Citation Nr: 1806733 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 10-41 238 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to higher initial ratings for service-connected left knee disability, currently rated as 10 percent disabling for limitation of flexion; 0 percent for instability; and 0 percent each for two left knee scars. 3. Entitlement to a compensable initial rating for the service-connected residuals of bilateral lower extremity stress fractures. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Alexander Neff, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1998 to April 2008. Her awards and decorations included: a National Defense Service Medal; an Armed Forces Expeditionary Medal; and a Global War on Terrorism Medal. The Board sincerely thanks the Veteran for her service to her country. These matters are before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Houston, Texas, Department of Veteran Affairs (VA) Regional Office (RO) that assigned noncompensable ratings for left knee meniscal tear (under Diagnostic Code 5257 for instability) and bilateral lower extremity stress fractures. The Veteran has since relocated to Colorado, although her representative remains the Texas Veterans Commission. In November 2015, a Video Conference hearing was held before the undersigned; a transcript of which is associated with the record. In March 2016, the Board remanded the above claims for further evidentiary development, to include VA examinations, and reajudication. Subsequently, an October 2017 rating decision granted a 10 percent rating for limitation of flexion of the left knee and 0 percent ratings for left lateral and left superomedial knee scars, all effective November 2, 2016. The issue of entitlement to service connection for a right knee disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the appeal, the Veteran's left knee manifested by 125 degrees of flexion with complaints of pain. 2. From December 13, 2013, the Veteran's left knee disability manifested with no more than slight lateral instability. 3. From March 19, 2015, the Veteran's residuals of a post-service meniscectomy are continued pain and occasional locking. 4. The Veteran's left knee scars are each 1 cm by 0.3 cm and not deep or painful or unstable. 5. During the period on appeal, Veteran's bilateral stress fracture residuals/shin splints have not been shown to manifest as a slight knee or ankle disability. CONCLUSIONS OF LAW 1. Throughout the appeal, the criteria for a 10 percent rating, but no higher, for limitation of flexion of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.322, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a (2017), Diagnostic Code 5260 (2017). 2. From December 13, 2013, the criteria for a 10 percent rating, but no higher, for left knee lateral instability have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.322, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 3. From March 19, 2015, the criteria for a 10 percent rating for symptomatic residuals of a meniscectomy have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.322, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5259. 4. The criteria for a compensable rating for left knee scars have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7805. 5. The criteria for a compensable rating for bilateral residuals of stress fractures/shin splints have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Legal Criteria A. Rating Disabilities Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A disability rating may require re-evaluation in accordance with changes in a Veteran's condition. Thus, it is essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id at § 4.1. Where, as here, the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Hart v. Mansfield, 21 Vet. App. 505 (2007). Moreover, adjudication of a claim for a higher initial disability rating should include specific consideration of whether staged ratings are appropriate. See Fenderson v. West, 12 Vet. App, 119 (1999). Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id at § 4.3. II. Left Knee and Bilateral Shin Splints A. Rating Criteria During the period on appeal, the Veteran's left knee disability has been rated under Diagnostic Codes 5257 (instability), 5260 (limitation of flexion) and 7805 (scars). Also during the period on appeal, the Veteran's bilateral shin splints have been rated under Diagnostic Code 5262. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45, pertaining to functional impairment. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. The Board has additionally considered the holding of Sharp v. Shulkin, 29 Vet. App. 26 (2017). This case regarded a VA joint examination where flare-ups were alleged; but the Veteran was not experiencing same during the examination. In such a situation, the VA examiner is required to consider the Veteran's statements, the claims file, and the medical record to estimate functional losses, if any, due to flare-ups, or to explain why such an opinion cannot be provided. Sharp v. Shulkin, 29 Vet. App. 26 (2017). If the manifestations of a service-connected disability cannot be separated from the manifestations of a non-service-connected condition based on the medical evidence of record, all manifestations will be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Further, the Board must consider all potentially applicable regulations or diagnostic codes to assign the highest rating. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991) The Board notes that during the period on appeal the Veteran's left knee disability was not shown to be manifested by ankylosis. Further, the record on appeal does not show that there was any nonunion or malunion of any bone, or genu recurvatum, or arthritis. As such, in rating this claim the Board shall not consider the related Diagnostic Codes. However, the record does show that the Veteran's left knee disability was manifested by limitation of motion, lateral instability, and symptomology related to the residuals of an post-service meniscectomy. As such, Diagnostic Codes 5257, 5258, 5259, 5260, and 5261 are for consideration. See Butts v. Brown, 5 Vet. App. 532, 538 (1993); see also Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). Diagnostic Code 5257 sets forth the criteria for evaluating recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. Id. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. Id. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. Id. Diagnostic Code 5258 states that a 20 percent rating is warranted for dislocated semilunar cartilage of the knee with frequent episodes of "locking," pain, and effusion. 38 C.F.R. § 4.71a. Diagnostic Code 5259 states that a 10 percent rating is warranted where removal of semilunar cartilage of the knee is symptomatic. Id. Chapter 38 C.F.R. §4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. Diagnostic Code 5260 sets forth the criteria for evaluating limitation of flexion of the leg. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A noncompensable rating is warranted where flexion is limited to 60 degrees. Id. A 10 percent rating is warranted where flexion is limited to 45 degrees. Id. A 20 percent rating is warranted where flexion is limited to 30 degrees. Id. A 30 percent rating is warranted where flexion is limited to 15 degrees. Id. Diagnostic Code 5261 sets forth the criteria for evaluating limitation of extension of the leg. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A noncompensable rating is warranted where extension is limited to 5 degrees. Id. A 10 percent rating is warranted where extension is limited to 10 degrees. Id. A 20 percent rating is warranted where extension is limited to 15 degrees. Id. A 30 percent rating is warranted where extension is limited to 20 degrees. Id. A 40 percent rating is warranted where extension is limited to 30 degrees. Id. A 50 percent rating is warranted where extension is limited to 45 degrees. Id. The Veteran's bilateral shin splints have been rated, by analogy, under Diagnostic Code 5262. Diagnostic Code 5262 sets forth the criteria for evaluating impairment of the tibia and fibula. 38 C.F.R. § 4.71a, Diagnostic Code 5262. A 10 percent rating is warranted where there is a malunion with slight knee or ankle disability. Id. A 20 percent rating is warranted where there is a malunion with moderate knee or ankle disability. Id. A 30 percent rating is warranted where there is a malunion with a marked knee or ankle disability. Id. A 40 percent rating is warranted where there is a nonunion of the tibia and fibular, with loose motion, that requires a brace. Id. Diagnostic Code 7801 provides for a 10 percent rating for a deep, nonlinear scar that is at least 6 square inches. Diagnostic Code 7802 provides for a 10 percent rating for superficial, nonlinear scars at least 144 square inches in area. Diagnostic Code 7804 provides for a 10 percent rating for one or two painful or unstable scars. Diagnostic Code 7805 provides for a rating for other disabling effects of scars not addressed in the other Diagnostic Codes related to scars. III. Factual Background and Analysis The Veteran filed her initial claim for service connection for her left knee and bilateral stress fractures in June 2008. These claims were granted in December 2008. At that time, her left knee meniscus tear was rated as noncompensable, under Diagnostic Code 5257, and her bilateral lower extremity stress fractures were rated as noncompensable, under Diagnostic Code 5262. In the October 2017 rating decision, the Veteran was granted a 10 percent rating, effective November 2, 2016, for limitation of flexion associated with left meniscus tear under Diagnostic Code 5260 and was also granted service-connection for two knee scars, both rated 0 percent disabling. Medical records from July 2008 showed that the Veteran experienced knee pain, wore a brace when she could, and that her knee would occasionally lock up. In a February 2012 private medical record, the Veteran complained of experiencing constant bilateral pain knee in cold weather. She had difficulty with stairs, and had increased stiffness in the mornings. The active range of motion for flexion of the left knee was 0 to 130 degrees, and for the right 0 to 140 degrees. Extension was to 0 degrees for both knees. Varus and valgus stress, anterior drawer, Lachman's, and pivot shift testing were negative for both knees. McMurray's medial and lateral testing were also negative. The patellar grind test was bilaterally positive, and the kneecaps were noted as mobile and painful. The Veteran was noted to have pain as well as impairment of active and passive range of motion, muscle performance, joint mobility, and motor function. It was observed that these impairments were due to localized inflammation and muscle performance. In other private medical records from this time, the Veteran complained of pain upon flexion and running. There was no knee joint stiffness, locking, or sudden buckling. There was no effusion, misalignment, crepitus, tenderness upon palpation, or pain elicited by motion. Anterior and posterior drawer testing, as well as Lachman's, were negative. McMurray's testing was positive. Motion of the left knee was observed as normal with no weakness. Right knee testing was also normal. Upon review of an X-ray taken during this time, the Veteran's left knee was noted to have two broad-based osteochondroses that involved the posterior femur and medial tibial metadiaphysis. An MRI from this time found that there was a small knee effusion, as well as infrapatellar bursal fluid. In April 2012, it was noted that the Veteran's left knee had: distal femoral osteochondroma without appreciable cartilage cap with mild mass effect upon the short head biceps femoris muscle belly; proximal medial tibial osteochondroma with in the cartilage cap, with mild mass effect upon the sartorius and gracilis tendons and mild adjacent bursitis without aggressive features; and focal chondral fissuring over the medial patellar facet. In a May 2012 private medical record, the Veteran complained of off and on left knee pain since service. The majority of the pain she experienced was a dull, achy-type sensation which could increase to a sharp stabbing sensation during an exacerbation. She was neurovascularly intact to the distal lower extremity. Her knee was stable to Lachman, varus, and valgus stress testing. She was then provided a steroid injection of the left medial proximal tibia. In a May 2012 private medical record, the Veteran complained of worsening left knee pain over the last four months during flexion and running. She reported that there was a large firm lump of the left knee that was tender when compressed. The lump was worse with nearly all activity, but especially when ascending stairs. The knee appeared to be normal without alignment abnormality or effusion. The clinician observed a palpable firm mass over proximal medial aspect of tibia. Range of motion testing was 0 to 135 degrees. The knee was ligamentously stable to Lachman, posterior, varus, and valgus testing. Imaging studies showed left knee distal femoral osteochondroma without appreciable cartilage cap with mild mass effect upon the short head biceps femoris muscle belly; proximal medial tibial osteochondroma with the cartilage cap, with mild mass effect upon the sartorius and gracilis tendons; and mild adjacent bursitis. The Veteran was diagnosed with osteochondroma of the left knee, and was provided with a steroid injection. In other medical records from this month, the Veteran complained of left knee pain, which could increase to a sharp stabbing sensation during an exacerbation. She has noted that her knee had become more painful during bad weather. A palpable mass was observed along the left proximal medial tibia. The knee was stable to Lachman, and varus and valgus stress testing. In May and June 2012, the Veteran complained of pain located in the left medial proximal tibia, as well as more proximally at the distal medial femur, and of both the medial and lateral aspects of the left patella. She was treated with injections, where after she complained of increased pain, to include during ambulation, and nausea. She reported a sensation of near-locking of the left knee while walking. Upon physical examination, the Veteran had a full range of motion, and no effusion was present. In the December 2013 VA knee and lower leg examination, the Veteran reported that she had experienced increasing amounts of bilateral knee pain. She reported flare-ups of increased pain with prolonged weight-bearing activities. She also complained of bilateral shin splints, particularly when walking up hills. It was noted that the Veteran experienced anterior lower leg pain when she walked uphill. The Veteran's left knee was observed not to cause the Veteran to have any significant physical deformity, ankylosis of the major joints, neurological impairment, or severe gait dysfunction. Left knee flexion was measured at 140 degrees or greater, and there was no objective evidence of painful motion. Extension ended at 0 degrees, and there was no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing, wherein the results were the same as above. No additional limitation of range of motion was observed following repetitive-use testing. There was functional loss/impairment of the knees and lower legs noted as pain on movement, disturbances of locomotion, and interference with sitting, standing, and weight-bearing. Bilateral anterior, posterior, and medial lateral stability was normal. There was no history of recurrent patellar subluxation or dislocation. The Veteran was noted to have a left knee meniscal tear, and frequent episodes of bilateral joint pain. The Veteran had not undergone a meniscectomy, or other arthroscopic or knee surgery. There was no functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. X-rays of the knees did not show degenerative or traumatic arthritis, or patellar subluxation. The functional impact of the Veteran's knee and lower conditions was noted as limitation of performing work duties that required deep knee bends, such as squatting, kneeling, or crawling. Her knee pain would limit prolonged weight-bearing activities, such as walking and standing. The Veteran would also be limited in climbing stairs or ladders. The Veteran was not prevented from participating in seated work duties. In a December 2013 private medical record, the Veteran complained of a two week history of left knee pain flare-ups. It was noted that cold weather seemed to exacerbate this pain. Her left knee was tender, and pain was elicited by motion. Lachman testing showed one plane of anterior instability. McMurray's and patellofemoral apprehension testing were positive. Tenderness was observed upon ambulation. No effusion, misalignment, or crepitus was observed. There were no anterior or posterior drawer signs. Her motion was noted as normal, and her left knee was observed as having weakness. In a June 2014 private medical record, the Veteran claimed that her left meniscus had split apart, and noted that her knee would catch. In July 2014, an MRI, in part, revealed a possible meniscus medial root tear. In another record from this time, the Veteran complained that most times when she squatted her left knee would lock. She reported that she would then have to move it, would feel a "pop", and then the knee would straighten out. She was observed with patellofemoral pain with resistance and compression maneuvers. She had a negative McMurray's test. She was noted to have tenderness of the medial femoral condyle, but not within the joint space. She received a knee injection at this time. In November 2014, the Veteran complained that if she used a treadmill she would experience significant pain afterwards. Thereafter, she would almost be incapacitated for the next few days. An MRI showed a possible meniscus medial root tear. Upon physical examination, the clinician did not detect a positive McMurray's sign. Crepitus was noted; however, there was no effusion, giving way, locking, or catching. In January 2015, the Veteran had a cyst rupture on a "tumor" in her left knee. In another medical record from this month, the Veteran was noted to have formed a cyst in her left knee due to palliative knee injections that ruptured the week prior. The pain related to this was so intense that she reported to the ER. She complained of increased pain with prolonged standing and walking, and noted some relief with sitting and lying down. She had to externally rotate her left leg to be comfortable while supine. She avoided stairs as these would significantly increase her pain. She also reported that she was very active with running and exercising, but was currently unable to do so due to her pain. The Veteran did report improved mobility due to performing certain recommended exercises and swimming. She additionally reported decreased pain in light of same. The clinician noted that the Veteran continued to be limited due to her osteochondroma, and anticipated that her range of motion would continue to be limited until it was removed. In January 2015, the Veteran reported that her left knee locked up once while she was getting her children into her car, and once at the grocery store. It was noted that she poorly tolerated physical therapy at this time, and that her knee had given out after the last session. In a February 2015 private medical record, the Veteran complained of significant left knee pain with any type of activity. She was unable to run or jog. She experienced a significant amount of catching and locking, mostly at the medial aspect right in the medial to posteromedial joint line. She denied other musculoskeletal complaints. The Veteran was observed to have full extension, flexion to 140 with minimal crepitus. There was a significant amount of pain in the medial joint line, and she had a positive McMurray's test. Her strength was noted as normal. In March 19, 2015, the Veteran underwent a partial meniscectomy of the left knee. It was noted that the Veteran had a small undersurface tear of the medial meniscus. The clinician noted that there was concern that this was causing the Veteran's left knee symptoms, especially the mechanical ones. In an April 2015 private medical record, the Veteran's left knee was noted to have a range of motion of 0 to 135. Her strength was good, and her neurovascularity was intact. At the November 2015 hearing, the Veteran reported that the bending and lifting that she did at work would cause her to take two or three days off due to pain or inflammation. This was one reason why she received ongoing steroid injections and pain medication to control her symptoms at work. She reported that while she was pregnant and at work, she was placed on short-term disability due to her knee locking. She noted that it was "basically [was] an ongoing situation" where, at times, she had to take personal time off in order to recuperate. In a March 2016 private medical record, the Veteran complained of left knee pain, locking, and catching in the medial aspect. Swelling and moderate effusion was noted. The left knee was stable to varus and valgus stress. Lachman testing was negative. McMurray's testing was positive on the medial side. She was observed to have a full range of motion. In another medical record from this time, McMurray's, Lachman's, and posterior drawer testing were negative. Varus and valgus testing showed no instability. The left knee's range of motion was 0 to135 degrees in flexion. There was no effusion, and its strength was normal. Pain was observed along the medial side, but not on the lateral side. The right knee's range of motion was 0 to135 degrees in flexion. In March 2016, the Veteran reported that she had been exercising more. She complained of worsening left knee pain symptoms. She was noted to have frequent catching and locking, but no giving way. She experienced tenderness on palpation along the medial joint line, and mild swelling. Pain was elicited on motion, and "tenderness" was observed upon ambulation. She was not found to have patellar crepitus, and her motion was normal. Anterior and posterior drawer, as well as McMurray's, testing was negative. No weakness of the left knee was observed. In an August 2016 private medical record, the Veteran complained of left knee pain and flare-ups during activities. McMurray's and Lachman's testing were negative, as was posterior drawer testing. There was no varus and valgus instability upon testing. No effusion was noted, and strength was observed as normal. Pain was observed along the medial side, and minor pain on the lateral side of the left knee. The left knee's range of motion was 0 to 135 degrees in flexion. The right knee was examined, and its range of motion was 0 to 135 degrees. In the November 2016 VA knee and lower leg examination, the Veteran stated that her left knee osteochondroma had progressed since service, and that in 2015 she underwent surgery for meniscus repair and removal of the osteochondroma. She reported since then her left knee has been consistently painful. Range of motion testing for the left knee showed flexion of 0 to 125 degrees, and extension of 125 to 0 degrees. The range of motion contributed to a functional loss of difficulty kneeling or squatting. Pain was observed upon flexion. There was objective evidence of moderate localized tenderness/pain at the medial proximal tibia, which was associated with pes anserine bursitis. There was evidence of pain on weight bearing, but there was no evidence of crepitus. There was no additional loss of function or range of motion after repetition testing. The Veteran was not examined immediately after repetitive use over time; however, her examination was medically consistent with her statements. Pain was noted as a factor that caused functional loss with repeated use over a period of time. The examiner could not describe this functional loss in terms of range of motion as there was no suspected loss, but an avoidance of triggering activities. The examination was not conducted during a flare-up, and was found to be neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during same. Regarding pain on motion, it was observed that the Veteran did not experience pain upon non-weight bearing movement. Her left knee was painful on passive range of motion testing, but the range of motion was not changed from active testing. Her right knee did not experience pain upon passive testing. Bilaterally, the Veteran had normal strength upon flexion and extension. She did not have muscle atrophy, or ankylosis. The examiner did not find a history subluxation or lateral instability of the knees. Stability testing was noted a "not indicated." The Veteran was observed to have had a left knee meniscal tear, which was later repaired in 2015, and its symptoms included occasional locking and pain. The Veteran used a brace for her left tibia and femur osteochondromas. During the examination, the Veteran was noted to have diagnoses of left tibia and femur osteochondromas, pes anserine bursitis, and shin splints that were likely the cause of the majority of the Veteran's knee pain. This was because her left knee meniscal tear was small and treated surgically. However, there was likely some pain related to the residuals of the left knee meniscus repair, but it overlapped too much with the other knee conditions and precluded differentiation. The examiner opined that the Veteran's knee or lower leg disabilities did not cause functional impairment of an extremity such that no effective functions remained other than that which would be equally well served by an amputation with prosthesis. Regarding shin splints, the Veteran did not report flare-ups regarding same, but reported a function loss/impairment as the inability to run, and that she could walk a maximum distance of half a mile before she needed a rest. Upon review of X-ray imaging, the Veteran was not found to have degenerative or traumatic arthritis of either knee. The X-rays did not show shin splints; however, subjective symptoms were reported with activity. The examiner noted that shin splints were a lesser severity condition along the continuum to stress fractures. The functional impact of the Veteran's shin splints was an avoidance of running, jumping, and kneeling. Noting that there was no tenderness upon examination, the examiner opined that the Veteran's stress fractures resolved/regressed, but she experienced recurrent shin splints. The examiner noted that shin splints were commonly a chronic problem, and they were present when the Veteran squatted, and walked for more than one half mile without rest break. The examiner found that the Veteran's shin splints, and bilateral stress fractures, did not affect either knee or ankle's range of motion. The examination report also noted that the Veteran had 2 scars due to her knee surgery, both measuring 1 centimeter (cm) by 0.3 cm. Neither scar was painful or unstable. As an initial matter, the Board notes that the November 2016 examiner observed that the Veteran had a number of left knee diagnosis in addition to her service-connected residuals of a meniscal tear. The examiner noted that that it was not possible to differentiate the symptoms caused by each diagnosis. As such, giving the Veteran the benefit of the doubt, the Board shall consider all left knee symptoms as related to her service-connected left knee disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Upon consideration of the foregoing, the Board finds that the record supports a grant of 10 percent, but no higher, throughout the appeal for painful left knee flexion. See 38 C.F.R. § 4.59. During the period on the appeal the Veteran has been shown to have both subjective and objective symptoms of pain upon flexion. A higher rating for limitation of motion of flexion is not warranted as the Veteran's left knee, has not been shown during the period on appeal to have a compensable limitation of flexion. A review of the record shows a limitation of flexion to 125 degrees with pain. Further, the Veteran is not entitled to a compensable rating for limitation of movement of extension, as the weight of the competent and credible medical evidence during the period on appeal does not demonstrate that she had a compensable limitation of extension, even due to pain. As such, the Board finds that the Veteran's limitation of motion is not to a degree that would warrant a rating in excess of 10 percent under Diagnostic Code 5260 during the period on appeal, or a compensable rating under Diagnostic Code 5261. Upon considered the of the provisions of 38 C.F.R. § 4.40, 4.45, and 4.59, as well as the holding in the DeLuca case, the Board finds that a rating in excess of 10 percent is not warranted for limitation of left knee flexion. The 10 percent rating takes into consideration the evidence of occasional swelling, weakness, and effusion and reports of stiffness, including reported flare-ups, as her degree of limitation of flexion is noncompensable. Likewise, the Board has considered the holding of Sharp, and observes that a higher rating is not warranted due to the Veteran's reported flare-ups. During the period on appeal, the Veteran has indicated that certain activities would cause her to be almost incapacitated for certain periods or to take time off of work due to pain. However, other portions of the record show that the Veteran was able to tolerate exercising and swimming. As such, the Board does not find that these pain-related flare-ups necessitate an even higher rating for limitation of motion, as the record demonstrates that the Veteran's pain flare-ups did not occur at such a frequency or consistency to more nearly equate to a greater limitation of motion as considered by Diagnostic Codes 5260 and 5261. Thus, the Board finds that the preponderance of the evidence is against finding any higher rating is warranted for loss of function or range of motion due to pain or flare-ups. The Board notes that during the period on appeal the Veteran on occasion reported that her left knee would catch and/or lock. In March 2016, the Veteran expressed that she has experienced frequent locking of the left knee, and in the November 2016 examination was objectively found to have occasional locking and pain. During the period on appeal, the record does not demonstrate that the Veteran had dislocated semilunar cartilage of the knee. Further, the Veteran was only shown on a few occasions to have experienced effusion. Upon consideration of the above, the Board does not find that the Veteran's disability picture more closely approximates the criteria of Diagnostic Code 5258. Notably, the Board has considered the March 2016 statements and does not find that this record alone is sufficient to warrant a separate compensable rating under Diagnostic Code 5258. As such, a separate rating under this Diagnostic Code is not warranted. In March 19, 2015, the Veteran underwent a meniscectomy of the left knee to resolve the residuals of her service-connected meniscus tear. Accordingly, the Board finds that a separate 10 percent rating is warranted for symptomatic residuals of this, such as locking and pain, effective from March 19, 2015. The Board observes that since December 2013, the Veteran has been shown on some occasions to have instability of the left knee. The Board notes that the Veteran is competent to describe such symptoms, and that these statements are credible evidence in support of this claim. The Board acknowledges that the December 2013 and November 2016 examiners found that there was no history of instability; however, the Board finds that the aforementioned competent and credible medical and lay evidence outweighs these findings. As such, the Board, giving the Veteran the benefit of the doubt, finds that as of December 13, 2013, the date of the December 2013 record, the weight of the evidence is in favor of a 10 percent rating, but no higher, for recurrent slight lateral instability under Diagnostic Code 5257. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. A higher rating is not warranted during this period on appeal as the record does not support a finding that the Veteran experienced recurrent moderate instability. The notations with respect to instability are only occasional on objective testing. Lastly, a compensable rating is not warranted for the Veteran's left knee scars. She does not have a deep, nonlinear scar that is at least 6 square inches; a superficial, nonlinear scar at least 144 square inches in area; or a painful or unstable scar. Although the November 2016 VA examiner noted that the Veteran did experience recurrent shin splints, they were not found to affect the range of motion of either the knees or ankles. The Board observes that the record contains references to the Veteran's bilateral shin splints, and notes subjective complaints of pain related to same. Notably, pain on ambulation for the left lower extremity has been considered above in the discussion of its limitation of motion. Further, the pain elicited from the shin splints has not been demonstrated elsewhere in the record to significantly expand upon, revise, or contradict the findings of the November 2016 examination. As such, a compensable rating for bilateral shin splints is not warranted. In summation, throughout the appeal, a 10 percent rating, but no higher, is warranted for limitation of motion; from March 19, 2015 a 10 percent rating for symptomatic residuals of a meniscectomy is warranted; and from December 13, 2013, a 10 percent rating, but no higher, for slight lateral instability is warranted. A compensable rating for bilateral shin splints is not warranted during the period on appeal. ORDER Throughout the appeal a rating of 10 percent, but no higher, for limitation of movement of the left knee is granted, subject to the laws and regulations governing monetary awards. From December 13, 2013, a rating of 10 percent, but no higher, for left knee subluxation and/or lateral instability is granted, subject to the laws and regulations governing monetary awards. From March 19, 2015, a rating of 10 percent for the symptomatic meniscectomy residuals is granted, subject to the laws and regulations governing monetary awards. A compensable rating for bilateral lower extremity shin splints is denied. REMAND The Board observes that in the November 2016 VA knee and lower leg examination, the examiner opined that the Veteran's right knee pes anserine bursitis was less likely than not related to service. This was because there was no evidence of right knee pain or complaints or other abnormality in the Veteran's STRs, and that the Veteran's first documented complaints of right knee pain were first noted in 2012. Subsequently, VA received records from the Brooke Army Hospital reflecting that the Veteran complained of right knee pain within a month or two of service. In May 2008, the Veteran complained of right knee pain that usually occurred along the medial aspect of the jointline and along the course of the medial collateral ligament. She reported a history of a torn meniscus in service, although only a left meniscal tear, not a right meniscal tear, is shown in the STRs provided by the Veteran. Meniscus, McMurray's, and Apley's testing in May 2008 found that the Veteran experienced pain along the medial joint line. The Veteran additionally experienced pain along the course of the medial collateral ligament with testing on the right side. In a June 2008 medical record, the Veteran complained of right knee pain and locking that had begun the week before. These records were created slightly over a month to two months after the Veteran's separation from service, and predates the examiner's observation by approximately four years. As the November 2016 examiner's direct service connection opinion relied on inaccurate information regarding the history of the Veteran's right knee symptoms, the Board finds that it is inadequate for adjudication purposes. As such, the Board observes that an addendum opinion is necessary to consider these post-service records. Accordingly, the case is REMANDED for the following action: 1. Please obtain any outstanding private and VA medical records and associate them with the record. 2. After completion of the above, please arrange for the November 2016 VA examiner to provide a supplemental opinion to respond to the following question. If the November 2016 VA examiner is unavailable, please provide a different VA clinician. If the opinion provider determines that an examination is necessary to form the requested opinion, please provide the Veteran with one. Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's right knee pes anserine bursitis is related to her service? In providing this opinion, please consider and discuss the post-service medical records from May and June 2008, within a few months of separation from service, wherein the Veteran complained of right knee pain and locking and was found to experience pain along the medial joint line and the course of the medial collateral ligament. 3. Finally, please readjudicate the claim. If the claim remains denied, issue an appropriate supplemental statement of the case and afford the Veteran and her representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs