that the Veteran had full range of motion of his left knee from zero to 140 degrees with pain noted on flexion and extension. There was no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or pain with weight bearing. The examiner observed objective evidence of pain with non-weight bearing. There was no additional limitation of motion or functional loss after repetitive use testing or passive range of motion testing. The examiner could not provide an opinion as to whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time or during flare ups because the examination was not being conducted immediately after repetitive use over time or during a flare up. The examiner noted additional contributing factors of the Veteran’s disability were weakened movement due to muscle injury or peripheral nerves injury, deformity, pain with daily use causing a weaker joint, and enlarged knee. Muscle strength testing reflected weakened muscle strength of 4/5 with the reduction entirely due to the service-connected knee disabilities. There was no evidence of ankylosis, muscle atrophy, recurrent subluxation, lateral instability, or recurrent effusion. All joint stability testing conducted was normal. The examiner noted that the Veteran had a meniscal repair that manifested as frequent episodes of locking, joint pain, and weakness. In consideration of the medical and lay evidence, the Board finds that a rating in excess of 10 percent under Diagnostic Code 5010 or a rating in excess of 20 percent under Diagnostic Code 5257 is not warranted. The Veteran is currently in receipt of a 10 percent disability rating under Diagnostic Code 5010 for x-ray evidence of degenerative joint disease with painful limitation of motion. The evidence throughout the entire period on appeal does not show compensable limitation of motion, or flexion limited to 45 degrees. The evidence shows that his flexion was, at worst, limited to 120 degrees with pain. Accordingly, only a 10 percent rating is warranted for painful but non-compensable limitation of motion. Moreover, the Veteran has had normal extension throughout the period on appeal; therefore, a separate rating based on limitation of extension is not warranted. The Veteran is also in receipt of a 20 percent disability rating under Diagnostic Code 5257 for moderate recurrent subluxation or lateral instability. At no point during the period on appeal has the Veteran demonstrated severe recurrent subluxation or lateral instability to warrant an increased, 30 percent disability rating. The Veteran presented with evidence of a grade I Lachman’s test with firm end point in June 2012, but all further ligamentous testing was normal. See VA examinations dated September 2010, April 2015, and December 2017. None of the Veteran’s VA examinations or VA treatment records noted any recurrent subluxation. While the Veteran reported episodes of buckling, ligamentous testing throughout the period on appeal has shown only a single mild instance of a level I Lachman’s test, while all other objective ligamentous testing throughout the period on appeal has shown no objective evidence of lateral instability. As such, an increased rating greater than 20 percent for moderate recurrent subluxation or lateral instability is not warranted. The Board has considered whether the Veteran would be entitled to a separate compensable rating under any other diagnostic code applying to the knees. Diagnostic Code 5256 is not applicable as there is no evidence the Veteran’s left knee disability manifests as ankylosis, or that his symptoms are severe enough to be analogous to ankylosis. The Board has considered whether the Veteran may be entitled to a separate compensable rating under Diagnostic Codes 5258 or 5259. In November 2017, the Court of Appeals for Veterans Claims (Court) held that evaluation of a knee disability under Diagnostic Code 5257 or 5261 or both, did not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under Diagnostic Codes 5258 or 5259. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). Initially, the Board notes that Diagnostic Code 5258 is not applicable, as it applies to dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion. However, as the Veteran underwent a meniscectomy in-service, his meniscal injury is more analogous to Diagnostic Code 5259, which applies to removal of the semilunar cartilage that remains symptomatic. As outlined above, the Veteran has continuously complained of knee pain. During his September 2010 VA examination, he reported symptoms of swelling and locking. Physical examination revealed locking pain but no evidence of effusion. The Veteran’s VA treatment records consistently reflect he experienced recurrent effusion of his left knee. See VA treatment records dated June 2012, July 2012, August 2016, and February 2017. During his April 2015 VA examination, the Veteran reported buckling, but no true instances of locking, and the examiner noted recurrent effusion with swelling of the left knee. The December 2017 examiner noted the Veteran had a symptomatic meniscus manifesting as recurrent pain and effusion. The Board finds that a separate 10 percent rating under Diagnostic Code 5259 is warranted