Citation Nr: 1815225 Decision Date: 03/09/18 Archive Date: 03/19/18 DOCKET NO. 14-01 266 DATE THE ISSUES 1. Entitlement to an increased disability evaluation for degenerative joint disease, left knee, status post tear medial collateral ligament, fracture with hardware in femur (left knee disability) in excess of 10 percent prior to October 24, 2013, and in excess of 40 percent thereafter. 2. Entitlement to an increased disability evaluation for degenerative joint disease, right knee, status post repair lateral collateral ligament, fracture with hardware in femur and tibia (right knee disability) in excess of 10 percent prior to October 24, 2013, and in excess of 40 percent thereafter. ORDER Prior to October 24, 2013, entitlement to a rating in excess of 10 percent for the left knee disability is denied. For the entire period on appeal, entitlement to a 10 percent rating, but not higher, for left knee instability is granted, subject to the regulations governing disbursement of VA monetary benefits. Beginning October 24, 2013, entitlement to a rating in excess of 40 percent for limitation of extension of the left knee is denied. Prior to October 24, 2013, entitlement to a rating in excess of 10 percent for instability of the right knee is denied. Prior to October 24, 2013, entitlement to a 10 percent rating, but not higher, for painful motion of the right knee is granted, subject to the regulations governing disbursement of VA monetary benefits. Beginning October 24, 2013, entitlement to a rating in excess of 40 percent for limitation of extension of the right knee is denied. Beginning October 24, 2013, entitlement to a separate rating of 10 percent, but not higher, for instability of the right knee is granted, subject to the regulations governing disbursement of VA monetary benefits. FINDINGS OF FACT 1. Prior to October 24, 2013, the Veteran's left knee disability manifested with slight lateral instability and painful motion, with flexion limited to 115 degrees and extension limited to less than 10 degrees, at worst, even considering painful motion and other factors; the evidence does not show ankylosis, impairment of the tibia and fibula, or genu recurvatum. 2. Beginning October 24, 2013, the Veteran's left knee disability manifested with slight lateral instability and painful motion with flexion limited to 70 degrees and extension limited to 30 degrees, at worst, even considering painful motion and other factors; the evidence does not show ankylosis, impairment of the tibia and fibula, or genu recurvatum. 3. Prior to October 24, 2013, the Veteran's right knee disability manifested with slight lateral instability and painful motion, with flexion limited to 120 degrees and extension limited to less than 10 degrees, at worst, even considering painful motion and other factors; the evidence does not show ankylosis, impairment of the tibia and fibula, or genu recurvatum. 4. Beginning October 24, 2013, the Veteran's right knee disability manifested with slight lateral instability and painful motion with flexion limited to 80 degrees and extension limited to 30 degrees, at worst, even considering painful motion and other factors; the evidence does not show ankylosis, impairment of the tibia and fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. Prior to October 24, 2013, the criteria for a rating in excess of 10 percent, for the left knee disabiltiy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (2017). 2. For the entire period on appeal, the criteria for a separate rating of 10 percent, but not higher, for instability of the left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2017). 3. Beginning October 24, 2013, the criteria for a rating in excess of 40 percent for limitation of extension of the left knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2017). 4. Prior to October 24, 2013, the criteria for a rating for instability of the right knee in excess of 10 percent have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2017). 5. Prior to October 24, 2013, the criteria for a separate rating of 10 percent, but not higher, for painful right knee motion have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003 (2017). 6. Beginning October 24, 2013, the criteria for a rating in excess of 40 percent for limitation of extension of the right knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2017). 7. Beginning October 24, 2013, the criteria for a separate rating of 10 percent, but not higher, for instability of the right knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introduction The Veteran served on active duty from June 1994 to September 1994 and from January 1998 to January 2001. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office in Atlanta, Georgia (RO), evaluating the left knee disability as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5262 (impairment of tibia and fibula) (2017) and the right knee disability as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5257 (recurrent subluxation or lateral instability) (2017). In a November 2013 rating decision, the RO evaluated each of the knee disabilities as 40 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5261 (limitation of extension) (2017) effective October 24, 2013. Because the RO did not assign the maximum disability rating possible, the appeal for a higher disability evaluation remains before the Board. AB v. Brown, 6 Vet. App. 35, 38 (1993). In May 2016, through his attorney, the Veteran withdrew his request for a Board videoconference hearing. 38 C.F.R. § 20.704(e) (2017). In July 2016, the Board remanded this matter for new VA examinations pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), and the case has been returned for appellate consideration. The Board finds there has been substantial compliance with its July 2016 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand). This appeal was processed using the Virtual VA (VVA) and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future review of this Veteran's case should take into consideration the existence of these electronic records. Veterans Claims Assistance Act of 2000 As required by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159(b) (2017). The Veteran has not raised any issues with the duty to notify or duty to assist. 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). As such, the Board will now review the merits of the Veteran's claims. Law and Analysis The Veteran essentially contends that his service-connected left and right knee disabilities are more disabling than contemplated by the assigned Diagnostic Codes and evaluations. In the Veteran's attorney's June 2016 brief, the appeal was characterized as seeking an effective date prior to October 24, 2013, for the 40 percent evaluations for the left and right knee disabilities. Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran's symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Disability evaluations are determined by assessing the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2 (2017). If there is a question as to which evaluation should be applied to the veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran's disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the standard 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 (2017). With particular respect to the joints, the disability factors reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 (2017). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Id. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Read together, 38 C.F.R. § 4.71a, Diagnostic Code 5003, and 38 C.F.R. § 4.59 (2017) provide that painful motion due to degenerative arthritis, that is established by X-ray, is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). The United States Court of Appeals for Veterans Claims (Court) has held that the provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Diagnostic Code 5256, which evaluates ankylosis of the knee, provides for a 30 percent rating for favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is assigned when there is ankylosis of the knee in flexion between 10 and 20 degrees. A 50 percent rating is assigned when there is ankylosis of the knee in flexion between 20 and 45 degrees. A 60 percent rating is assigned when there is extremely unfavorable ankylosis of the knee in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256 (2017). Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of the knee, and provides for a 10 percent rating for slight impairment; a 20 percent rating for moderate impairment; and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2017). Diagnostic Code 5258 provides for when semilunar cartilage is dislocated with frequent episodes of locking, pain, and effusion into the joint, and a 20 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2017). Diagnostic Code 5259 provides for when semilunar cartilage has been removed, but remains symptomatic, and a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2017). Diagnostic Code 5260, which evaluates limitation of flexion, provides for a noncompensable rating when flexion is limited to 60 degrees; a 10 percent rating when flexion is limited to 45 degrees; a 20 percent rating when flexion is limited to 30 degrees; and a 30 percent rating when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2017). Diagnostic Code 5261, which evaluates limitation of extension, provides for a noncompensable rating when extension is limited to 5 degrees; a 10 percent rating when extension is limited to 10 degrees; a 20 percent rating when extension is limited to 15 degrees; a 30 percent rating when extension is limited to 20 degrees; a 40 percent rating when extension is limited to 30 degrees; and a 50 percent rating when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2017). Diagnostic Code 5262, which evaluates impairment of the tibia and fibula, provides for a 10 percent disability rating for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating for malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating for malunion of the tibia and fibula with marked knee and ankle disability; and a 40 percent rating for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2017). Diagnostic Code 5263, which evaluates genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated), provides for a 10 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5263 (2017). Separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Additionally, VAOPGCPREC 23-97 held that a claimant who has both arthritis and instability of the knee may receive two separate disability ratings under Diagnostic Codes 5003 through 5010 and Diagnostic Code 5257 (or under Diagnostic Codes 5258 and 5259) without violating the prohibition of pyramiding of ratings. It was specified that, for a knee disorder already rated under Diagnostic Code 5257, a claimant would have additional disability justifying a separate rating if there is limitation of motion under Diagnostic Codes 5260 or 5261. The Veteran's Benefits Administration (VBA) has determined that separate ratings for subluxation or lateral instability under Diagnostic Code 5257 and a meniscus disability Diagnostic Code 5258 or 5259 would violate the rule against pyramiding. The rationale is that the criteria for all of those codes contemplate instability; dislocation and locking under Diagnostic Code 5258 is consistent with instability; the broad terminology of "symptomatic" under Diagnostic Code 5259 also contemplates instability. See VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.j. VBA has also determined that separate evaluations for a meniscus condition under Diagnostic Code 5258 or 5259 and limitation of motion of the same knee under Diagnostic Code 5260 (limitation of flexion) or 5261 (limitation of extension) would also violate the rule against pyramiding. The rationale is that the criteria for all of those codes contemplate limitation of motion. Although Diagnostic Code 5258 refers to "dislocated" cartilage and "locking" of the knee, the rating criteria contemplate limitation of motion through functional impairment with use (namely pain and effusion). Diagnostic Code 5259 provides for a compensable evaluation for a "symptomatic" knee post removal of the cartilage. VAOPGCPREC 9-98 states that Diagnostic Code 5259 requires consideration of 38 C.F.R. §§ 4.40 and 4.45 because removal of semilunar cartilage may result in complications producing loss of motion. See VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.i. The Board defers to VA's reasonable interpretation of its own laws and regulations. Chevron U.S.A., Inc., v. Nat. Res. Def. Council, Inc., 467 U.S. 837, 843, 104 S. Ct. 2778, 81 L. Ed.2d. 694 (1984). When assigning ratings, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68 (2017). Amputation not improvable by prosthesis controlled by natural knee action warrants a 60 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5164 (2017). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Here, the Board reviewed all evidence in the claims file, with an emphasis on that which is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. The appeal period before the Board begins on April 22, 2009, the date VA received the claims for increased ratings, plus the one-year look-back period. 38 U.S.C. §§ 5110(a), (b)(3) (2012); 38 C.F.R. § 3.400(o)(2) (2017); Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The Board notes that the Veteran is competent to report that which he perceives through the use of his senses, including symptoms of knee disability. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting that lay evidence is competent with regard to facts perceived through the use of the five senses). He is not, however, competent to state whether his symptoms warrant a specific rating under the General Rating Formula. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran does not contend and there is no evidence of record to suggest that the Veteran has experienced ankylosis or genu recurvatum of either knee during the appeal period. Accordingly, separate ratings under Diagnostic Codes 5256 (ankylosis) and 5263 (genu recurvatum) are not warranted. Prior to October 24, 2013 The Veteran's medical records show that he was seen in August 2009 for the purpose of referrals to orthopedics for his knees and to general surgery. Under review of systems, it was noted that there was no knee joint swelling, no intermittent knee locking, and the knees did not suddenly buckle. The Veteran's medical records show that in October 2009 he was seen for the purpose of establishing continuity of care for bilateral knee pain. It was noted that the Veteran had undergone bilateral ligamentous knee reconstructions. It was noted that imaging showed the hardware intact without evidence of loosening. There was radiographic evidence of arthritis. It was recorded that the Veteran reported "occasional subjective instability." The Veteran was afforded a VA examination in August 2010, during which he reported weakness, stiffness, heat, giving way, lack of endurance, locking, fatigability, tenderness, and pain. The Veteran reported flare-ups as often as three times per week and each one lasting for three days; their severity was at 10. The Veteran reported difficulty with standing and walking, walking limited to less than twenty minutes, but he denied any period of incapacitation during the previous twelve months. He also denied redness, deformity, drainage, effusion, subluxation, and dislocation. The examiner noted that the Veteran walked with an antalgic gait and that it was unsteady with attribution assigned as due to the Veteran's knees. It was also noted that the Veteran required braces on his knees. The Veteran's VA medical records show that in November 2010 the Veteran was seen for a chief complaint of bilateral knee chondromalacia patellae. It was noted that the Veteran was doing physical therapy. VA medical records from May 2011 show that the Veteran was seen for a chief complaint of chronic bilateral knee pain. VA medical treatment records from August 2011 show that the Veteran was prescribed 800 mg ibuprofen to be taken three times a day for pain. Left Knee Disability During medical treatment in August 2009, it was noted that for the left knee there was effusion and that tenderness was observed on ambulation. It was noted that there was no erythema and no misalignment. It was noted that the patella demonstrated no crepitus, that motion was normal, and that no crepitus on motion was noted; no pain was elicited by motion. It was noted that no weakness of the left knee was observed and that no sensory exam abnormalities were noted. An August 2009 imaging report of the left knee showed that no acute fractures or other bony abnormalities were noted and no soft tissue abnormalities were noted. During medical treatment in October 2009, it was noted that during examination of the left knee there was no pivot shift, no effusion, motor and sensory intact, and no hypermobile patella. The Veteran's medical records show that his left knee was evaluated in March 2010. It was recorded that there was effusion. It was noted that there was no erythema, no misalignment, and no tenderness on palpation. It was noted that the patella demonstrated no crepitus and that no crepitus on motion was noted. It was recorded that motion was normal, that no pain was elicited by motion, and that no tenderness was observed on ambulation. No sensory examination abnormalities were noted and no weakness of the left knee was observed. It was recorded that the Veteran's balance and gait were normal. In the August 2010 VA examination report, the examiner noted that there was tenderness and crepitus on the left knee, It was noted that there were no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, or drainage. It was noted that there was no subluxation, no genu recurvatum, locking pain, or ankylosis. Initial range of motion testing produced flexion to 120 degrees with pain at 120 degrees and extension to 0 degrees with pain at 0 degrees. The Veteran was able to perform repetitive-use testing, producing the same results as the initial range of motion testing. It was noted that the left knee joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive-use testing. It was noted that the medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test and the medial/lateral meniscus stability test were all within normal limits for the left knee. During a treatment examination in November 2010, it was recorded that the initial range of motion for the left knee was 0 to 130 degrees, and it was noted that there was no effusion. It was recorded that there were no sensory exam abnormalities and the motor exam demonstrated no dysfunction. The Veteran's VA medical records reveal that during a May 2011 examination, the initial range of motion of the Veteran's left knee was 0 to 115 degrees; there was no effusion; there was some laxity with valgus stress at 0 and 30 degrees. It was noted that there was instability due to spasticity. Imaging of the Veteran's left knee performed in May 2011 showed an intraosseous screw; no acute fracture identified; no suprapatellar joint effusion; no soft tissue abnormality. The impression was postsurgical and degenerative changes of the left knee. It was noted that this was consistent with imaging reports from August 2009. With respect to the Veteran's left knee disability, prior to October 24, 2013, it was evaluated as 10 percent disabling under Diagnostic Codes 5010 (arthritis) - 5262 (impairment of the tibia and fibula). The Board finds that a rating for impairment of the left tibia and fibula is not supported by the facts in this case because there is no evidence of record showing nonunion or malunion of the left tibia and fibula. Furthermore, during the August 2010 VA examination, no misalignment, deformity, or impairment of the left tibia or fibula was found. There is, however, X-ray evidence of degenerative arthritis and evidence of painful motion, which warrants compensable ratings for the knee joints under Diagnostic Codes 5003 (arthritis, degenerative) - 5010. Compensation for pain in limited to a minimal compensable rating per joint even when there is "no actual or compensable limitation of motion." See Mitchel v. Shinseki, 25 Vet. App. 32, 36 (2011). The criteria under Diagnostic Code 5003 for the next higher rating, 20 percent, have not been met because there is no evidence of record showing occasional incapacitating exacerbations, and the Veteran has not claimed otherwise. Therefore, a rating in excess of 10 percent is not warranted under this criteria. Prior to October 24, 2013, there is no evidence of compensable limitation of flexion of the left knee under Diagnostic Code 5260, i.e., flexion limited to 45 degrees. The August 2010 VA examination report shows that the Veteran had left knee flexion to 120 degrees on both initial testing and after repetitive-use testing. Medical records show that in November 2010 the Veteran's left knee flexion was to 130 degrees, and in May 2011, it was to 115 degrees. Likewise, prior to October 24, 2013, there is no evidence of compensable limitation of extension under Diagnostic Code 5261, i.e., extension limited to 10 degrees. The August 2010 VA examination report shows that the Veteran had left knee extension to 0 degrees on both initial testing and after repetitive-use testing. Additionally, none of the treatment records show limitation of extension. The Board finds that prior to October 24, 2013, the Veteran's disability picture more nearly approximates the criteria for a 10 percent rating, but not higher, under Diagnostic Code 5257 (current subluxation or lateral instability), and a separate rating is warranted. The evidence shows slight impairment of the left knee in that during the August 2010 VA examination the Veteran reported weakness, stiffness, locking, and fatigability. It was noted that the Veteran's gait was unsteady and that he wore braces. During medical evaluation in May 2011, the presence of laxity and spasticity was noted in the left knee. The evidence does not support more than an evaluation of 10 percent. There is no evidence of recurrent subluxation or dislocation of the left knee, and indeed, the Veteran denied this during the August 2010 VA examination. As such, the Board finds that prior to October 24, 2013, the evidence of record does not support the assignment of a disability rating in excess of 10 percent for the left knee. Because the Veteran is in receipt of a left knee disability rating under Diagnostic Code 5257, a separate evaluation is not warranted on the basis of a meniscus condition under Diagnostic Codes 5258 or 5259. See VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.j. In summary, the Board finds that prior to October 24, 2013, Veteran's service-connected left knee disability is not entitled to an evaluation in excess of 10 percent disabling under Diagnostic Code 5010 (arthritis), but he is entitled to a separate 10 percent rating, but not higher, under Diagnostic Code 5257 (lateral instability). Right Knee Disability During medical treatment in August 2009, it was noted that for the right knee there was effusion and that tenderness was observed on ambulation. It was noted that there was no erythema and no misalignment. It was noted that the patella demonstrated no crepitus, that motion was normal, and that no crepitus on motion was noted; no pain was elicited by motion. It was noted that no weakness of the right knee was observed and that no sensory exam abnormalities were noted. An August 2009 imaging report of the right knee showed that no acute fractures or other bony abnormalities were noted and no soft tissue abnormalities were noted. During medical treatment in October 2009, it was noted that on examination of the right knee there was guarding with pivot, no effusion, motor and sensory intact, and no hypermobile patella. Medical notes for October 2009 note slight anterior laxity of the right knee but the Veteran's major complaint was not subjective instability. The Veteran's medical records show that his right knee was evaluated in March 2010. It was recorded that there was no effusion, no erythema, no misalignment, and no tenderness on palpation. It was noted that the patella demonstrated no crepitus and that no crepitus on motion was noted. It was recorded that motion was normal, that no pain was elicited by motion, and that no tenderness was observed on ambulation. No sensory examination abnormalities were noted and no weakness of the right knee was observed. It was recorded that the Veteran's balance and gait were normal. In the August 2010 VA examination report, the examiner noted that there was tenderness and crepitus of the right knee. It was noted that there were no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment, or drainage. It was noted that there was no subluxation, no genu recurvatum, locking pain, or ankylosis. Initial range of motion testing produced flexion to 140 degrees with pain at 149 degrees and extension to 0 degrees with pain at 0 degrees. The Veteran was able to perform repetitive-use testing, producing the same results as the initial range of motion testing. It was noted that the right knee function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive-use testing. It was noted that the medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test and the medial/lateral meniscus stability test were all within normal limits for the right knee. During a treatment examination in November 2010, it was recorded that the initial range of motion for the right knee was 0 to 130 degrees, and it was noted that there was no effusion. It was recorded that there were no sensory exam abnormalities and the motor exam demonstrated no dysfunction. The Veteran's VA medical records show that during a May 2011 examination of his knees that the initial range of motion of his right knee was 0 to 120 degrees; it was stable to valgus stress at zero with some pseudo-laxity at 30 degrees. It was noted that the Veteran's right knee was somewhat spastic during the examination. Imaging of the Veteran's right knee performed in May 2011 showed no evidence of fracture or dislocation; intraosseous screw was seen within the lateral femoral condyle with an anchor in the lateral tibial plateau; there were intra-articular loose bodies seen overlying tibial spines and lateral joint compartment. The impression was postsurgical and degenerative changes of the right knee. This was consistent with imaging reports from August 2009. With respect to the Veteran's right knee disability, prior to October 24, 2013, it was evaluated as 10 percent disabling under Diagnostic Codes 5010- 5257 (recurrent subluxation and lateral instability). The Board finds that prior to October 24, 2013, the Veteran's right knee instability was slight and, therefore, an evaluation in excess of 10 percent disabling is not warranted. During the August 2010 VA examination, the Veteran reported weakness, stiffness, locking, fatigability, and he wore braces. The Veteran's gait was noted to be unsteady. During medical evaluation in May 2011, the presence of pseudo-laxity and spasticity was noted in the right knee. There is no evidence of recurrent subluxation or dislocation of the right knee, and the Veteran denied same during the August 2010 VA examination, and as such, the Board finds that prior to October 24, 2013, the evidence of record does not support the assignment of a disability rating in excess of 10 percent for the right knee. Prior to October 24, 2013, there is no evidence of compensable limitation of flexion of the right knee under Diagnostic Code 5260, i.e., flexion limited to 45 degrees. The August 2010 VA examination report shows that the Veteran had right knee flexion to 140 degrees on both initial testing and after repetitive-use testing. Medical records show that in November 2010 the Veteran's right knee flexion was to 130 degrees, and in May 2011, it was to 120 degrees. Likewise, prior to October 24, 2013, there is no evidence of compensable limitation of extension under Diagnostic Code 5261, i.e., extension limited to 10 degrees. The August 2010 VA examination report shows that the Veteran had right knee extension to 0 degrees on both initial testing and after repetitive-use testing. Additionally, none of the treatment records show limitation of extension. There is, however, X-ray evidence of degenerative arthritis and evidence of painful motion, which warrants compensable ratings for the knee joints under Diagnostic Code 5010. Accordingly, the Board finds that prior to October 24, 2013, a separate 10 percent rating for painful motion of the right knee joint is warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchel v. Shinseki, 25 Vet. App. 32, 36 (2011); VAOPGCPREC 9-2004. The criteria under Diagnostic Code 5010 for the next higher rating, 20 percent, have not been met because there is no evidence of record showing occasional incapacitating exacerbations, and the Veteran has not claimed otherwise. The Board finds that prior to October 24, 2013, a rating for impairment of the right tibia and fibula under Diagnostic Code 5262 is not warranted because there is no evidence of record showing nonunion or malunion of the right tibia and fibula. Furthermore, during the August 2010 VA examination, no misalignment, deformity, or impairment of the right tibia or fibula was found. As with the left knee, because the Veteran is in receipt of a right knee disability rating under Diagnostic Code 5257, a separate evaluation is not warranted on the basis of a meniscus condition under Diagnostic Codes 5258 or 5259. See VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.j. In summary, the Board finds that prior to October 24, 2013, the Veteran's service-connected right knee disability is not entitled to an evaluation in excess of 10 percent disabling under Diagnostic Code 5257 (lateral instability) and is entitled to a separate rating evaluated as 10 percent disabling, but not higher, under Diagnostic Code 5010 (arthritis) for painful motion. Beginning October 24, 2013 The Veteran was afforded a VA examination in October 2013. The Veteran reported that his left and right knee disabilities had worsened and that he wore knee braces. The Veteran stated that he had started to use his back to lift things instead of bending his knees. The Veteran reported flare-ups that cause his legs to tingle with chronic pain. He reported knee stiffness with prolonged sitting; disruption of sleep due to pain; and back pain due to change in gait because of knee pain. The examiner recorded that the Veteran had a history of shin splints but the Veteran did not report any symptoms. The examiner opined that there was 10 degrees of flexion lost bilaterally due to pain during flare-ups. The Veteran was afforded a VA examination in October 2016. The Veteran reported knee pain on a daily basis, which was localized diffusely in the knees. He stated that it feels like they are going to blow up. He reported taking naproxen daily for pain management. The Veteran reported flare-ups with increased pain with cold weather and prolonged weigh bearing. The examiner noted that the Veteran had decreased weight bearing tolerance. The examiner indicated that there was no history of tibial or fibular impairment, including shin splints. It was indicated that the Veteran did not use any assistive devices as a normal mode of locomotion. The examiner opined that the Veteran's left and right knee disabilities had likely been chronically progressing since the time of his initial injury. In February 2017, the examiner who performed the October 2016 VA examination prepared an addendum report. It was stated that the October 2016 VA examination report documented active and passive range of motion of the Veteran's knees and that on both active and passive range of motion testing, the Veteran's motion was pain-limited. It was stated that the knee cannot be ranged in a weightbearing position so such a request is unreasonable. The examiner stated that the Veteran experienced pain in the knees in weightbearing and non-weightbearing positions. In regards to the a retrospective review of the Veteran's left and right knee disabilities, the examiner opined that the degenerative changes have been progressive. It was opined that the October 2013 examination was likely completed during a flare-up, with the October 2016 examination demonstrating the more accurate progression of the Veteran's knee symptoms since the October 2016 examination was not performed during a flare-up or completed after repetitive-use testing. The Veteran's VA medical records show that between May and November 2016 he reported pain in his knees ranging from 7 to 10, described as dull aching and tingling. In September 2016, the Veteran was seen in the emergency room for bilateral knee pain. The Veteran reported that he did not usually take medication, Motrin was not working, but his knees had been aching more the last few days. It was noted that there was a mild effusion on the right knee. It was discussed that opioids were not good for chronic pain, and the Veteran agreed to use naproxen and follow up with his primary care physician. In November 2016 it was recorded that the Veteran was employed full-time, and there was no tenderness to palpation of the knees. The Veteran reported he was taking naproxen. He reported that cold weather, walking too much, and bending down made the knee pain worse. He reported that it affected his sleep and mood. Left Knee Disability During the October 2013 VA examination, initial range of motion testing of the left knee produced flexion to 95 degrees with pain at 95 degrees and extension to 30 degrees with pain at 30 degrees. During a flare-up, flexion would be to 85 degrees. The Veteran was able to perform repetitive-use testing, producing the same results as the initial range of motion testing. It was indicated that functional loss of the left knee was manifested in less movement than normal; pain on movement; instability of station; and disturbance of locomotion. It was indicated that the Veteran's left knee disability interfered with sitting, standing, and weight-bearing; there was tenderness to palpation. It was indicated that muscle strength was normal on flexion and extension. The examiner indicated that joint stability testing could not be performed. It was indicated that there was no history of recurrent patellar subluxation/dislocation. It was recorded that the Veteran had left knee meniscal dislocation, meniscal tear, frequent episodes of locking, frequent episodes of joint pain, and frequent episodes of joint effusion. It was indicated that there was imaging evidence of left knee degenerative or traumatic arthritis and that there was not X-ray evidence of left knee patellar subluxation. During the October 2016 VA examination, initial range of motion testing of the left knee produced flexion from 10 to 70 degrees and extension from 70 to 10 degrees. Pain was noted on flexion and extension and caused functional loss. It was indicated that the abnormal range of motion contributed to functional loss by affecting sitting and standing. Due to pain exacerbation, the Veteran was not able to perform repetitive-use testing of the left knee. The examiner indicated that the examination was not performed during a flare-up of the left knee disability and concluded that the examination was medically consistent with the Veteran's report of functional loss due to pain during a flare-up. The examiner recorded that additional contributing factors of the Veteran's left knee disability were disturbance of locomotion and interference with sitting and standing. It was indicated that muscle strength was normal on flexion and extension; there was no muscle atrophy. There was no ankylosis. The examiner indicated that there was no history of recurrent subluxation, recurrent lateral instability, or recurrent effusion. The examiner indicated that left knee joint stability testing was performed and that there was no instability. The examiner noted that the Veteran had MCL repair of the left knee in 1999. It was indicated that there was imaging evidence of left knee degenerative or traumatic arthritis and that there was evidence of postoperative changes. With respect to the Veteran's left knee disability, beginning October 24, 2013, it was evaluated as 40 percent disabling under Diagnostic Code 5261 (limitation of extension). The Board finds that an evaluation in excess of 40 percent disabling is not warranted. The October 2013 VA examination report shows that the Veteran's left knee extension was limited to 30 degrees with objective evidence of painful motion at 30 degrees. While weakness, fatigability, and incoordination contributed to the Veteran's disability, there was no additional limitation of motion with repetitive testing. The evidence does not show that the Veteran' left knee extension was limited to 45 degrees, even in contemplation of functional loss caused by symptoms such as pain, swelling, weakness, fatigue, or incoordination as a result of repetitive motion or flare-ups. Indeed, the examiner opined in the February 2017 medical opinion that this examination was performed during a flare-up, indicating that this report demonstrates the severity of the Veteran's left knee disability. The examiner opined in the February 2017 medical opinion that the October 2016 examination was reflective of the natural progression of the Veteran's degenerative left knee disability. During that examination the Veteran's left knee extension was limited to 10 degrees, which by itself would be evaluated as 10 percent disabling. The Board notes, however, that the Veteran was not able to do the repetitive-use testing because of exacerbation of pain. Hence, beginning October 24, 2013, taking into account left knee performance during a flare-up and functional loss, including due to pain, the Board finds that a rating in excess of 40 percent under Diagnostic Code 5261 is not warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchel v. Shinseki, 25 Vet. App. 32, 36 (2011). Because the Veteran is in receipt of a disability rating based on actual limitation of extension, a separate evaluation for painful motion under Diagnostic Code 5003 (arthritis, degenerative) is not warranted. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that beginning October 24, 2013, there is no evidence of compensable limitation of flexion under Diagnostic Code 5260, i.e., flexion limited to 45 degrees. The October 2013 VA examination report shows left knee flexion to 95 degrees. At worst, however, it could be to 85 degrees taking into consideration the examiner's opinion that there might be an additional 10 degrees of flexion lost during a flare-up. The October 2016 VA examination report shows left knee flexion to 70 degrees. Additionally, none of the Veteran's treatment records show limitation of flexion. The Board finds that beginning October 24, 2013, a separate 10 percent rating, but not higher, is warranted for lateral instability under Diagnostic Code 5257. The Board notes that the rating schedule does not require objective medical evidence to substantiate knee instability. The Veteran's statements regarding instability, manifested by giving way, and difficulty with ambulation are competent and credible. See 38 C.F.R. § 3.159(a)(2) (2017) (defining competent lay evidence); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that competent lay evidence requires facts perceived through the use of the five senses). The Veteran's medical records show that he has worn knee braces since 2006. It was indicated on the October 2013 VA examination report that joint stability testing could not be performed but it was noted that there was no X-ray evidence of patellar subluxation. In the February 2017 VA medical opinion, it was opined that the October 2016 VA examination was performed during a flare-up. It was indicated on the October 2016 VA examination report that the Veteran did not have a history of recurrent subluxation or recurrent lateral instability; it was indicated that all of the left knee stability testing was normal. Resolving reasonable doubt in the Veteran's favor due to the record evidence of lateral instability of the left knee prior to October 24, 2013, and the degenerative nature of the Veteran's disability, the Board finds a separate rating for instability is warranted. The Veteran's left knee instability has been slight and, therefore, warrants a 10 percent rating, but not higher. The evidence of record shows that there has been no true giving way or dislocation of the left knee, including examination by X-ray. The Veteran has described the instability as being occasional and he has not contended anything more than a minimal impact on his daily functioning; accordingly, a higher rating of 20 percent for moderate instability is not warranted. Because the Veteran is in receipt of a left knee disability rating under Diagnostic Code 5261 (limitation of extension), a separate evaluation is not warranted on the basis of a meniscus condition under Diagnostic Codes 5258 or 5259. See VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.i. The Board finds that beginning October 24, 2013, there is no credible evidence of record showing nonunion or malunion of the left tibia and fibula to support a rating under Diagnostic Code 5262. While the October 2013 VA examiner noted asymptomatic shin splints, the record is otherwise silent for nonunion or malunion of the tibia or fibula. See VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.l (noting that shin splints are to be evaluated analogously with 38 C.F.R. § 4.71a, Diagnostic Code 5262). Additionally, on the October 2016 VA examination report it was indicated that the Veteran did not have left tibial or fibular impairment. In summary, the Board finds that beginning October 24, 2013, the Veteran's service-connected left knee disability is not entitled to an evaluation in excess of 40 percent disabling under Diagnostic Code 5261 (limitation of extension) and is entitled to a separate rating evaluated as 10 percent disabling, but not higher, under Diagnostic Code 5257 (lateral instability). Right Knee Disability During the October 2013 VA examination, initial range of motion testing of the right knee produced flexion to 90 degrees with pain at 90 degrees and extension to 30 degrees with pain at 30 degrees. The Veteran was able to perform repetitive-use testing, producing the same results as the initial range of motion testing. It was indicated that functional loss of the right knee was manifested in less movement than normal; pain on movement; instability of station; and disturbance of locomotion. It was indicated that the Veteran's right knee disability interfered with sitting, standing, and weight-bearing; there was tenderness to palpation. It was indicated that muscle strength was normal on flexion and extension. The examiner indicated that joint stability testing could not be performed. It was indicated that there was no history of recurrent patellar subluxation/dislocation. It was recorded that the Veteran had right knee meniscal dislocation, meniscal tear, frequent episodes of locking, frequent episodes of joint pain, and frequent episodes of joint effusion. It was indicated that there was imaging evidence of right knee degenerative or traumatic arthritis and that there was not X-ray evidence of right knee patellar subluxation. During the October 2016 VA examination, initial range of motion testing of the right knee produced flexion from 10 to 80 degrees and extension from 80 to 10 degrees. Pain was noted on flexion and extension and caused functional loss. It was indicated that the abnormal range of motion contributed to functional loss by affecting sitting and standing. Due to pain exacerbation, the Veteran was not able to perform repetitive-use testing of the right knee. The examiner indicated that the examination was not performed during a flare-up of the right knee disability and concluded that the examination was medically consistent with the Veteran's report of functional loss due to pain during a flare-up. The examiner recorded that additional contributing factors of the Veteran's right knee disability were disturbance of locomotion and interference with sitting and standing. It was indicated that muscle strength was normal on flexion and extension; there was no muscle atrophy. There was no ankylosis. The examiner indicated that there was no history of recurrent subluxation, recurrent lateral instability, or recurrent effusion. The examiner indicated that right knee joint stability testing was performed and that there was no instability. The examiner noted that the Veteran had LCL repair of the right knee in 1999. It was indicated that there was imaging evidence of right knee degenerative or traumatic arthritis and that there was evidence of postoperative changes. With respect to the Veteran's right knee disability, beginning October 24, 2013, it was evaluated as 40 percent disabling under Diagnostic Code 5261 (limitation of extension). The Board finds that an evaluation in excess of 40 percent disabling is not warranted. The October 2013 VA examination report shows that the Veteran's right knee extension was limited to 30 degrees with objective evidence of painful motion at 30 degrees. While weakness, fatigability, and incoordination contributed to the Veteran's disability, there was no additional limitation of motion with repetitive testing. The evidence does not show that the Veteran' right knee extension was limited to 45 degrees, even in contemplation of functional loss caused by symptoms such as pain, swelling, weakness, fatigue, or incoordination as a result of repetitive motion or flare-ups. Indeed, the examiner opined in the February 2017 medical opinion that this examination was performed during a flare-up, indicating that this report demonstrates the severity of the Veteran's right knee disability. The examiner opined in the February 2017 medical opinion that the October 2016 examination was reflective of the natural progression of the Veteran's degenerative knee disability. During the October 2016 examination, the Veteran's right knee extension was limited to 10 degrees, which by itself would be evaluated as 10 percent disabling. The Board notes, however, that the Veteran was not able to do the repetitive-use testing because of exacerbation of pain. Hence, beginning October 24, 2013, taking into account right knee performance during a flare-up and functional loss, including due to pain, the Board finds that a rating in excess of 40 percent under Diagnostic Code 5261 is not warranted. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchel v. Shinseki, 25 Vet. App. 32, 36 (2011). Because the Veteran is in receipt of a disability rating based on actual limitation of extension, a separate evaluation for painful motion under Diagnostic Code 5003 (arthritis, degenerative) is not warranted. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that beginning October 24, 2013, there is no evidence of a compensable limitation of flexion under Diagnostic Code 5260, i.e., flexion limited to 45 degrees. The October 2013 VA examination report shows right knee flexion to 90 degrees. At worst, however, it could be to 80 degrees taking into consideration the examiner's opinion that there might be an additional 10 degrees of flexion lost during a flare-up. The October 2016 VA examination report shows right knee flexion to 80 degrees. Additionally, none of the Veteran's treatment records show limitation of flexion. The Board finds that beginning October 24, 2013, a separate 10 percent rating, but not higher, is warranted for lateral instability under Diagnostic Code 5257. The Board notes that the rating schedule does not require objective medical evidence to substantiate knee instability. The Veteran's statements regarding instability, manifested by giving way, and difficulty with ambulation are competent and credible. See 38 C.F.R. § 3.159(a)(2) (2017); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that competent lay evidence requires facts perceived through the use of the five senses). The Veteran's medical records show that he has worn knee braces since 2006. It was indicated on the October 2013 VA examination report that joint stability testing could not be performed but it was noted that there was no X-ray evidence of patellar subluxation. In the February 2017 VA medical opinion, it was opined that the October 2013 VA examination was performed during a flare-up. It was indicated on the October 2016 VA examination report that the Veteran did not have a history of recurrent subluxation or recurrent lateral instability; it was indicated that all of the right knee stability testing was normal. Resolving reasonable doubt in the Veteran's favor due to the record evidence of lateral instability of the right knee prior to October 24, 2013, and the degenerative nature of the Veteran's disability, the Board finds a separate rating for instability is warranted. The Veteran's right knee instability has been slight and, therefore, warrants a 10 percent rating, but not higher. The evidence of record shows that there has been no true giving way or dislocation of the right knee, including examination by X-ray. The Veteran has described the instability as being occasional and he has not contended anything more than a minimal impact on his daily functioning; accordingly, a higher rating of 20 percent for moderate instability is not warranted. As with the left knee, because the Veteran is in receipt of a right knee disability rating under Diagnostic Code 5261 (limitation of extension), a separate evaluation is not warranted on the basis of a meniscus condition under Diagnostic Codes 5258 or 5259. See VAOPGCPREC 9-98; VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.i. The Board finds that beginning October 24, 2013, there is no credible evidence of record showing nonunion or malunion of the right tibia and fibula to support a rating under Diagnostic Code 5262. While the October 2013 VA examiner noted asymptomatic shin splints, the record is otherwise silent for nonunion or malunion of the tibia or fibula. See VBA Manual M21-1, Pt. III, subpt. iv, ch. 4, sec. A.4.l (noting that shin splints are to be evaluated analogously with 38 C.F.R. § 4.71a, Diagnostic Code 5262). Additionally, on the October 2016 VA examination report it was indicated that the Veteran did not have right tibial or fibular impairment. In summary, the Board finds that beginning October 24, 2013, the Veteran's service-connected right knee disability is not entitled to an evaluation in excess of 40 percent disabling under Diagnostic Code 5261 (limitation of extension) and is entitled to a separate rating evaluated as 10 percent disabling, but not higher, under Diagnostic Code 5257 (lateral instability). In conclusion, the Board has considered the Veteran's claims and decided entitlement based on the evidence. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. 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). ______________________________________________ LANA K. JENG Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD Leanne M. Innet, Associate Counsel Copy mailed to: Karl A. Kazmierczak, Attorney at Law Department of Veterans Affairs