Citation Nr: 18151385 Decision Date: 11/20/18 Archive Date: 11/16/18 DOCKET NO. 16-12 043 DATE: November 20, 2018 ORDER Entitlement to service connection for the residuals of a cold injury to the bilateral hands is denied. Entitlement to service connection for the residuals of a cold injury to the bilateral feet is denied. Entitlement to a rating in excess of 20 percent for a low back disability is denied. Entitlement to a rating in excess of 10 percent for right knee arthritis is denied. Entitlement to a rating in excess of 10 percent for right knee instability is denied. Entitlement to a rating in excess of 10 percent for a left knee disability is denied. Entitlement to a rating in excess of 10 percent for left knee instability is denied. FINDINGS OF FACT 1. The Veteran does not have any current cold injury residuals of the hands. 2. The Veteran does not have any current cold injury residuals of the feet. 3. The Veteran’s low back disability is not manifested by flexion of 30 degrees or less or unfavorable or favorable ankylosis at any time during the appeal period, to include during flare-ups. 4. The Veteran’s right knee disability is not manifested by flexion that is limited to 30 degrees or less, to include during flare-ups. 5. The Veteran’s right knee disability is not manifested by moderate recurrent subluxation or lateral instability. 6. The Veteran’s left knee disability is not manifested by flexion that is limited to 30 degrees or less, to include during flare-ups. 7. The Veteran’s left knee disability is not manifested by moderate recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for the residuals of a cold injury to the bilateral hands have not been met. 38 U.S.C. §§ 1110, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for entitlement to service connection for the residuals of a cold injury to the bilateral feet have not been met. 38 U.S.C. §§ 1110, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for entitlement to a rating in excess of 20 percent for a back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Code (DC) 5295. 4. The criteria for entitlement to a rating in excess of 10 percent for right knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DCs 5260-5010. 5. The criteria for entitlement to a rating in excess of 10 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DC 5257. 6. The criteria for entitlement to a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DCs 5299-5260. 7. The criteria for entitlement to a rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1994 to May 1998. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2014 and June 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran withdrew her Board hearing request in a February 2017 statement. See 38 C.F.R. § 20.704(e). The Board remanded the matter in June 2017 and April 2018 for additional development.   Service Connection 1. Entitlement to service connection for residuals of a cold injury to the bilateral hands is denied. 2. Entitlement to service connection for residuals of a cold injury to the bilateral feet is denied. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection on a direct basis requires evidence demonstrating: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the claimed in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Here, the Veteran attributes her current hand and foot symptoms (including arthritis) to exposure to cold weather while serving in Korea. In an April 2016 written statement, a fellow servicemember reported that they were frequently exposed to below freezing cold weather during their service in South Korea in 1997 and 1998. During one occasion, they shared a tent for seven days in below freezing temperatures without proper cold weather equipment. The Veteran asserts that she experiences cold sensitivity and pain in her hands and feet as a result of her in-service injury. The Veteran’s service treatment records reveal that she complained of a repeated cold weather injury involving her fingers and toes in November 1997. She reported that her toes were blue and her fingers were swollen. Physical examination revealed cyanosis, edema, blisters, itching, and good circulation. Her hands and feet were dry with good capillary refill and neurovascularly intact. Thus, an in-service injury is conceded. Nevertheless, the evidence dated since her claim was received in April 2016 reflects that she does not have any current disability attributable to cold weather exposure in service. The Board notes that the Veteran is service-connected for bilateral plantar fasciitis and pes planus. Indeed, the Veteran was afforded a VA cold injury residuals examination in October 2017. Physical examination of the feet and hands revealed no objective signs, symptoms, or findings of residuals of a cold injury. Specifically, there were no findings of arthralgia or other pain, cold sensitivity, color changes, hyperhidrosis, numbness, tissue loss, locally impaired sensation, or nail abnormalities. X-rays also revealed no evidence of arthritis. The remaining medical record is likewise silent for current cold injury residual diagnoses during the period on appeal. The Veteran has not presented persuasive evidence showing that she has symptoms that result in any functional impairment. Thus, the Board finds the recent decision of Saunders v. Wilkie, 886 F.3d. 1356 (Fed. Cir. 2018) is not applicable as neither pain nor functional limitations related to residuals of a cold injury of either the hands or feet are shown in the record. The Board has considered the Veteran’s own assertions that she has current cold injury residuals of the bilateral feet and hands. Although she is competent to report her symptoms, she does not have the medical training or expertise to render a competent opinion as to a medical diagnosis or etiology of this disorder. See 38 C.F.R. § 3.159(a)(1)-(2); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Moreover, the credibility of the general assertions is severely undermined by the absence of any post-service diagnosis of the condition. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1330-33 (Fed. Cir. 1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As the evidence does not show that the Veteran had a cold injury or cold injury residuals at the time she filed her claim or any time during the pendency of her appeal, service-connection for residuals of a cold injury is denied. See Brammer, 3 Vet. App. at 225. Increased Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation of parts of the system, to perform the normal working movements of the body with normal excursion, strength, coordination, and endurance. 38 C.F.R. § 4.40. The functional loss may be due to the loss of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology, and evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. Other important factors include excess fatigability, or incoordination (to include during flare-ups or with repeated use), and those factors are not contemplated in the relevant rating. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided. 38 C.F.R. § 4.14. The Veteran seeks increased ratings for her service-connected back and bilateral knee disabilities. She filed her claim for increased ratings for these disabilities in July 2013, which begins the period of appellate review now before the Board (plus consideration of the one-year look back period prior to the filing of that claim). See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). 3. Entitlement to a rating in excess of 20 percent for a low back disability is denied. The Veteran’s back disability has been assigned a 20 percent rating throughout the appeal period under Diagnostic Code 5295. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine. Pursuant to this formula, a 20 percent disability rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasm or guarding is severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less; or, when there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating requires unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating requires unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormalities, including but not limited to bowel or bladder impairment, are to be evaluated separately under the appropriate diagnostic codes. 38 C.F.R. § 4.71a, Note (1). Spinal disabilities may alternately be rated under DC 5243, if intervertebral disc syndrome (IVDS) is present. 38 C.F.R. § 4.71a, DC 5243. The Veteran does not contend, and the record does not otherwise show, a diagnosis of IVDS of the thoracolumbar spine. Thus, a rating is not available under DC 5243. Here, the Veteran asserts that her service-connected back disability is more severe than the currently assigned rating due to her limited range of motion and functional limitations. After review of the medical and lay evidence of record, the Board finds that a rating in excess of 20 percent rating is not warranted. The Board’s June 2017 remand determined that joint testing conducted in December 2015 was inadequate, pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016) (38 C.F.R. § 4.59 requires that VA examinations include joint testing 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.). The March 2014 VA examination report is similarly problematic. The Board’s April 2018 remand determined that joint testing conducted in October 2017 was inadequate, pursuant to Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (finding orthopedic examination inadequate where the examiner declined to provide an estimate of the degree of additional loss of motion due to flare-ups because such would require resort to speculation). Thus, the only adequate VA examination during the appeal period in regards to range of motion testing is the June 2018 VA examination report. Additionally, the Board will consider the Veteran’s lay statements and other favorable medical findings. Thus, there is no prejudice to the Veteran in not considering the prior VA examinations to rate her disability based on limitation of motion and DeLuca factors. A May 2014 VA chiropractic consultation record indicates that the Veteran complained of back pain that at times is sharp, throbbing, aching with numbness, burning, and swelling that is relieved by medication, ice, heating pads, rest, and stretching. Physical examination revealed forward flexion to 30 degrees. A May 2014 VA MRI revealed mild degenerative disc disease without any signs of compression on the nerves exiting the spine. A June 2014 private treatment record revealed forward flexion to 50 degrees. In the Veteran’s May 2014 Notice of Disagreement (NOD), she indicated that she received two cortisone injections during her chiropractic visits between August 2013 and May 2013. During the June 2018 VA examination, the Veteran reported flare-ups that can be described as sharp throbbing continuous pain. She further reported the regular use of a brace. Range of motion testing revealed forward flexion to 90 degrees. The examiner noted that pain noted on examination does not result in or cause functional loss. Repetitive use testing revealed forward flexion to 85 degrees. The examiner noted that the additional limitation of motion on repetitive testing is caused by pain but not fatigue, weakness, lack of endurance, or incoordination. The examination was not conducted during a flare-up, but the examiner indicated that the observed repetitive use examination was consistent with the Veteran’s functional loss during a flare-up. There was no evidence of pain on passive range of motion testing, with weight-bearing, or nonweight-bearing. The examiner noted that the Veteran had functional impairment of the spine, to include less movement than normal, the inability to stand or sit for longer than 10 minutes, and the inability to lift any objects weighing more than 15 pounds. The contemporaneous X-ray was normal. The examiner found no IVDS of the spine or ankylosis. A rating in excess of 20 percent is not warranted, as the medical evidence does not reveal forward flexion of the thoracolumbar spine limited to 30 degrees or less, even when considering flare-ups. The Board finds that the May 2014 finding of forward flexion limited to 30 degrees is not a true depiction of the Veteran’s disability picture. In this regard, the May 2014 finding is inconsistent with June 2014 flexion findings and the June 2018 VA examination report. The June 2018 examination showed flexion is essentially limited to no less than 85 degrees following repetitive motion and during a flare-up. Thus, the Board affords greater probative value to the June 2014 and June 2018 physical examinations regarding the limitation of flexion of the back, as the examinations are consistent with each other and the historical record. Further, even considering the effects of pain, the Veteran retained motion in the thoracolumbar spine and any additional limitation due to pain does not more nearly approximate a finding of forward flexion of the thoracolumbar spine to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine. Accordingly, the 20 percent rating contemplates the functional loss due to pain and less movement. There is no basis for the assignment of additional disability due to pain, weakness, fatigability, weakness or incoordination. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 206-07. Thus, a rating in excess of 20 percent is not warranted. As previously noted, a higher rating is also not warranted under Diagnostic Code 5243, as the Veteran does not contend, and the record does not otherwise show, a diagnosis of IVDS of the thoracolumbar spine. Thus, a rating is not available under DC 5243. As for objective neurologic abnormalities, the Veteran has consistently denied any bowel or bladder complaints during VA examinations. Additionally, a separate 10 percent rating for left extremity radiculopathy, sciatic nerve branch, was granted effective June 13, 2018 in a September 2018 rating decision under DC 8520. In this regard, the Veteran complained of mild constant pain and mild paresthesias and/or dysesthesias in the left lower extremity during the June 2018 VA examination. The June 2018 examiner found normal muscle strength testing, except in right knee extension which showed decreased muscle strength (4/5), indicating active movement against some resistance. Sensory examination was decreased in the left upper anterior thigh. Straight leg raising was positive bilaterally. Reflex examination was normal. The examiner found mild left lower extremity radiculopathy involving the sciatic nerve and noted no other signs or symptoms of radiculopathy. Moreover, the June 2018 VA examiner’s finding of right knee extension strength at 4 out of 5 with no evidence of atrophy is reflective of only a slight muscle disability and therefore does not support a separate rating under 38 C.F.R. § 4.73, DCs 5311-5312. Accordingly, a rating in excess of 10 percent for left lower extremity is not warranted, as the evidence does not reflect moderate incomplete paralysis of the sciatic nerve. Prior to June 13, 2018, there is no evidence that a separate rating for radiculopathy was factually discernible. In September 2013, the Veteran reported to the VA emergency department for back pain. At the time she denied radiation of pain. During a November 2013 VA rehabilitation consult, she reported back pain with rare radiation down her posterior thigh, midcalf for approximately three weeks. The treating physician found no clinical signs of radiculopathy. Similarly, the March 2014, December 2015, and October 2017 VA examiners found no signs or symptoms due to radiculopathy. Muscle strength, reflex, straight leg raising, and sensory examinations were normal at all three VA examinations. In March 2014, ten days after denying radiculopathy symptoms to the VA examiner, she reported to the emergency department for left low back pain radiating down the left leg along lateral aspect to the great toe. As previously noted, the May 2014 MRI revealed degenerative disc disease without any signs of compression on the nerves existing the spine. The Board acknowledges that in advancing this appeal, the Veteran believes that her back disability is more severe than the assigned disability rating reflects. However, the VA examination reports offering detailed specific specialized determinations pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also contemplate the Veteran’s descriptions of her symptoms. In sum, the preponderance of the evidence weighs against the award of a rating in excess of 20 percent for the Veteran’s back disability for the entire appeal period. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 4. Entitlement to a disability rating in excess of 10 percent for right knee arthritis is denied. 5. Entitlement to a disability rating in excess of 10 percent for right knee instability is denied. 6. Entitlement to a disability rating in excess of 10 percent for a left knee disability is denied. 7. Entitlement to a disability rating in excess of 10 percent for left knee instability is denied. The Veteran is in receipt of a 10 percent rating for right and left knee instability under DC 5257, a 10 percent rating for right knee arthritis under 5260-5010, and 10 percent rating for left knee patellofemoral syndrome and chondromalacia patella under 5299-5260. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned). An unlisted disease, injury, or residual condition is rated by analogy with the first two digits selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be “99” for all unlisted conditions. Id. Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). DC 5257 evaluates recurrent subluxation or lateral instability of a knee, and provides a 10 percent rating for slight impairment, a 20 percent rating for moderate impairment, and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a. The words “slight”, “moderate,” and “severe” used in DC 5257 are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Under DC 5260, a noncompensable rating is assigned for flexion limited to 60 degrees. A 10 percent disability rating is assigned 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. 38 C.F.R. § 4.71a, DC 5260. A noncompensable rating is warranted for limitation of extension to 5 degrees, and a 10 percent rating is warranted for limitation of extension to 10 degrees, a 20 percent rating is warranted for limitation of extension to 15 degrees with higher ratings available for more severe limitation. 38 C.F.R. § 4.71a, DC 5261. Diagnostic Code 5010 provides that arthritis due to trauma is to be evaluated as degenerative arthritis pursuant to Diagnostic Code 5003. Diagnostic Code 5003 provides that degenerative arthritis substantiated by x-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion. A 20 percent evaluation is warranted for x-ray evidence of involvement of 2 or more major or minor joints, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. As a preliminary matter, the Board notes that although the Veteran presented for VA examinations in March 2014, July 2014, December 2015, and October 2017, the most recent June 2018 VA examination is the only examination that is compliant with the requirements set forth by Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Accordingly, only the June 2018 examination report will be utilized for evaluation of the Veteran’s knee disabilities based on range of motion, as it is the only adequate examination of record. A November 2013 VA treatment record shows bilateral knee flexion to 130 degrees without swelling or effusion. During the June 2018 VA examination, the Veteran reported long standing knee pain that worsens when the temperature drops below 55 degrees. She further described flare-ups of swelling, pain, and locking when bending the knee too far. Physical examination of the right knee revealed flexion and extension to 130 degrees, with pain on flexion. Physical examination of the left knee revealed flexion and extension to 140 degrees, without pain. Repetitive testing revealed right knee flexion and extension to 125 degrees. There was no additional loss of function or range of motion after repetitive testing of the left knee. There was no objective evidence of pain on passive and non-weight bearing range of motion testing of the left knee. Although the examination was not conducted during a flare-up, the Veteran described right knee flexion to 125 degrees with pain during a flare-up. She further reported that her left knee results in only pain without additional limitation of motion during a flare-up. The examiner noted that pain without fatigue, weakness, lack of endurance, or incoordination is likely to occur during a flare-up. The examiner noted that prolonged standing for more than 10 minutes and walking more than 500 feet contributed to functional loss. Joint stability testing was normal. Muscle strength testing was normal in the left knee. Muscle strength testing in the right knee was 4 out of 5 in flexion and extension, entirely due to the service-connected knee disabilities. The examiner found no ankylosis or history of recurrent subluxation, lateral instability, or recurrent effusion. The x-ray was negative, to include no radiographic evidence of right knee arthritis. Based on the evidence presented, the Board finds against the claim for a rating in excess of 10 percent for bilateral knee instability, as the evidence is against a finding of moderate recurrent subluxation or lateral instability. The Veteran is competent to report her symptoms of instability and has presented credible evidence of weakness, instability, swelling, catching, and popping. See December 2015 VA examination report. However, objective joint stability testing of the right and left knee revealed no lateral instability, recurrent subluxation and/or current effusion throughout the appeal period, much less moderate instability. See March 2014 to June 2018 VA examination reports. Additionally, the June 2018 x-ray revealed no subluxation of the right or left knee. The Board acknowledges that the June 2018 examiner noted instability of station of the right knee; however, objective clinical testing was normal. Accordingly, a rating in excess of 10 percent for bilateral knee instability is not warranted. A review of the record is also against the assignment of a rating higher than 10 percent for right and left knee limitation of flexion. In this regard, collectively the evidence does not show right or left knee flexion that is limited to 30 degrees or less. Furthermore, the Veteran herself reported right knee flexion to 125 degrees during a flare-up and no additional limitation of motion in the left knee to the June 2018 examiner. The reported symptom of pain in the right and left knee is already contemplated in the 10 percent rating under 5260. 38 C.F.R. § 4.59. Consideration is also given to additional limitation on repetition related to pain, fatigue, incoordination, weakness or lack of endurance. DeLuca, supra, 8 Vet. App. 202. The more probative evidence, however, is devoid of any showing of flexion limited to 30 degrees or less, even when considering the factors of Deluca. Accordingly, a rating in excess of 10 percent for right and left knee limitation of flexion is not warranted. As noted above, the June 2018 VA examiner’s finding of right knee extension strength at 4 out of 5 with no evidence of atrophy is reflective of only a slight muscle disability and therefore does not support a separate rating under 38 C.F.R. § 4.73, DCs 5311-5312. Additionally, the Board has considered whether higher or separate ratings are warranted under alternate diagnostic codes. There is no indication of ankylosis, removal of semilunar cartilage, tibia and fibula impairment, or genu recurvatum. As such, ratings under DCs 5256, 5259, 5262, and 5263 are precluded. The Board acknowledges that an August 2012 MRI of the left knee revealed mild thinning of the lateral femorotibial cartilage with effusion. An August 2013 MRI of the bilateral knees was normal. A March 2014 MRI associated with the Veteran’s VA examination revealed an intact left cartilage without evidence of defects. The June 2018 examiner identified a meniscus condition manifested by frequent episodes of joint locking, pain, and effusion without dislocation or tear. Therefore, the Board finds that a separate rating for dislocated cartilage is not warranted under DC 5258. Finally, VA examinations noted a left knee scar, but indicated that it was not painful or unstable, or the total area was greater than 39 square cm (6 square   inches). Thus, a separate compensable rating for any related scar is not warranted. See 38 C.F.R. § 4.118, DCs 7801, 7802, 7804, 7805. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Forde, Counsel