Citation Nr: 1818079 Decision Date: 03/23/18 Archive Date: 04/03/18 DOCKET NO. 12-33 609 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to an initial rating greater than 10 percent for right knee degenerative changes. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Lewis, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from June 1989 to February 1997, including in the southwest Asia theater of operations during the Persian Gulf War, and in the U.S. Navy from November 1997 to August 2002. He also had additional unverified service. This matter comes before the Board of Veterans Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which granted, in pertinent part, the Veteran's claim of service connection for right knee degenerative changes, assigning a 10 percent rating effective December 8, 2008. The Veteran filed a Notice of Disagreement (NOD) in March 2010 and a Statement of the Case (SOC) was issued in October 2012. The Veteran filed a timely Substantive Appeal (VA Form 9) in November 2012. Thus, the Veteran perfected a timely appeal of the issues. In August 2015, the Veteran testified at a video conference Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript has been associated with the claims file. This appeal was previously before the Board in January 2016, at which time the Board remanded the claim for further development. The matter is once again before the Board for appellate consideration of the issues on appeal. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record, as well as the Veteran's Virtual VA paperless claims file. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's right knee disability has been manifested by pain and limitation of motion; it has not manifested ankylosis, limitation of extension or impairment of the tibia and fibula. 2. Throughout the appeal period, the Veteran's right knee disability has manifested flexion limited to, at worst, 35 degrees and extension limited to, at worst, 0 degrees. 3. The Veteran underwent a right knee partial medial meniscectomy in May 2012; since March 9, 2016, the Veteran's right knee disability, status post right knee medial meniscectomy has been manifested by frequent symptoms associated with dislocated semilunar cartilage, including "locking," pain, crepitus, and effusion. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent under Diagnostic Code 5299-5257 for right knee degenerative changes prior to March 9, 2016 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4, 4.71, Diagnostic Code 5299-5257 (2017). 2. From March 9, 2016, the criteria for a rating of 20 percent under Diagnostic Code 5258 (reassigned from 5299-5257) for status-post right knee medial meniscectomy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.7, 4, 4.71, Diagnostic Code 5258 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claim submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. § 5103 (a) (West 2012); 38 C.F.R. § 3.159 (b) (2017). In regards to increased rating claims, VA is required to provide the Veteran with generic notice - that is, the type of evidence needed to substantiate the claim. This includes evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA's duty to notify was satisfied by letters in April 2007 and February 2009. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA has a duty to provide assistance to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records, private treatment records, VA medical records and examination, hearing testimony, and statements from the Veteran and his representative have been obtained. All relevant evidence has been obtained and associated with the record. Neither the Veteran, nor his representative, has identified any additional existing evidence that is not of record that is necessary for a fair adjudication of his appeal. The Board is also satisfied that there has been substantial compliance with the January 2016 remand directives, which included affording the Veteran a VA examination. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999); see also Stegall v. West, 11 Vet. App. 268 (1998). The Veteran was afforded VA examinations in March 2016 and May 2016. The Board thus finds that all necessary development has been accomplished and appellate review may proceed. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Increased Ratings Applicable Laws and Regulations Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Here, the relevant evidentiary window begins one year before the Veteran filed his claim for an increased rating, and continues to the present time. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). Factual Background The Veteran filed an initial claim for service connection (claimed as bilateral knees) in December 2008. In connection with his claim, the Veteran underwent a VA examination in December 2009. The Veteran reported that he sustained an injury to his right knee during a parachute landing in 1991. He complained of right knee pain which had progressed through the years. He reported that his pain increased with "constant standing, running, certain shoes and cold, wet weather." He further reported that the knee was sore most of the time and indicated that he felt vibrations from his knee to his groin area with sensations of numbness. The examiner noted pain, tenderness, stiffness, weakness, and decreased speed of joint motion for the right knee. There was no evidence of deformity, instability, incoordination, effusion, or episodes of dislocation, subluxation, or locking. He further noted that the condition affected joint motion and noted flare-ups that were severe and occurred on a weekly basis, lasting hours. There was crepitus and guarding of movement. Range of motion testing revealed flexion to 90 degrees and extension to 0 degrees. After repetitive use flexion was 80 degrees. See December 2009 VA Examination Report. In January 2010, the RO granted service connection for right knee degenerative changes, assigning a 10 percent rating, effective December 8, 2008. The 10 percent evaluation was based on pain following repetitive motion, crepitus, tenderness, and guarding of movement. See January 2010 Rating Decision. In a March 2010 notice of disagreement, the Veteran disagreed with his initial evaluation. He stated that his right knee condition was very painful and that he had difficulty walking and climbing or descending stairs. See March 2010 NOD. In January 2012, the Veteran was seen at OrthoGeorgia Orthopaedic Specialists for right knee pain. The Veteran reported medial pain and daily discomfort in the medial aspect of the knee. He reported that the knee felt weak and he was uncertain when he stood or bore weight on it. He did not have swelling or locking and did not describe any pivot shift instability. X-ray results showed standing of the knee within normal limits, without arthritis. The assessment was a medial meniscus tear to the right knee. The treatment plan was to obtain an MRI and follow-up after the test. See January 2012 OrthoGeorgia Treatment Notes. February 2012 radiology results revealed minimal knee joint effusion, tearing in the body and posterior horn of the medial meniscus, and very slight lateral subluxation of the patella. See February 2012 OrthoGeorgia Radiology Results. In a February 2012 follow-up to the MRI, it was noted that there was a complex medial meniscus tear. The assessment was symptomatic and chronic right medial meniscus tear related to an injury. The risk and benefits of right knee arthroscopy with meniscectomy were discussed with the Veteran. See February 2012 OrthoGeorgia Treatment Notes. In May 2012, the Veteran underwent a right knee partial medial meniscectomy. In describing the procedure, the physician noted that the Veteran had chronic medial right knee pain since a twisting injury. MRI and physical examination were consistent with a medial meniscal tear. Imaging studies showed mild evidence of degenerative changes to the articular cartilage. See May 2012 Macon Outpatient Surgery, LLC Operative Report. In a May 2012 follow-up visit at Ortho Georgia, the Veteran reported that he was doing much better than prior to surgery, with only mild complaints of some stiffness with exercise. He reported completing physical therapy and felt that it was going well. He did not feel that he had fully regained his strength or endurance. The doctor noted no effusion of the right knee and active range of motion of 0 to 100 degrees with stiffness reported. The assessment noted that the Veteran was approximately two weeks status post right knee medial meniscectomy and was doing well. The Veteran was to continue with physical therapy and continue work restrictions of no running, jumping, climbing, squatting, kneeling, and no prolonged standing for more than 20 minutes. The doctor indicated that such restrictions would be in effect until a scheduled follow-up. See May 2012 OrthoGeorgia Treatment Note. In a June 2012 follow-up, the Veteran reported that he was doing well with no pain to report. He reported popping and stiffness in the back of his knee with prolonged walking and standing. Examination revealed no effusion and active range of motion within normal limits. The Veteran had mild tenderness to palpation along the medial hamstring down to the pes anserine insertion and medial border of the patella. The knee was ligamentously stable. The assessment was five weeks status post right knee medial meniscectomy with mild clinical findings suggestive of synovitis and medial hamstring tendonitis. The Veteran was instructed in proper icing techniques for his right knee and the aforementioned work restrictions were continued. See June 2012 OrthoGeorgia Treatment Note. In a July 2012 follow-up it was noted that active range of motion of the right knee was within normal limits with no effusion noted. The Veteran had mild crepitus and tenderness to palpation along the medial border of the patella. The knee was ligamentously stable and no joint line tenderness was noted. See July 2012 OrthoGeorgia Treatment Note. The Veteran was next afforded a VA examination in September 2012. The examiner noted a diagnosis of right knee minimal degenerative