Citation Nr: 18147887 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 04-20 367A DATE: November 6, 2018 ORDER Entitlement to an initial rating in excess of 10 percent for service-connected instability of the right knee is denied. Entitlement to a separate 10 percent rating, but no higher, for service-connected degenerative arthritis of the right knee is granted. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the left knee is denied. Entitlement to an initial rating of 10 percent, but no higher, for left knee instability is granted. Entitlement to a separate 10 percent rating for service-connected meniscal tear of the left knee from October 27, 2003 is granted. Entitlement to compensation under 38 U.S.C. § 1151 for residuals of a pterygium excision performed at the Long Beach VA Medical Center (VAMC) in November 1985 is denied. (The issues of entitlement to higher initial ratings for right and left hip disabilities have been addressed in a separate decision.) FINDINGS OF FACT 1. The service-connected right knee disability has been manifested by no more than slight lateral instability. 2. The right knee disability is manifested by degenerative arthritis with flexion limited to no less than 100 degrees with pain and flare-ups, and extension to zero degrees. 3. The service-connected degenerative arthritis of the left knee is manifested by flexion limited to no less than 75 degrees with pain and flare-ups, and extension to zero degrees. 4. The Veteran’s service-connected left knee disability has been manifested by no more than slight lateral instability from the date of service connection, October 27, 2003. 5. The left knee disability is manifested by a meniscal tear with frequent episodes of stiffness, pain, and effusion into the joint, and these symptoms are sufficiently distinct from painful limitation of motion to warrant a separate rating. 6. The Veteran did not incur an additional disability, to include residuals of pterygium excision of the right eye, due to VA hospital care or medical treatment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5257 (2017). 2. The criteria for a separate 10 percent rating for service-connected degenerative arthritis of the right knee are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261 (2017). 3. The criteria for a disability rating in excess of 10 percent for degenerative arthritis of the left knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261 (2017). 4. The criteria for a rating of 10 percent, but no higher, for the service-connected instability of the left knee are met from the date of service connection, October 27, 2003. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, DC 5257 (2017). 5. The criteria for a separate rating of 20 percent for meniscal injury of the left knee with frequent episodes of stiffness, pain, and effusion into the joint are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.27, 4.71a, DC 5258 (2017). 6. The criteria for entitlement to compensation under the provisions of 38 U.S.C. § 1151 for residuals of right eye pterygium excision have not been met. 38 U.S.C. § 1151 (2012); 38 C.F.R. § 3.361 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1975 to October 1978. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated June 2003, November 2004, and August 2006 of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In September 2011, the Veteran presented sworn testimony during a personal hearing in Oakland, which was chaired by the undersigned. A transcript of the hearing has been associated with the Veteran’s VA claims file. In Board decisions dated April 2012 and January 2018, the claims were remanded for further evidentiary development. In a June 2018 rating decision, the RO granted a separate 10 percent rating for instability of the left knee. The Veteran has not expressed satisfaction with the separate disability rating. The Board will therefore consider this issue as part of the higher initial rating claim. C.f. AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The VA Appeals Management Center (AMC) most recently issued a supplemental statement of the case (SSOC) in a June 2018. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. As indicated above, the issues of entitlement to higher initial ratings for right and left hip disabilities have been addressed in a separate decision. Increased Ratings Entitlement to an initial rating in excess of 10 percent for service-connected instability of the right knee. Entitlement to a separate rating for degenerative arthritis of the right knee. Entitlement to an initial rating in excess of 10 percent for service-connected degenerative arthritis of the left knee. Entitlement to an initial rating in excess of 10 percent for service-connected left knee instability of the left knee. Entitlement to a separate rating for meniscal tear of the left knee. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (“Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record”); 38 U.S.C. § 5107(b) (“Secretary shall consider all information and lay and medical evidence of record in a case”). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s appeal. The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint’s functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016). In this case, the Veteran’s right knee disability is assigned a 10 percent rating pursuant to DC 5257 (knee, other impairment of), effective from May 9, 2003. See the rating decision dated July 2003. In a November 2004 rating decision, the RO granted service connection for left knee strain and assigned a 10 percent rating under DC 5260 (limitation of flexion), effective from October 27, 2003. As indicated above, a June 2018 rating decision granted a separate 10 percent rating for left knee instability under DC 5257 from July 18, 2017. Diagnostic Code 5003 provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). DC 5257 provides the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257. DC 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258 (2017). DC 5259 provides that a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259 (2017). In this matter, the Veteran was afforded a VA examination in March 2002 at which time the examiner noted the Veteran’s report of left knee pain managed with Motrin. The Veteran denied right knee pain. He exhibited a normal gait. Physical examination of the right knee was within normal limits. There was no pain, redness, swelling, effusion, drainage, or abnormal movement. Range of motion testing revealed flexion to 140 degrees and extension to zero degrees on the right. Range of motion testing of the left knee also revealed flexion to 140 degrees with pain throughout motion, and extension to zero degrees. The examiner noted, “[t]he left knee joint had some mild left medial knee joint tenderness with full range of motion.” There was no crepitus or joint instability. The examiner stated that there was no pain, weakness, fatigability, or lack of endurance exhibited in either knee. A VA examination of the right and left knees was subsequently performed in June 2003. At that time, the Veteran complained of right knee pain. He stated that, “[i]f he stands for more than two hours, he has more pain on the right side, around the right kneecap area, and around the posterior right knee.” He reported trouble squatting, lifting objects, and walking for more than 20 minutes. He stated that he lost two days of work due to his right knee problems. Physical examination of the knees documented bilateral flexion to 140 degrees and bilateral extension to zero degrees. The examiner explained, “[t]here is some pain with full flexion of the right knee. There was no fatigue, weakness, lack of endurance, or incoordination with range of motion of the knees.” The examiner noted very slight antalgia in the Veteran’s gait following the left lower extremity. X-ray of the right knee revealed a tiny patellar spur. The examiner diagnosed the Veteran with right knee strain. VA treatment records dated in December 2003 documented the Veteran’s report of constant bilateral knee pain, left greater than right with walking. His pain was relieved with sitting or lying down. The knee pain was associated with some mild swelling without warmth or instability. The treatment provider noted clicking of the left knee with walking. X-rays of the knees revealed mild bilateral compartment osteoarthritis. The treatment provider reported that in both knees there was negative pain on palpation of the joint line. It was noted that there was good stability of the knees. The Veteran’s left knee did exhibit some crepitation on deep bending. The Veteran was afforded a VA examination in June 2004 at which time the examiner noted that the Veteran experienced right knee pain and numbness. The examiner explained, “[t]he functional impairments are pain on climbing stairs, on walking, and on prolonged standing. He has lost time from work about four times per year.” The Veteran reported pain on prolonged standing, as well as climbing and descending stairs. Flexion and extension was normal bilaterally. The examiner reported, “[t]here is Deluca issue of pain and lack of endurance involving the right knee.” He explained that pain has the major functional impact on range of motion of the right knee. The examiner indicated that the Veteran’s right knee does not exhibit fatigue, weakness, or incoordination. The examiner stated that there was no “Deluca issue” in the left knee. There was no evidence of ankylosis. The examiner reported that there was a slight McMurray sign, bilaterally. The Veteran’s right and left knees also exhibited crepitus. The examiner reported that the Veteran is a testing technician and has difficulty with prolonged standing and walking, as well as climbing and descending stairs. VA treatment records dated in August 2004 noted that the Veteran was last seen in May 2004 and exhibited signs of patellofemoral syndrome, bilaterally, as well as a probable left medial meniscus tear. The treatment provider stated that the Veteran “[s]till has most pain in the right patellar region and deep within medial side of left knee joint worsened by prolonged walking or sitting.” Climbing stairs exacerbates his knee pain. The Veteran also reported occasional clicking and catching in the left knee, but no gross instability. He denied focal weakness, numbness, or falls. VA treatment records dated in March 2005 noted that magnetic resonance imaging (MRI) shows evidence of degenerative tear in the posterior horn of the medial meniscus in the left knee. In May 2006, the Veteran reported increasing bilateral knee pain with weight-bearing over 30 minutes, walking more than four city blocks, climbing two flights of stairs, and lifting. He indicated that his knee pian is diminished by sitting. He described locking and clicking of the knees, left greater than right without swelling, erythema, or instability. Physical examination revealed crepitation on the deep flexion of the knees; there was no evidence of instability. The Veteran was afforded a VA examination of the bilateral knees in June 2007. The examiner confirmed diagnoses of right and left knee strains. Physical examination of the knees revealed normal range of motion without recurrent subluxation, locking pain, joint effusion, or crepitus bilaterally. There was no evidence of anklylosis. Range of motion testing revealed flexion to 140 degrees and extension to zero degrees, bilaterally. There was no evidence of pain, fatigue, weakness, lack of endurance, or incoordination. The examiner reported, “[a]fter repetitive use, there is no additional limitation of motion but he will have pain at the end of normal flexion without fatigue, weakness, lack of endurance or incoordination.” Stability testing was normal, bilaterally. The Veteran’s motor strength and deep tendon reflexes were intact. The Veteran stated that he bought a cane, but does not require an assistive device to walk. The examiner reported, “[t]here is no evidence of limitation of standing or walking.” X-rays of the bilateral knees revealed early osteoarthritis. The examiner indicated that the effect of the bilateral knee disabilities on the Veteran’s usual occupation and daily activities is that “the Veteran has difficulty with prolonged standing, walking, sitting, squatting, kneeling and difficulty with frequent heavy lifting. VA treatment records dated in September 2007 noted the Veteran’s report of intermittent clicking and popping of both knees, especially after walking one city block. He reported locking and instability in the left knee with associated swelling. Physical examination of the left knee revealed medial malformation of the left knee with slight swelling of the suprapatella bursa. There was no crepitation. Flexion of the left knee was to 75 degrees. Physical examination of the right knee was negative for malformation, swelling, and crepitation. Flexion of the right knee was to 90 degrees. VA treatment records dated in May 2008 noted that the Veteran experienced worsening knee pain. He stated that his knees are swelling up despite medication. MRI of the left knee showed “mild thinning of the articular cartilage, but no evidence of acute meniscal injury.” The Veteran was afforded a VA examination of the knees in March 2011 at which time he reported stiffness, swelling, lack of endurance, tenderness and pain. There was no evidence of weakness, heat, redness, giving way, locking, fatigability, deformity, drainage, effusion, subluxation, or dislocation. The Veteran endorsed flare-ups of bilateral knee symptoms, occurring six days per week and lasting for four hours. He reported that his flare-ups are 9/10 in severity, and are precipitated by standing and walking. The Veteran stated that, during flare-ups, his functional impairment is limited by pain with activities such as prolonged standing, walking, repetitive kneeling, squatting, and running. He exhibited a normal gait. In both knees, there was slight tenderness and slight patellar tendon tenderness and mild excessive laxity of the patellofemoral complex consistent with patellofemoral pain syndrome. There was no sign of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, drainage, or subluxation. There was crepitus in both knees, but no gen recurvatum or locking in either knee. There was no evidence of ankylosis. Range of motion testing revealed flexion to 140 degrees and extension to zero degrees. There was additional limitation of 10 degrees of flexion upon repetitive use testing. The examiner opined, “the joint function is additionally limited by . . . pain, fatigue, and lack of endurance.” The examiner stated that lack of endurance has the major functional impact. There was no functional impairment due to weakness or incoordination. Stability testing was normal. The examiner stated that the effect of the bilateral knee disability on the Veteran’s usual occupation is “impaired prolonged standing, walking, repetitive kneeling, squatting, and running.” VA treatment records dated in April 2011 indicated that the Veteran’s “[k]nee pain [is] likely related to left medial meniscus tear and right patellofemoral syndrome based upon combination of history, exam, and imaging findings.” The treatment provider further stated, “MCL and ACL possibly pathology not currently symptomatic.” The Veteran was afforded a VA examination in June 2012 at which time the examiner confirmed diagnoses of osteoarthritis of the bilateral knees. The Veteran described flare-ups of bilateral knee symptomatology manifested by constant pain aggravated by sitting, standing, and walking. Range of motion testing revealed flexion of the right knee to 120 degrees with pain at 90 degrees and extension to zero degrees with pain. In the left knee, the Veteran exhibited flexion to 90 degrees with pain at 45 degrees and extension to zero degrees with pain. Upon repetitive testing, flexion of the right knee was to 120 degrees and flexion of the left knee was to 80 degrees. Extension to zero degrees was maintained, bilaterally. The examiner indicated that there was tenderness/pain on palpation in both knees. Muscle strength was intact, with no evidence of atrophy. Stability testing yielded normal results, bilaterally. There was no recurrent subluxation or dislocation. The examiner reported that the Veteran has a meniscal condition with frequent episodes of joint pain, bilaterally. He endorsed regular use of a brace and occasional use of cane for ambulation. The examiner reported, “[t]he impact of the knee/lower leg condition on the claimant’s ability to work is that the patient does desk work as a VA case representative. He has to sit for extended periods which aggravates his knees and hips.” VA treatment records dated February 2018 documented knee arthralgia, a meniscal tear, and chondromalacia patella. Pursuant to the January 2018 Board Remand, the Veteran was afforded a VA examination in March 2018 at which time the examiner confirmed a diagnosis of bilateral degenerative arthritis. The Veteran reported knee instability; specifically, the left knee giving him more problems. He indicated that he was provided a knee brace, but does not wear it because it irritates his knee. He uses a cane for ambulation because his left knee is giving him a lot of problems and it is swollen. The Veteran explained that his knee pain is constant, but he does experience flare-ups of pain. His most recent flare-up occurred last month when going up stairs. Range of motion testing revealed flexion to 100 degrees and extension to 100 degrees, bilaterally. There was pain throughout motion; however, there was no evidence of pain on weight-bearing. There was no localized tenderness or pain on palpation. There was no crepitus in either knee. The examiner reported that there was no additional limitation of motion on repetitive use testing. The examiner reported that pain, weakness, fatigability, and/or incoordination do not significantly limit functional ability with repeated use over a period of time or during a period of flare-up. The Veteran’s muscle strength of the bilateral knees was intact. There was slight lateral instability, bilaterally. There was no evidence of recurrent subluxation. Joint testing was normal. Instability testing of the left knee was 1+ as to anterior instability, posterior instability, medical instability, and lateral instability. The examiner indicated that the Veteran does have a meniscal tear on the left. The examiner further stated that there is evidence of pain on passive range of motion testing. The examiner concluded that the Veteran’s right and left knee disabilities do not impact his ability to work. Based on the evidence of record, the Board observes that the Veteran has degenerative arthritis of the bilateral knees with limitation of motion to no more than 100 degrees in the right knee and 75 degrees in the left knee, with extension to zero degrees in both knees. As to the right knee, indicated above, the Veteran is currently assigned a 10 percent rating pursuant to DC 5257 (knee, other impairment of) for instability. Accordingly, the Board finds that because he is diagnosed with degenerative arthritis of the right knee with noncompensable limitation of motion, a separate 10 percent rating is warranted under DC 5003 (arthritis, degenerative). The RO has rated the Veteran’s left knee degenerative arthritis as 10 percent under DC 5260 based upon limitation of flexion. The Board has thoroughly reviewed the evidence of record and finds that ratings in excess of 10 percent are not warranted for degenerative arthritis either the left or right knee. To this end, the Board observes that separate disability ratings due to limitation of extension and flexion are not warranted for either knee. The VA examination and treatment records referenced above demonstrate, at worst, 100 degrees of flexion of the right knee and 75 degrees of flexion of the left knee with pain. The March 2011 VA examiner indicated that the Veteran’s left knee flexion was additionally reduced by 10 degrees to 130 degrees upon repetitive use testing and the June 2012 VA examiner reported that the Veteran’s left knee flexion was reduced to 80 degrees upon repetitive use testing. Nevertheless, such findings warrant noncompensable disability ratings under DC 5260. Moreover, the right and left knees exhibited no worse than zero degrees of extension, warranting noncompensable disability ratings under DC 5261. Critically, functional loss must be rated under the diagnostic code pertaining to limitation of motion of the affected joint, pursuant to 38 C.F.R. § 4.40; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991) (noting that functional loss due to pain is to be rated at the same level as where motion is impeded); DeLuca v. Brown, 8 Vet. App. 202, 205-06 (noting that the disabling effect of painful motion must be considered when rating joint disabilities) (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (stating that functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion)); c.f., Petitti v. McDonald, No. 13-3469 (U.S. Vet. App. October 28, 2015). Hence, there is no basis upon which to find additional limitation due to functional factors. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 202; Mitchell, 25 Vet. App. at 32. As indicated above, the Veteran’s impaired flexion upon repetitive motion and during flare-ups is contemplated in the assigned 10 percent ratings for degenerative arthritis with limitation of motion in the right and left knees. He nevertheless does not meet the criteria for the assignment of a separate disability rating for limitation of flexion or extension in his right and left knees under VAOPGCPREC 09-2004, VAOPGCPREC 23-97, or VAOPGCREC 9-98. As indicated above, the Veteran is also assigned separate 10 percent ratings for lateral instability of the right and left knees pursuant to DC 5257. As indicated in the Introduction, the rating for instability of the left knee is assigned a 10 percent rating from July 18, 2017. However, the evidence of record shows that the Veteran is entitled to a 10 percent initial rating for service-connected left knee disability from the date of service connection, October 27, 2003. In this regard, the Veteran has repeatedly reported right and left knee instability with use of a left knee brace and a cane for ambulation. There was a specific finding of slight instability in the left knee (1+) on the March 2018 VA examination and normal or near normal instability findings documented in the other VA examination reports of record. These findings are consistent with the 10 percent ratings currently assigned under Diagnostic Code 5257 for slight lateral instability and do not more nearly approximate moderate or severe instability such as that manifested by 2+ (5 to 10mm) or 3+ (10 to 15mm), respectively. Thus, the medical and lay evidence reflects competent evidence of instability in the right and left knees, and thus, warrants ratings no higher than 10 percent under DC 5257. Moreover, as the evidence of record has consistently documented the Veteran’s report of instability, the Board finds that the 10 percent rating for left knee instability should be granted from the date of service connection. Additionally, as to the left knee, the Board finds that a separate 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint is also warranted. Here, the evidence clearly documents a meniscal tear of the left knee, coupled with consistent documentation of locking, pain, crepitus, and effusion. Accordingly, a separate 20 percent rating is warranted for left meniscal tear under DC 5258. In sum, the Board has considered the entire record, including the Veteran’s reported symptomatology and the objective clinical evidence. For the reasons set forth above, the Board finds that a separate 10 percent rating is warranted for osteoarthritis of the right knee from the date of service connection; however, an initial rating in excess of 10 percent is not warranted for right knee instability. As to the left knee, the Board finds that a rating in excess of 10 percent is not warranted for osteoarthritis of the left knee. The Board additionally finds that a separate 10 percent rating, but no higher, for left knee instability is warranted from the date of service connection. A separate 20 rating is also warranted for a meniscal tear of the left knee from the date of service connection. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). While there may have been day-to-day fluctuations in the manifestations of the Veteran’s service-connected right and left knee disabilities, the evidence shows no distinct periods of time during the appeal period, when his disabilities varied to such an extent that additional and/or higher evaluations would be warranted. Hart, supra. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to compensation under 38 U.S.C. § 1151 for residuals of a pterygium excision performed at the Long Beach VAMC in November 1985. In pertinent part, 38 U.S.C. § 1151 reads as follows: “(a) Compensation under this chapter and dependency and indemnity compensation under chapter 13 of this title shall be awarded for a qualifying additional disability or a qualifying death of a veteran in the same manner as if such additional disability or death were service-connected. For purposes of this section, a disability or death is a qualifying disability or qualifying death if the disability or death was not the result of the veteran’s willful misconduct and—(1) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the Secretary, either by a Department employee or in a Department facility as defined in section 1701(3)(A) of this title, and the proximate cause of the disability or death was (A) careless, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or (B) an event not reasonably foreseeable.” To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran’s additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish cause. See 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. See 38 C.F.R. § 3.361(c)(2). (ii.) Carelessness, negligence, etc.—To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran’s additional disability or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran’s additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran’s informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. See 38 C.F.R. § 3.361(d)(1). (iii.) Foreseeability—Whether the proximate cause of a veteran’s additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d). In this matter, the Veteran asserts that he is entitled to compensation under 38 U.S.C. § 1151 for a right eye disability. Specifically, he contends that he suffers from residuals of a pterygium excision performed on his right eye in November 1985 at the Long Beach VAMC. See, e.g., the Board hearing transcript dated September 2011. VA treatment records dated November 7, 1985 noted that the Veteran underwent excision of a right pterygium; it was indicated that the procedure was well tolerated. On November 9, 1985, the Veteran sought emergency room treatment due to right eye pain. He stated that he has been using his eye ointment regularly, but was a bit vague about the details. VA treatment records dated in January 1986 indicated that the Veteran was status-post excision of pterygium of the right eye, with evidence of recurrence. In July 1986, it was indicated that, prior to the November 1985 surgery, the Veteran was aware of the possibility of pterygium recurrence. He was advised of alternative measures to treat the pterygium. It was noted, “[a]t this point, medical treatment to decrease inflammation was recommended.” It further reported that the Veteran did not appear for a follow-up appointment. A March 2005 VA optometry note indicated that the Veteran has no visual complaints; his vision was 20/20 bilaterally. It was noted that the Veteran was diagnosed with myopia and presbyopia of the bilateral eyes. He continued to have pterygium of the right eye. In his September 2005 claim for compensation under 38 U.S.C. § 1151, the Veteran reported that his right eye continues to be irritated following the November 1985 surgery and the irritation interferes with his vision. Private treatment records dated in April 2006 documented a small pterygium of the right eye. A March 2015 VA ophthalmology note indicated that the Veteran suffers from optical migraine symptoms. The Veteran reported permanently decreased vision on the left. The Veteran’s treatment provider stated that the Veteran’s “history [is] very suggestive of migraine with bilateral central graying and light sensitivity for 30 minutes, followed by headache.” The treatment provider additionally reported that the Veteran had recurrent pterygium of the right eye. Pursuant to the January 2018 Board Remand, a VA medical opinion was obtained in February 2018. The examiner reviewed the Veteran’s medical history in detail and reported, At the Veteran’s multiple visits at West LA from 2007 to 2015, his best corrected visual acuity was noted to be 20/20. There was a mild recurrence of the pterygium noted in the right eye nasally, extending only about 1 to 2 mm. onto the cornea. Recurrence of pterygium after excision is a common occurrence after surgery, and in this case, it did not appear to have any effect on the Veteran’s visual acuity. The Veteran did mention in a[n] April 2007 visit that he had some irritation, foreign body sensation, and tearing in the right eye after pterygium excision, however this is also common with any pterygium or pterygium recurrence and should not represent a disability to the Veteran if the vision is not affected. It is less likely than not (less than 50 percent probability) that his symptoms are a direct result of his pterygium surgery; rather, these symptoms of irritation of foreign body sensation are more likely than not related to the pterygium growth itself. The examiner continued, It is less likely than not (less than 50 percent probability) that the Veteran incurred any additional disability as a result of his 1985 pterygium excision in the right eye. There appears to be no vision loss as a direct result of the pterygium excision, which was otherwise uncomplicated. The Veteran was seen on multiple follow-up visits at the West LA VA and while there was a mild recurrence of the pterygium on the right cornea, it was deemed not involving the visual axis and not visually significant. The Veteran also was seen multiple times at the West LA VA for visual disturbance in the right eye and left eyes, which he described as a dimming of the vision bilaterally followed by headache. He was diagnosed with ocular migraine at the ophthalmology clinic and was also seen by Neurology for the same purpose. He had multiple MRI exams of the brain and orbits, which were unrevealing. The visual symptoms are NOT consistent with pterygium or pterygium excision in any way and is unlikely to have resulted from his 1985 surgery. The Veteran also had sub normal visual field testing in June 2015. The examiner emphasized, “it is less likely than not (less than 50 percent probability) that the pterygium surgery in 1985 led to any disability to the Veteran.” The examiner explained that the ocular migraine symptoms “are NOT related to any history of pterygium surgery. There is no evidence that there was any carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of the VA.” The examiner continued, “[t]here is no evidence that the VA did not follow any standard of care in treatment of this Veteran regarding his 1985 pterygium surgery. The other workup regarding the Veteran’s ocular migraines also appeared to have followed standard of care.” When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The Court has held that claims file review, as it pertains to obtaining an overview of a claimant’s medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. “It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” Following a review of the record, the Board finds that the preponderance of the evidence demonstrates that the Veteran did not have an increase in disability in the pterygium of the right eye as a result of VA medical treatment. As the Veteran did not sustain additional disability as a result of VA medical treatment, service connection under 38 U.S.C. § 1151 cannot be established. Crucially, the Board finds the February 2018 VA medical opinion to be probative as to the questions of additional disability and etiology, as the opinion is based upon a thorough review of the record and a detailed rationale based upon the Veteran’s entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). The February 2018 VA examiner provided a detailed rationale to support his conclusions. Notably, he provided a definitive opinion that the Veteran did not incur an additional disability as a result of the November 1985 excision of the right pterygium. In this case, the Board finds that the February 2018 VA examiner’s opinion is sufficiently supported by a thorough rationale. Importantly, the conclusion set forth by the February 2018 VA physician was rendered based upon review of the entire claims file, discussion of the clinical record, and thorough analyses of pertinent medical treatise evidence. The VA physician is specific as to symptoms and clinical findings before and after the pterygium excision procedure and supports the opinion with detailed information. The rationale set forth in the February 2018 opinion was substantial, thorough, and based on the overall record. The Veteran has not submitted a medical opinion to contradict the conclusions of the February 2018 VA examiner. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C. § 5107(a) (it is the claimant’s responsibility to support a claim for VA benefits). The Board has considered the lay statements and testimony of the Veteran. To the extent that the Veteran is contending that he has an additional right eye disability due to the November 1985 right pterygium excision, the Board observes that a determination of additional disability as a result of treatment at a VA facility requires competent evidence. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the Veteran’s assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). To this end, the Veteran is not competent to report that these perceived symptoms are manifestations of an additional disability caused by VA treatment. Any such assertions by the Veteran are not competent medical evidence and are, therefore, afforded little probative weight. Moreover, the lay theory of the Veteran is contradicted by the conclusion of the February 2018 VA examiner who specifically considered these lay contentions, as well as the Veteran’s medical history in rendering his negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the February 2018 VA examination to be of greater probative weight than the more general lay assertions of the Veteran. For reasons explained above, the Board concludes that no permanent disability has been demonstrated as being due to VA medical care. The Board is charged with weighing the positive and negative evidence; resolving reasonable doubt in the Veteran’s favor when the evidence is in equipoise. Considering the overall evidence, including the post-service medical evidence, the uncontradicted February 2018 VA medical opinion, and the medical and lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. Accordingly, the competent evidence of record demonstrates that the Veteran does not have an additional disability resulting from VA medical care. See 38 U.S.C. § 1151. In the absence of additional disability due to VA medical treatment, the matter of alleged VA negligence is moot. That is, in the absence of an additional disability which is demonstrated to be the result of VA medical care, whether such medical care was careless or not is of no consequence. Similarly, in the absence of disability due to VA medical treatment, the matter of (un)foreseeability need not be discussed. See 38 U.S.C. § 1151. In short, for the reasons and bases expressed above, the Board concludes that a preponderance of the evidence is against the Veteran’s claim for VA compensation under the provisions of 38 U.S.C. § 1151. His claim is accordingly denied. James L. March Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. K. Buckley, Counsel