for the entire period on appeal, as the evidence demonstrates the Veteran had removal of his semilunar cartilage that remained symptomatic, manifesting as recurrent effusion, locking pain, and knee pain. The Board further finds that there is no basis for the assignment of ratings in excess of those upheld or awarded herein 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. The Court has held that “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. While the record shows knee pain, reduced walking and standing, swelling, and locking pain, the evidence does not show that his symptoms and flare-ups produce functional loss that is manifested by adequate evidence of disabling pathology for higher ratings. Indeed, the Veteran did not experience additional limitation of motion after repetitive use testing and his disability rating is already based on the extent to which his symptoms reduce range of motion, impair stability, and cause effusion and locking pain. In light of the Veteran’s reported symptoms and the medical evidence, the Board finds that the Veteran is not entitled to any higher or separate ratings for his left knee disability. In summary, the Board finds that an increased rating greater than 10 percent is not warranted for his service-connected traumatic arthritis of the left knee, and a rating greater than 20 percent is not warranted for his service-connected left knee anterior cruciate ligament insufficiency with subluxation, status post reconstructive surgery. However, the evidence supports the grant of a separate 10 percent evaluation, and no more, under Diagnostic Code 5259 for the entire period on appeal. The benefit of the doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application as there is not an approximate balance of evidence. See generally Gilbert, supra; Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). 7. Entitlement to an initial compensable rating for service-connected left leg discrepancy The Veteran asserts he is entitled to an initial compensable rating for his service-connected left leg discrepancy. He currently receives a noncompensable rating for his left leg discrepancy under Diagnostic Code 5275. To warrant a compensable rating under Diagnostic Code 5275, the Veteran’s left leg discrepancy would have to manifest as shortening of the lower extremity from one and a quarter to two inches (or 3.175 to 5.08 centimeters). There is no evidence in the claims file reflecting that the Veteran’s left leg is one and a quarter to two inches shorter than his right leg. The Veteran was afforded a VA examination in September 2010, during which is right leg measured 106 centimeters and his left leg measured 104 centimeters, a discrepancy of two centimeters. During his December 2017 VA examination, his right leg measured 100 centimeters, and his left leg measured 98 centimeters; again, a discrepancy of two centimeters. There are no other leg measurements contained in the claims file. As such, there is no evidence that the Veteran’s left leg discrepancy warrants an increased compensable rating, as his left leg is not one and a quarter to two inches shorter than his right leg. Entitlement to an initial compensable rating for service-connected left leg discrepancy is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); Gilbert, 1 Vet. App. at 49. 8. Entitlement to an initial compensable rating for service-connected left knee scars The Veteran asserts he is entitled to an initial compensable rating for his service-connected left knee scars. Currently, the Veteran is in receipt of four noncompensable ratings for the scars of his left knee: noncompensable rating under Diagnostic Code 7804 for two scars of his medial left knee; one noncompensable rating under Diagnostic Code 7805 for left knee scar; one noncompensable rating for scars, left knee under Diagnostic Code 7805; and one noncompensable rating for a scar of the left lateral knee under Diagnostic Code 7805. To warrant an increased, compensable rating under diagnostic code 7804, the Veteran would have to have one or two scars that are painful or unstable. Diagnostic Code 7805 instructs scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 should have any disabling effects not considered in a rating provided under diagnostic codes 7800 through 7804 evaluated under an appropriate diagnostic code. None of the Veteran’s VA or private treatment records contain any complaints or treatment with regard to his left knee scars. The Veteran was afforded a VA examination to evaluate his left knee scars in September 2010. The examiner identified a linear scar on the left knee measuring 10 centimeters by .5 centimeters; a linear scar on the lateral left knee measuring six centimeters by .6 centimeters; a linear scar on the left medial knee measuring three centimeters by .5 centimeters; and a scar on the left medial knee measuring four centimeters by .6 centimeters. None of the scars were painful, disfiguring, or unstable. There was no evidence of adherence, underlying tissue damage, keloid formation, or disfigurement. The scars did not limit the Veteran’s range of motion. The Veteran was afforded a second VA examination to evaluate his scars in April 2015. Again, his scars were not noted to be unstable or painful, and the examiner noted the total length of his scars was nine centimeters. The Veteran was afforded a final VA examination to determine the severity of his left knee scars in December 2017. The examiner noted several scars: a nine-centimeter-long by one-centimeter wide scar on his anterior left knee; a seven-centimeter-long by .5-centimeter-wide scar on his lateral left knee; and a six-centimeter-long by .25-centimeter-long scar on his posterior left knee. None of the scars were painful, unstable, had a total area greater than 39 square centimeters, or were located on the head, face, or neck. During his June 2014 Board hearing, the Veteran testified that the scars on his left knee were raised and caused him pain. However, his testimony is in direct conflict with the objective medical evidence showing that his scars were linear, superficial, and were not painful or unstable. The September 2010 VA examiner specifically noted that none of his scars showed evidence of adherence, underlying tissue damage, keloid formation, or disfigurement. Additionally, of his three VA examinations, the Veteran never reported that his scars were painful or unstable. There is no evidence that the Veteran has one or two scars that are painful or unstable to warrant a 10 percent disability rating under Diagnostic Code 7804. VA examinations conducted in September 2010, April 2015, and December 2017 consistently noted his scars were not painful or unstable. The Board finds that the objective medical evidence provided in the September 2010, April 2015, and December 2017 VA examinations indicating that the Veteran’s scars were superficial, linear, and not painful or unstable more probative than the Veteran’s testimony that his scars caused him pain made during his Board hearing. Harvey, 6 Vet. App. at 394. The Board has considered whether the Veteran would be entitled to a compensable rating for his scars under any other diagnostic code. Diagnostic Code 7800 is not applicable because the scars are not of the Veteran’s head, face, or neck; Diagnostic Code 7801 is not applicable because the Veteran’s scars are not burn scars and are not deep and nonlinear. Diagnostic Code 7802 is not applicable because, although the Veteran’s scars are superficial and linear, they do not cover an area of 144 square inches (929 square centimeters). The Veteran’s scars similarly are also not adherent, and there is no evidence of adherence, underlying tissue damage, keloid formation, disfigurement, or that they cause limitation of motion of the Veteran’s left knee. Accordingly, there are no additional disabling effects caused by the Veteran’s scars that are not contemplated under Diagnostic Codes 7800 through 7804. Entitlement to an initial compensable rating for service-connected left leg scars is not warranted. As the preponderance of the evidence is against assignment of any higher rating, the benefit-of-the doubt doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND 1. Entitlement to service connection for asthma The Veteran seeks entitlement to service connection for asthma. Specifically, he argues that his asthma was caused by inhalation of a white powdery substance that he was exposed to when cleaning out WWII bunkers without gas masks. The Veteran’s service treatment records contain a signed document on which the Veteran stated he was unsure whether he had been exposed to asbestos during a rip out procedure or worked regularly with asbestos or asbestos products. The Veteran was afforded a VA examination to determine the etiology of his asthma in May 2015. The examiner opined that the Veteran was diagnosed with modest component asthma in 2012 by a VA allergy clinic. However, a private treatment record with an illegible date noted the Veteran was treated for asthmatic bronchitis. Prior private treatment records reflect the Veteran had previously been treated for bronchitis and was prescribed Albuterol in April 2002. As these private treatment records date from approximately 2002 through 2008, it is clear from the record that he was diagnosed with asthmatic bronchitis well before 2012. Additionally, there was no discussion from the examiner of whether the Veteran’s asthma is related to any in-service asbestos exposure. The Board cannot make a fully informed decision on the issue of entitlement to service connection for asthma because no VA examiner has opined whether the Veteran’s asthma is etiologically related to his active duty service, to include any in-service asbestos exposure. Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from October 2017 to the present. 2. Only after the above development is completed, to the extent possible, request an addendum VA medical opinion from a medical professional to address whether it is at least as likely as not (at least 50 percent probability or greater) that the any current diagnosed asthma is etiologically related to the Veteran’s active duty service, to include exposure to asbestos. The entire claims folder and a copy of this REMAND should be reviewed by the examiner. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Parsons, Associate Counsel