disease. Range of motion testing revealed flexion to 90 degrees with painful motion beginning at 90 degrees. Right knee extension was noted as 0. Range of motion after repetitive-use testing revealed flexion of 85 degrees and extension of 0 degrees. The examiner noted additional limitation in range of motion of the knee following repetitive-use testing. Factors contributing to functional loss included less movement than normal, excess fatigability, and pain on movement. The examiner noted tenderness or pain on palpation of the right knee. Muscle strength was normal. There was no anterior instability, posterior instability, or medial-lateral instability and no evidence of patellar subluxation/dislocation. The examiner noted that the Veteran had a meniscus (semilunar cartilage) condition, noting the right knee meniscal tear; however he indicated that the Veteran had not had a meniscectomy. See September 2012 VA Examination Report. The Veteran testified at a Board hearing in August 2015. He described right knee swelling and severe pain. He indicated that he was unable to balance himself on his knee and was prone to falling. The Veteran reported that he had undergone right knee surgery. He indicated that he was told he had torn tendons in his knee and that his doctor had told him his kneecap was more flexible than it needed to be. The Veteran indicated that, following the surgery, his pain level had not decreased but that episodes were not as frequent as they used to be. He said he had the same aching and pain feelings in his knee and noted that he used a knee brace. See August 2015 Hearing Transcript. In January 2016, the Board remanded the Veteran's claim, noting that he had essentially asserted that his condition had worsened since the time of his last VA examination in September 2012. The Board directed the RO to provide the Veteran with an examination to determine the nature and severity of his right knee degenerative changes and to comment on whether the Veteran's condition was manifested by moderate or severe recurrent subluxation or lateral instability. See January 2016 Remand. In accordance with the Board remand, the Veteran was afforded a VA examination in March 2016. The examiner reported a diagnosis of minimal degenerative changes of the right knee. He noted that the Veteran had a right knee arthroscopy performed in May 2012 and received physical therapy. The Veteran treated his pain with a brace, capsaicin, ibuprofen, acetaminophen, heating pads, ice, and home exercises that provided temporary relief. The Veteran reported flare-ups of the knee which he described as an itching, burning sensation, akin to running a fever. He reported that the knee swelled and ached. He gets off the knee for relief. The Veteran reported functional loss with respect to exercise, standing long periods of time and overexerting himself such as by going up stairwells. See March 2016 VA Examination Report. The examiner noted abnormal range of motion with flexion to 40 degrees and extension to 0 degrees that contributed to functional loss through limited kneeling and crouching. Pain was exhibited on flexion and extension and caused functional loss. There was evidence of pain on weight bearing and objective evidence of localized tenderness or pain on palpation of the joint, as well as tenderness on palpation of the anterior knee. There was no objective evidence of crepitus. The Veteran was unable to perform repetitive use testing due to severe pain. The examiner noted that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time. Factors that caused functional loss included pain, fatigue, weakness, and lack of endurance. In terms of range of motion flexion to 35 degrees, extension to 0 degrees. Additional contributing factors of the disability were swelling, disturbance of locomotion, interference with sitting and standing. The Veteran described daily swelling and he demonstrated abnormal posture limited by knee flexion and required use of a single cane for ambulation. The Veteran's right knee displayed a reduction in strength with flexion and extension noted as 3/5, which is described as "active movement against gravity." This reduction of strength was entirely due to the right knee condition. There was no evidence of ankylosis. The examiner noted that there was a history of severe recurrent subluxation or lateral instability of the right knee. He further noted a history of recurrent effusion, citing the Veteran's reports of daily swelling. Joint stability testing was indicated but could not be performed because the Veteran was unable to tolerate manipulation of the knee for stability testing. Id. The examiner noted that the Veteran had a meniscus (semilunar cartilage) condition that manifested with frequent episodes of joint "locking," pain, and effusion. This was described as daily right knee swelling and pain with signs of joint locking. The examiner noted the Veteran's May 2012 right knee partial medial meniscectomy. He noted that the Veteran used a knee brace on a constant basis as well as a cane. Diagnostic testing was performed and imaging studies revealed degenerative or traumatic arthritis of the right knee. The examiner noted that the Veteran was retired but that his right knee condition would affect his ability to perform occupational tasks in that he had severe difficulty standing, walking, kneeling, and crouching. Id. In May 2016, the Veteran underwent a VA contract examination. The examiner noted right knee degenerative arthritis and right meniscal tear, status post arthroscopy. The Veteran reported flare-ups as unbearable pain, swelling, and inability to balance. He reported functional loss as inability to balance well, loss of strength, running, walking, bending, going up stairs, driving, and operating a forklift. Range of motion was abnormal with flexion to 90 degrees and extension to 0 degrees, with pain exhibited on both. Range of motion contributed to functional loss and there was objective evidence of localized tenderness over the medial knee. There was evidence of crepitus and pain on weight bearing. After repeated use, range of motion revealed flexion to 85 degrees and extension to 0 degrees with pain. The examination was conducted during a flare up. The examiner indicated that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time and with flare-ups. Factors causing functional loss included pain and weakness. See May 2016 VA Contract Examination. Symptoms included; less movement than normal; swelling; disturbance of locomotion; weakened movement; difficulty with bending, ascending stairs, running, and repeated downward motion on forklift. Reduction of strength was noted on the right knee as 4/5. There was no muscle atrophy, no ankylosis. The examiner noted no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed and indicated no joint instability. The examiner indicated that the Veteran never had a meniscus condition, however she went on to note an arthroscopy in the 2000s with residual signs or symptoms described as pain and swelling. She noted the Veteran's use of a brace and a cane. Imaging studies documented degenerative or traumatic right knee arthritis. Id. Analysis The Veteran's right knee disability, characterized as right knee minimal degenerative changes, is rated under Diagnostic Code 5299-5257. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2017). Diagnostic Code 5299 refers to an unlisted disability of the musculoskeletal system, while Diagnostic Code 5257 pertains to other impairment of the knee as well as knee instability. Diagnostic Codes 5256 through 5263 address disability ratings for the knee and leg. Diagnostic Code 5256 governs ankylosis of the knee and permits a 30 percent rating for favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees, while a 40 percent rating is called for with flexion between 10 and 20 degrees, and a 50 percent rating for flexion between 20 and 45 degrees. Extremely unfavorable ankylosis, with flexion at an angle of 45 degrees or more warrants a maximum 60 percent evaluation. Under Diagnostic Code 5257, a 10 percent rating will be assigned for slight recurrent subluxation or lateral instability of a knee; a 20 percent rating will be assigned for moderate recurrent subluxation or lateral instability; and a 30 percent rating will be assigned for severe recurrent subluxation or lateral instability. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent evaluation. Under Diagnostic Code 5259, symptomatic removal of semilunar cartilage warrants a 10 percent rating. Under Diagnostic Code 5260, a noncompensable rating will be assigned for limitation of flexion of the knee to 60 degrees, a 10 percent rating will be assigned for limitation of flexion of the knee to 45 degrees, a 20 percent rating will be assigned for limitation of flexion of the knee to 30 degrees, and a 30 percent rating will be assigned for limitation of flexion of the knee to 15 degrees. Under Diagnostic Code 5261, a 10 percent disability rating is warranted for knee extension limited to 10 degrees, a 20 percent disability rating is assigned for extension limited to 15 degrees, a 30 percent disability rating is assigned for extension limited to 20 degrees, a 40 percent disability rating is assigned for extension limited to 30 degrees, and a 50 percent disability rating is assigned for extension limited to 45 degrees. Under Diagnostic Code 5262, impairment of the tibia and fibula warrants a 10 percent rating where there is malunion of the tibia and fibula with slight ankle or knee disability. A 20 percent rating is warranted where there is malunion of the tibia and fibula with moderate ankle or knee disability. A 30 percent rating is warranted where there is malunion of the tibia and fibula with marked ankle or knee disability. A maximum 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion, requiring brace. Diagnostic Code 5263 provides a 10 percent rating where there is evidence of acquired genu recurvatum or traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. The VA General Counsel held that a knee disability may receive separate ratings under diagnostic codes evaluating instability (Code 5257) and those evaluating range of motion (Codes 5003, 5010, 5256, 5260, and 5261). See VAOPGCPREC 23- 97. Additionally, the General Counsel held that separate ratings under Code 5260 (limitation of flexion of a knee) and Code 5261 (limitation of extension of a knee) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. §§ 4.40 and 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). As noted above, the Veteran is currently assigned a 10 percent disability rating for right knee degenerative changes under Diagnostic Code 5299-5257. Under Diagnostic Code 5257, a 10 percent evaluation is warranted where impairment of the knee involves slight subluxation or lateral instability. A 20 percent evaluation is warranted where the impairment is moderate, and a 30 percent evaluation will be assigned where the impairment is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board observes that the words "slight," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. 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. The Board also notes that the provisions of 38 C.F.R. §§ 4.40 and 4.45 are inapplicable to ratings under DC 5257 because that Code is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). As previously mentioned, DC 5257 also applies to other impairment of the knee. At the time of the Veteran's initial rating, the 10 percent evaluation was assigned based on pain following repetitive motion, crepitus, tenderness, and guarding of movement. Range of motion was noncompensable under DC 5260 and DC 5261. It does not appear that the RO based its assignment on any indication of instability. At the time of the initial rating decision in January 2010, there was no evidence of right knee instability. A February 2012 radiology report revealed "very slight" lateral subluxation of the patella. Following the February 2012 radiology report, 2012 treatment notes and the September 2012 VA examination contain no findings of instability. At the August 2015 hearing, the Veteran reported balance issues. The March 2016 VA examination noted a history of severe recurrent subluxation or lateral instability of the right knee, however joint instability testing could not be performed because the Veteran was unable to tolerate manipulation of the knee for stability testing. The Board notes that the March 2016 report of severe recurrent subluxation or lateral instability appears to be an outlier when viewed with the entirety of the record. An examination two months later in May 2016 again noted no findings of instability. The Board finds that the most probative evidence of record suggests that the Veteran has at most experienced a "very slight" instability of the right knee for a very brief period and therefore not demonstrative of the overall impairment of the knee as such symptom was not demonstrated again upon further examination in May 2012, June 2012, July 2012, and September 2012. The March 2016 VA examination notes a history of severe recurrent subluxation or lateral instability. As noted, the Board finds this finding to be an outlier and unreflective of the evidence of record. Nothing in the medical record prior to the March 2016 examination suggests a "history" of severe recurrent subluxation or lateral instability. Further, examination findings from May 2016 again report no instability, which is far more consistent with the totality of the medical record. As such, the Board finds that the evidence does not support a finding for an initial rating in excess of 10 percent under DC 5299-5257, nor does the evidence warrant a rating in excess of 10 percent at any point in the appeal period. However, the Board finds that, from March 9, 2016, the Veteran's right knee condition more nearly approximates the criteria set forth under Diagnostic Code 5258. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent evaluation. In this case, the Veteran's right knee, status-post medial meniscectomy has been manifested by frequent symptoms of joint "locking," pain, and effusion, with evidence of daily knee swelling and pain as well as crepitus. See March 2016 VA Examination Report (showing locking, pain, effusion, and swelling); May 2016 VA Examination Report (showing crepitus, pain, and swelling). As such, the Board finds that a 20 percent rating for the Veteran's right knee disability under Diagnostic Code 5258 is more appropriate and warranted. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as it is supported by reasons and bases as well as the evidence. Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). It is permissible to switch Diagnostic Codes to reflect more accurately a claimant's current symptoms. See also Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the diagnostic code associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). The Board notes that the Veteran's right knee partial medial meniscectomy was in March 2012. Post-procedure treatment notes from 2012 detail steady improvement with some signs of popping, stiffness, and pain. Although the September 2012 VA examiner incorrectly noted that the Veteran had not had a meniscectomy, he did note the Veteran's meniscus tear and despite the omission of the meniscectomy, the Board has no reason to question the objective range of motion testing conducted that day or the report of the Veteran's symptoms. The Veteran reported pain, swelling and balance issues at his August 2015 hearing. To the extent that the record reflects symptoms of painful movement, stiffness, swelling, and balance issues, the Board finds that such symptoms were contemplated by the 10 percent rating in effect under DC 5299-5257 at that time. The first objective evidence of record that the Veteran experienced symptoms of locking, pain, joint effusion, and swelling, such that would warrant a 20 percent rating under DC 5258, comes from the March 2016 VA examination. The Board notes that a rating under Diagnostic Code 5260 is not warranted as the evidence shows the Veteran's greatest limitation of range of motion on flexion was 35 degrees (initially demonstrated in 2016), even considering additional limitation of motion due to pain. Under DC 5260, the Veteran could receive no more than a 10 percent evaluation based on this range of motion. To warrant the next highest rating of 20 percent, the Veteran would have to display flexion of 30 degrees. As the Veteran has been evaluated at 10 percent for the entirety of the appeal period, and does not warrant a higher evaluation under DC 5260, switching his diagnostic code to 5260 provides no added benefit to the Veteran. The Board notes that a rating under Diagnostic Code 5261 is not warranted as the evidence does not show a sufficient limitation of range of motion for compensation at any point during the appeal period. Range of motion on extension has consistently been recorded at 0 degrees and thus noncompensable under DC 5261 for the entirety of the appeal period. Additionally, the Board finds that the Veteran may not be assigned separate ratings under both DC 5260 (limitation of flexion) and DC 5261 (limitation of extension), and DC 5258 (frequent episodes of "locking," pain, and effusion into the joint) as a separate rating under DC 5260 and DC 5261 would constitute pyramiding with DC 5258. The Veteran's right knee disability has been manifested by joint swelling, crepitus, painful motion, and effusion. The diagnostic codes overlap in ratings based on pain, swelling, and crepitus as forms of limitation of motion; therefore, assigning separate ratings under DC 5260/DC 5261 and DC 5258 would violate the prohibition against pyramiding under the particular facts of this case. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). A rating under Diagnostic Code 5259 is also not warranted in the present case. Under Diagnostic Code 5259, a maximum 10 percent rating is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Looking to the plain meaning of the terms used in the rating criteria, "symptomatic" means indicative, relating to, or constituting the aggregate, of symptoms of disease. STEDMAN'S MEDICAL DICTIONARY, 1743 (27th ed. 2000). A symptom is any morbid phenomenon or departure from the normal in a structure, function, or sensation, experienced by a patient and indicative of disease. Id. at 1742. Thus, the second Diagnostic Code 5259 requirement being "symptomatic" is broad enough to encompass all symptoms, including pain, limitation of motion, stiffness, and instability. The Board finds that any symptomatic residuals associated with the Veteran's meniscectomy are already compensated in the assigned 20 percent rating under Diagnostic Code 5258. The record shows that the Veteran's knee disability is manifested by findings and symptoms which include crepitus, swelling, limitation of motion, and functional loss due to pain and weakness. These symptoms are already contemplated in the rating currently assigned under Diagnostic Code 5258. A rating under Diagnostic Code 5256 is not warranted as the Veteran's right knee has not demonstrated ankylosis at any point during the appeal period. The evidence does not demonstrate any impairment of the tibia and fibula, thus a rating under Diagnostic Code 5262 is not warranted. Lastly, there is no evidence that the Veteran exhibits genu recurvatum, thus a rating under Diagnostic Code 5263 is unwarranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. Reasonable doubt has been resolved in favor of the Veteran when possible. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). The Veteran has not raised any other issues with respect to the increased rating claim for his right knee, nor have any other assertions been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial rating in excess of 10 percent under Diagnostic Code 5299-5257 for right knee degenerative changes prior to March 9, 2016 is denied. Entitlement to a rating of 20 percent under Diagnostic Code 5258 (reassigned from 5299-5257) for status-post right knee partial medial meniscectomy is granted, from March 9, 2016, subject to the law and regulations governing the award of monetary benefits. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs