Citation Nr: 1808517 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 08-38 217 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an increased disability rating for degenerative joint disease (DJD) of the right knee, currently rated as 10 percent disabling. 2. Entitlement to an increased disability rating for DJD of the left knee, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Anderson, Counsel INTRODUCTION The Veteran served on active duty from February 1984 to March 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2009, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. In June 2014, the Board denied the Veteran's claims for increased ratings for his right and left knee disabilities. He appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In March 2015 and pursuant to a Joint Motion for Remand (JMR), the Court vacated the Board's decision and remanded the claims to the Board for appropriate action in accordance with the JMR. During the pendency of the appeals, a September 2017 rating decision granted service connection for left knee limitation of motion rated as noncompensable. The Board remanded the claims in June 2015, May 2016, and March 2017 for additional development. They are again before the Board. FINDINGS OF FACT 1. Throughout the pendency of the appeal, the preponderance of the evidence indicates that the Veteran's right knee disability was manifested by limitation of motion, intermittent crepitation, swelling, subjective sensations of grinding, weakness, and giving away; probative evidence indicates that it was not manifested by recurrent subluxation, lateral instability, or dislocated semilunar cartilage. 2. Throughout the pendency of the appeal, the preponderance of the evidence indicates that the Veteran's left knee disability was manifested by limitation of motion, pain, and intermittent crepitation, swelling, subjective sensations of grinding, weakness, and giving away; probative evidence indicates that it was not manifested by recurrent subluxation, lateral instability, or dislocated semilunar cartilage. CONCLUSIONS OF LAW 1. The criteria for a right knee disability rating in excess of 10 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5257, 5258, 5260, 5261 (2017). 2. The criteria for a left knee disability rating in excess of 10 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5257, 5258, 5260, 5261 (2017). 3. The criteria for a separate 10 percent rating for symptomatic post-operative meniscectomy of the right knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5259 (2017). 4. The criteria for a separate 10 percent rating for symptomatic post-operative meniscectomy of the left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5259 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has raised no issues with the duty to notify or duty to assist or remand compliance. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2017). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2017); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2017); where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2017); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2017). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2017); see also 38 C.F.R. §§ 4.45, 4.59 (2017). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2017). Under Diagnostic Code 5260, flexion that is limited to 60 degrees warrants a 0 percent rating; flexion that is limited to 45 degrees warrants a 10 percent rating; flexion that is limited to 30 degrees warrants a 20 percent rating; and flexion that is limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2017). Under Diagnostic Code 5261, extension that is limited to 5 degrees warrants a 0 percent rating; extension that is limited to 10 degrees warrants a 10 percent rating; and extension that is limited to 15 degrees warrants a 20 percent rating; extension that is limited to 20 degrees warrants a 30 percent rating; extension that is limited to 30 degrees warrants a 40 percent rating; and extension that is limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2017). Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2017). Under Diagnostic Code 5257, recurrent subluxation or lateral instability of the knee warrants a 10 percent rating when it is slight, a 20 percent rating when it is moderate, and a 30 percent rating when it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2017). Under Diagnostic Code 5259, symptomatic removal of semilunar cartilage warrants a maximum rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2017). The Veteran essentially contends that his service-connected right and left knee disabilities are worse than currently rated. A June 2006 VA treatment record noted that the Veteran had worsening knee pain, which was more prevalent at night. He reported treating the pain with Ibuprofen. He described the pain as a sharp and endorsed some swelling and a lot of grinding and crepitus. Upon examination, there was decreased range of motion bilaterally but no evidence of pain. The Veteran was prescribed Naproxen for his pain. At a July 2006 appointment the Veteran reported that Naproxen had been helpful in alleviating his pain. He continued to endorse knee grinding, which was worse in his left knee. However, the orthopedist noted that there were no mechanical symptoms of catching, locking, or other similar symptoms. The Veteran reported occasional sharp knee pain and noted it was associated with a sensation of his knee giving out. He stated this symptom was more prevalent when he walked on rough terrain. He also noted that carrying heavy loads at work increased his knee discomfort. Upon examination, the Veteran had some mild lipping of the tibial plateua and medial femoral condyles, mild tenderness along the medial joint line, and slight thickening of the synovial membrane in the left knee greater than the right. Upon range of motion testing, the Veteran had bilateral extension to zero degrees and flexion to 115 degrees. Patellofemoral crepitus was noted and patellar mobilization and compression produced increased discomfort; irregularity was felt bilaterally. At a July 2006 appointment, the Veteran noted increased pain with pounding activities like going up and down hills. Testing revealed somewhat reduced muscle strength with active movement against gravity and some resistance. Crepitus was observed, but the Veteran's gait was normal, reciprocal, and symmetric. A November 2006 VA treatment record noted that the Veteran had increasing bilateral knee discomfort. He reported his knees were most bothersome when driving and at night. Upon examination, he had tenderness along the bilateral medial joint lines. He displayed good range of motion and stability bilaterally. He was prescribed 800 milligrams of Ibuprofen to be taken up to three times per day. At his January 2007 VA examination, the Veteran reported increasing knee pain. He noted he that his knee pain began to increase around lunch time secondary to his walking, bending, and lifting work duties. He rated the pain as 1 out of 10 in the morning, 3 out of 10 at noon, and 5 out of 10 at night. He described the pain as a raw, grinding, and sharp sensation. He endorsed mild swelling in both knees and noted difficulty with activities like hiking, camping, mountain climbing, and kneeling. He reported that he was able to walk more than one mile at his own pace and ascend and descend 1 to 2 flights of stairs with difficulty. Upon examination, muscle mass, tone, and strength were normal. There was no evidence of medial or lateral laxity, but moderate bilateral crepitus was evident. Range of motion testing, revealed right and left knee extension to zero degrees, right knee flexion to 125 degrees, with pain at 120 degrees, and left knee flexion to 120 degrees, with pain at 110 degrees with active, passive, and repetitive use. The examiner opined that the Veteran's bilateral DJD had a moderate impact on his functional abilities. On his August 2007 Notice of Disagreement, the Veteran indicated that he had increasing difficulty maintaining his current activity levels at work and home due to his deteriorating knees and increased pain. In August 2007 the Veteran reported worsening knee pain. He denied any knee swelling or falls, but endorsed sensations of pressure and weakness in his knees. On examination, the Veteran had pain over the patellar area. A January 2008 VA treatment record noted that the Veteran had ongoing knee pain but was still able to perform desired activities. He reported that if he stomped his left foot he had pain that radiated all the way through his left side. In a February 2008 correspondence, the Veteran indicated that his knee disabilities caused daily problems and caused a raw sensation that radiated out from his knees. At his February 2008 VA examination, the Veteran stated that he had a raw burning sensation, which he rated as 3 out of 10 in his right knee and 4 out of 10 in his left knee. He noted that extended use from bending, walking, twisting, lifting, and sitting increased the pain bilaterally to 6 out of 10. He reported that his knee gave out 3 to 4 times per week, but denied any history of falls. He denied needing any assistive device, recent surgery, or having a history of dislocation or subluxation. He endorsed experiencing slight swelling daily in both knees. With regard to functional impairment, he reported that his knees limited his ability to run, carry heavy equipment, climb stairs, hike, play sports, and walk on uneven ground. The Veteran noted that walking on uneven ground commonly caused his knees to give out. However, he indicated that he was still able to walk two miles per day and climb 1 to 2 flights of stairs with pain. Upon testing, he had active, passive, and repetitive right and left knee extension to zero degrees with pain. He had active right and left knee flexion to 135 degrees, passive flexion to 140 degrees, and repetitive motion to 135 degrees. There was evidence of pain during range of motion testing at 90 degrees in the right knee and at 110 degrees in left knee. There was no evidence of decreased muscle strength, medial or lateral laxity or instability, effusion, or right knee crepitus. Left knee crepitus and popping noises were observed. The examiner opined that the Veteran's knee disabilities resulted in minimally reduced range of motion and pain, but there was no evidence that repetitive use, fatigue, weakness, lack of endurance, or incoordination caused additional impairment. At a March 2008 VA appointment the Veteran reported a recent onset of increased pain, burning, and tingling when he stomped his left foot. Examination revealed no evidence of pain, tenderness, or abnormal range of motion. It was noted that the Veteran should be assessed for neuropathy. VA treatment records from October 2008 and April 2009 note ongoing knee pain, which was aggravated by ascending and descending stairs. The Veteran reported that his knee pain was controlled with Ibuprofen, and he declined injections or other medication. Upon examination, there was no evidence of pain, tenderness, or abnormal range of motion. At his May 2009 hearing, the Veteran testified that his job required both office and field work. He noted that when was in the office he had fewer problems at the end of the day. However, when he performed field work he had pain and swelling after approximately four hours. On a ten point pain scale, the Veteran rated his pain as .5 to 1 in the morning, a 3 to 4 at the end of office days, and a 6 to 7 at the end of field work days. He reported that he took 800 mg of Ibuprofen six times per day and that his left knee was slightly worse than his right knee. He denied any knee locking, but noted his knee did "click." He stated that while he was able to squat at the beginning of the day, he was unable to do so at the end of the day. He stated his knees gave out 2 to 3 times per week. However, he noted he was unsure whether the knee was actually giving out or he was reacting to pain. At his February 2010 VA examination, the Veteran reported progressive knee pain. He stated that his knees were essentially pain free in the morning, but became increasingly painful throughout the day. He rated his pain as 3 out of 10 on office days, 4 to 5 out of 10 on fieldwork days, and 6 out of 10 when lifting over 50 pounds. He noted that if he sat or drove too long he had a burning knee pain. He stated he prevented this by stretching and moving his knee every five minutes. He noted that walking generally did not bother his knee unless he was carrying something greater than 25 pounds, wherein he would have burning knee pain. He endorsed sensations of giving away and fatigue, which he described as having to put more effort into moving his knees; he denied complete giving away or any falls. He denied missing any work due to his knee disabilities, stated his standing ability was not limited, and that he was limited to no more than 30 minutes of walking. Upon examination, the Veteran's knees were properly aligned and muscle mass, tone, and strength were normal. Increased bilateral knee pain and mild crepitus were noted during strength testing, but there was no evidence of incoordination. Upon stability testing, the Veteran's anterior cruciate, posterior cruciate, and collateral ligaments were stable to varus and valgus force bilaterally. McMurray testing revealed increased pain in the medial compartment and anterior knee and grind testing revealed retropatellar pain. There was no evidence of warmth, erythema, effusion, or genu varum / genu valgum deformity. The Veteran had right knee passive flexion to135 degrees with pain at 90 degrees and 130 degrees, active flexion to 120 degrees with pain at 100 degrees, repetitive flexion to 110 degrees with pain at 90 degrees, passive extension to zero degrees without any increase in pain, active extension to zero degrees with a slight increase in pain, and repetitive extension to zero degrees with a sustained increase in pain. He had left knee passive flexion to 135 degrees with pain at 90 degrees and at 130 degrees, active flexion to 115 degrees with pain at 100 degrees, repetitive flexion to 100 degrees with pain at 90 degrees, passive extension to zero degrees without change in pain, active extension to zero degrees with slight increase in pain, and repetitive extension to zero degrees with a sustained increase in pain. Concerning functional impairment, the examiner opined that the Veteran had decreased motion due to ongoing pain and increased pain with repetitive movement. He opined that notwithstanding the subjective sensations of fatigue and giving away, there was no evidence of fatigue or giving away. A May 2011 VA treatment record indicates the Veteran's knee pain was stable on tramadol. Examination was negative for pain, tenderness, or decreased motion. A March 2012 VA treatment record noted that the Veteran had bilateral knee pain that radiated into his hip. He stated the pain was aggravated by descending stairs. He denied any swelling or locking. Upon examination, there was no decrease in motion, but point tenderness along the lateral aspect of the knees was noted. An April 2012 treatment record noted that the Veteran had increasing bilateral knee pain, which he rated on average as 2 to 3 out of 10 and 4 to 5 out of 10 while descending stairs. Physical examination revealed tenderness along the bilateral medial and tibio-femoral joints. He had bilateral extension to zero degrees and flexion to 130 degrees. Muscle strength testing was normal and the Veteran declined any interventions such as a lateral wedge, knee braces, and injections. An August 2012 VA treatment record noted that the Veteran had pain with sensations of locking when descending stairs. Upon examination, he had tenderness and pain over the medial aspect of his knee. An October 2012 orthopedic record noted that the Veteran had bilateral knee pain, which was aggravated by descending stairs and hills. He described the pain as a hot sensation in his medial knee area. He endorsed intermittent swelling, but denied any locking. Upon examination, there was tenderness along his medial joint lines, but no evidence of joint effusion, or laxity with valgus, varus, anterior drawer, and Lachman's stress testing. The Veteran had bilateral extension to 5 degrees, right knee flexion to 120 degrees, and left knee flexion to 110 degrees. He underwent bilateral knee injections for pain management. A September 2013 VA treatment record noted the Veteran had short-term knee pain improvement following steroid injections. There was no evidence of effusion and the Veteran reported he was still able to work every day. At an October 2013 orthopedic appointment, the Veteran noted that his knee injections helped for several months. He said he still performed field work at his job, which aggravated his knee symptoms. Upon examination, there was significant peripatellar crepitation in the right knee and very minimal crepitation in the left knee. There was no evidence of joint effusion, misalignment, or instability. He received bilateral knee injections. An October 2014 VA treatment record indicates that the Veteran endorsed constant swelling and pain in his knees. VA treatment records from November 2014 indicate that the Veteran reported some symptom improvement after his knee injections. He reported increased knee pain with activity, such as ascending and descending stairs, which was alleviated with rest. He noted that he was no longer able to tolerate running but continued to walk three miles per day. Upon examination, the Veteran had bilateral extension to zero degrees and flexion to 115 degrees, both knee joints were stable, his strength was adequate, and there was no evidence of effusion or knee warmth. Tenderness to palpation and crepitus were present bilaterally. A December 2014 VA treatment record noted that examination revealed no evidence of any effusion or increased knee warmth. He completed his third and final round of bilateral knee injections. At his August 18, 2015 VA examination, the Veteran endorsed chronic knee pain, which he described as a constant raw pulsating pain. He rated the pain as 1 to 3 out of 10. He endorsed flare-ups characterized by his knee giving out secondary to a sharp pain approximately 3 to 4 times per day. With regard to functional loss, he reported that he could not climb mountain trails, go on long walks, or run. He also noted increasing difficulty using the stairs. Upon range of motion testing, the Veteran had bilateral extension to zero degrees and flexion to 100 degrees. Upon repetitive use testing, the Veteran had no additional left knee functional loss, but his right knee was limited to 10 degrees of extension and 90 degrees of flexion. The examiner opined that while pain was evident during range of motion testing, it did not result in or cause functional loss. Crepitus and tenderness along the Veteran's medial and lateral joint line were evident. The examiner noted that the Veteran's knee disabilities resulted in a disturbance of locomotion. Muscle strength testing was normal with no evidence of any reduction in muscle strength or atrophy. Bilaterally, there was no evidence of recurrent subluxation, lateral instability, anterior instability, posterior instability, medial instability, recurrent effusion, recurrent patellar dislocation, or any tibial or fibular impairment. While the examiner acknowledged the Veteran's history of prior meniscectomies, she indicated that the Veteran did not currently have any semilunar cartilage condition. With regard to functional impact, the examiner opined that the Veteran's knee pain caused difficulties carrying more than 50 pounds and standing up from a kneeling position. It was noted that despite his difficulties the Veteran was still able to perform the aforementioned activities. A January 2016 VA treatment record noted that the Veteran reported increased bilateral knee pain and locking sensations associated with using stairs. Upon examination, he was noted to have bilateral knee pain and tenderness to palpation. In a July 2016 addendum opinion the August 2015 examiner opined that it was not possible to determine the cause of the knee noises, which were noted at the February 2010 examination. The examiner explained that while crepitus was observed during her August 2015 VA examination, the physical findings described by the February 2010 examiner were not evident. Consequently, the cause of the knee noises and other physical findings could not be determined without resorting to speculation. She noted that medical literature indicated that patients may describe a variety of knee noises, including crepitation, clicking, grindings, popping, and snapping sounds. The literature also indicated that such noises frequently accompany osteoarthritis and patellofemoral syndrome, but may also occur with meniscal tears and iliotibal band syndromes. Therefore, such noises are nonspecific and may not be associated with knee pathology. An August 2016 VA orthopedic note indicates that the Veteran reported numbness and tingling in his left lower extremity from his lateral knee to toes. Upon examination, he had mild left knee effusion and tenderness to palpation along the medial and lateral joint lines. He had left knee extension to zero degrees and flexion to 90 degrees. He was assessed with paresthesias, which was noted to be possibly due to peroneal neuropathy. He was referred for a neurology consultation. An October 2016 record from Mercy Ruan Neurology Clinic noted that, despite the Veteran's chronic issues, his neurological symptoms were not believed to be a knee problem. He was assessed with resolving left peroneal mono neuropathy. An April 2017 VA treatment record noted that the Veteran endorsed bilateral knee pain and swelling. He denied any locking, but endorsed subjective sensations of giving out secondary to pain particularly when going down stairs. A May 24, 2017 VA treatment record noted that the Veteran reported that, at times, his knee felt stiff, clicked, and swelled up. Upon examination, there was tenderness laterally along both lateral joint lines. The Veteran had bilateral extension to zero degrees, right knee flexion to 120 degrees, and left knee flexion to 110 degrees. Crepitus was observed during range of motion testing. It was noted that the Veteran's left knee had some pain with patellar compression and a small amount of effusion. Anterior drawer testing was negative, but the Veteran was noted to have moderate laxity with valgus stress testing. At his May 31, 2017 VA examination, the Veteran denied any significant changes since his last VA examination. He continued to report constant moderate to moderately severe knee pain and mild swelling, which worsened throughout the day. He noted that his knees would "catch and lock" 2 to 3 times per week. He denied any significant flare-ups. With regard to functional impairment, the Veteran reported that he could not run. He also noted that he had difficulty, pain, and swelling with prolonged standing, crawling, and squatting, but could still perform these activities. Upon range of motion testing the Veteran had right knee extension to zero degrees and flexion to 100 degrees. The Veteran had left knee extension to zero degrees and flexion to 90 degrees. Repetitive use testing resulted in no additional right knee limitations, but the Veteran's left knee was limited to 5 degrees of extension and 90 degrees of flexion. The examiner noted that there was evidence of bilateral knee pain with active range of motion, passive range of motion, ligament stability testing, weight bearing, non-weight bearing, and at rest. However, she opined that the Veteran's bilateral knee pain did not result in or cause functional loss. She also noted that crepitus and pain on palpation were observed. Bilateral muscle strength testing and joint stability testing revealed no reduction in muscle strength, muscle atrophy, recurrent subluxation, lateral instability, anterior instability, posterior instability, medial instability, recurrent effusion, or ankylosis in either knee. The examiner opined that the Veteran did not have recurrent patellar dislocation, tibial or fibular impairment, or any semilunar cartilage condition. With regard to functional impairment, the examiner opined that the Veteran was unable to run, and experienced increased pain and swelling with prolonged standing, crawling, and squatting. With regard to the Veteran's crepitus that was evident during the February 2010 VA examination, she noted that the cause of the crepitus could not be determined without speculating because crepitus was a non-specific finding that is not pathognomonic for any specific joint pathology. Therefore, it may or may not be related to the Veteran's knee joint pathology. She acknowledged that she observed crepitus during range of motion testing; however, she again opined that the exact cause of the crepitus could not be determined for the above reasons. She cited medical literature indicating that knee noises frequently accompany osteoarthritis and patellofemoral syndrome, but may occur with meniscal tears and iliotibial band syndromes. Therefore, such noises are nonspecific and may not be associated with knee pathology. Upon review of the evidence, the Board finds that the criteria for right and left knee ratings in excess of 10 percent based on limitation of motion have not been met. In this regard, at worst, the Veteran had right knee flexion to 100 degrees and left knee flexion to 90 degrees. Bilateral extension was generally no worse than 5 degrees. Such findings do not support the criteria for a compensable rating under Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a (2017). Thus, the 10 percent rating assigned was based on painful motion. Moreover, the rating decision initially awarding a 10 percent rating in 1993 did so based on symptoms of limitation of motion, swelling, effusion and positive patellar grind. Similarly, the rating on appeal noted only minimal limitation of motion, but found the 10 percent rating continued to be warranted based on functional loss including weakness, fatigability with use, incoordination, and painful motion pursuant to DeLuca. The Board acknowledges that the August 2015 VA examination report indicated the Veteran's right knee extension was limited to 10 degrees after repetitive use secondary to pain and lack of endurance. Even assuming arguendo, that the Veteran's extension after repetitive use more nearly approximated the criteria for a 10 percent rating under Diagnostic Code 5261, it would not result in a rating in excess of 10 percent. The Veteran's current 10 percent disability rating for his right knee is based on his painful motion. In Petitti v. McDonald, 27 Vet. App. 415 (2015), the Court held that 38 C.F.R. § 4.59 does not provide a freestanding avenue for disability compensation that may be applied without an underlying diagnostic code. Accordingly, the Veteran cannot receive a 10 percent disability rating for painful motion through 38 C.F.R. § 4.59 and a compensable rating under 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2017). At no time has the Veteran had both flexion limited to 45 degrees and extension limited to 10 degrees such that separate compensable ratings for limitation of flexion and extension can be assigned. In addition to the above, the Board notes that the Veteran also reported bilateral knee symptoms included pain at rest, crepitus, locking, and the knees giving way. The Veteran's history is notable for prior right and left knee meniscectomies. The January 2007, February 2008, February 2010, February 2015, and March 2017 VA examination reports as well as the October 2012 and October 2013 orthopedic notes indicated that the knees were stable on testing and did not evidence any ligament laxity. However, the Board acknowledges that a May 24, 2017 VA treatment record noted that there was evidence of laxity with valgus stress. Such a finding supports the Veteran's subjective reports of his knee giving way on activity. Thus, resolving all doubt in the Veteran's favor, the Board finds that the Veteran's symptoms of pain at rest, crepitus, locking, giving way and an isolated finding of laxity support a 10 percent rating for each knee under Diagnostic Code 5259 for symptomatic removal of semilunar cartilage. See Lyles v. Shulkin, --- Vet. App.--- , No. 16-0994, U.S. App. Vet. Claims LEXIS 1704 (Vet. App. Nov. 29, 2017) (a rating under a Diagnostic Code based on limitation of motion does not preclude, as a matter of law, a rating under Diagnostic Code 5259 as long as the manifestations of the disability have not already been compensated via an assigned evaluation under a particular Diagnostic Code). The Board has considered whether the Veteran is entitled to a higher or separate rating under Diagnostic Code 5257 for recurrent subluxation or lateral instability. However, the medical evidence consistently indicated that the Veteran did not have recurrent subluxation or lateral instability. Moreover, the complaints of giving way have been utilized to support the assignment of a compensable rating under Diagnostic Code 5259 as symptomatic of meniscus removal. Similarly, with respect to Diagnostic Code 5258, the evidence does not establish that the Veteran has dislocated semilunar cartilage, and his reported symptoms of locking have also been utilized to support the compensable rating assigned under Diagnostic Code 5259. Thus, higher or separate ratings under Diagnostic Codes 5257 and 5258 are not warranted. 38 C.F.R. § 38 C.F.R. § 4.14 (the evaluation of the same manifestation or disability under different diagnoses is to be avoided). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against ratings in excess of those assigned, that doctrine is not applicable. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to a rating in excess of 10 percent for right knee degenerative joint disease is denied. Entitlement to a rating in excess of 10 percent for left knee degenerative joint disease is denied. Entitlement to a separate 10 percent rating for symptomatic post-operative meniscectomy of the right knee is granted, subject to the rules and regulations governing the payment of VA monetary benefits. Entitlement to a separate 10 percent rating for symptomatic post-operative meniscectomy of the left knee is granted, subject to the rules and regulations governing the payment of VA monetary benefits. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs