Citation Nr: 20031604 Decision Date: 05/05/20 Archive Date: 05/05/20 DOCKET NO. 08-16 696 DATE: May 5, 2020 ORDER Service connection for a right knee disability is denied. Service connection for a right foot disability is denied. An initial rating in excess of 20 percent for dislocated semilunar cartilage, left knee, is denied. An initial rating in excess of 10 percent for left knee arthritis is denied. FINDINGS OF FACT 1. The weight of the evidence is against a finding that a right knee disability was manifested during the Veteran’s period of active service, or that it is otherwise the result of a disease or injury during active service, or that it is proximately due to or aggravated by a service-connected disability. 2. The weight of the evidence is against a finding that a right foot disability was manifested during the Veteran’s period of active service, or that it is otherwise the result of a disease or injury during active service. 3. The left knee is not manifested by ankylosis, tibia/fibula impairment or genu recurvatum; it is manifested by dislocated semilunar cartilage and episodes of locking, pain, and effusion into the joint. 4. From March 25, 2010, the left knee is manifested by degenerative arthritis without flexion limited to 30 degrees nor extension limited to 15 degrees. 5. Prior to March 25, 2010, the left knee is manifested by degenerative arthritis without limitation of flexion or extension. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a right foot disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for a disability rating in excess of 20 percent for dislocated semilunar cartilage, left knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Part 4, Diagnostic Codes 5003, 5258. 4. For the period from March 25, 2010, the criteria for a disability rating in excess of 10 percent for left knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Part 4, Diagnostic Codes 5003, 5260, 5261. 5. For the period prior to March 25, 2010, the criteria for a separate rating for left knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Part 4, Diagnostic Codes 5003, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1978 to March 1990. The Veteran testified before the undersigned Veterans Law Judge in April 2011; the transcript is of record. In August 2011, the Board, in pertinent part, denied a disability rating in excess of 10 percent for a left knee disability, and remanded the issues of service connection for right knee and right foot disabilities. The Veteran, in pertinent part, appealed the portion of the August 2011 Board decision that denied the higher rating for the left knee disability. Pursuant to a January 2012 Joint Motion for Partial Remand (JMPR) and United States Court of Appeals for Veterans Claims (Court) Order, the denial of an increased rating for a left knee disability was vacated and remanded for adjudication consistent with the JMPR. The issue was remanded in November 2012. In April 2016, the Board, in pertinent part, granted a 20 percent disability rating for degenerative changes of the left knee status post meniscectomy, and assigned a separate rating of 10 percent for subluxation or lateral instability, left knee, and remanded the right knee and right foot issues. In a May 2016 rating decision, such ratings were implemented, effective August 25, 2006. The Veteran, in pertinent part, appealed the portion of the decision granting a rating of 20 percent for degenerative changes of the left knee status post meniscectomy. Pursuant to a May 2017 JMPR and Court Order, the portion of the rating decision that denied a rating in excess of 20 percent was vacated and remanded for further adjudication consistent with the JMPR. In a September 2017, the Board remanded the degenerative changes of left knee, right knee, and right foot issues. In an August 2019 rating decision, a 10 percent disability rating was assigned for left knee arthritis, effective March 25, 2010. Degenerative changes of the left knee (20%) was recharacterized as dislocated semilunar cartilage, left knee. Service Connection The Veteran asserts that she has a disability of the right knee that is due to service and/or due to a service-connected disability, and that she has a disability of the right foot due to service. Specifically, she asserts that she injured her foot in October 1982. 08/25/2006 VA 21-526 Veterans Application for Compensation or Pension. She has reported foot problems including pain, pronation, cramping, and cold toes. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has current disabilities that began during service or are at least as likely as not related to an in-service injury, event, or disease, or whether she has a disability of the right knee that is due to or aggravated by a service-connected disability. The Board concludes that, while the Veteran has current diagnoses of a degenerative joint disease (DJD)/degenerative arthritis and chondromalacia patellae of the right knee, and right foot calcaneal bone spur, the preponderance of the evidence weighs against finding that these disabilities began during service or are otherwise related to an in-service injury, event, or disease, or that the right knee disability is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). While service treatment records reflect injury to the left little toe, the records do not reflect any in-service right foot injury. However, the Veteran asserts that her foot problems began after her well-documented in-service motor vehicle accident. Service treatment records reflect that the Veteran sustained lumbar and cervical spine injuries following a June 1984 motor vehicle accident. 09/01/2006 STR-Medical (1) at 21-22. There were no reported injuries pertaining to the right knee or right foot. In an August 1982 Report of Medical History the Veteran denied ‘“trick” or locked knee’ and ‘foot trouble.’ Id. at 70. A November 1985 Report of Medical Examination reflects that his ‘lower extremities’ and ‘feet’ were clinically evaluated as normal. Id. at 68. Service branch treatment records reflects podiatry treatment in February 1997 due to pronation, and orthotics were prescribed in April 1997. A bone spur was diagnosed in December 2000. A May 2002 record reflects that the Veteran missed a step and fell onto her knees. She had no swelling but there was mild tenderness in her right knee. 11/09/2007 Medical Treatment Record-Government Facility at 2. An August 2006 MRI of the right knee reflects mild to moderate osteoarthritis; small to moderate joint effusion; and, no medical meniscus tear. 04/27/2012 Medical Treatment Record-Government Facility. A June 2007 examination is negative for any objective findings pertaining to the right knee. A November 2007 Independent Medical Evaluation by Dr. C.N.B. reflects that the Veteran’s medical records were reviewed for the purpose of making a medical opinion regarding multiple claimed disabilities. With regard to the bilateral knees, it was indicated that the Veteran had initial signs and symptoms of problems with this organ system during service, per lay statements and medical records. She participated in military sports and engaged in aerobic exercise including jogging on a daily basis, as documented in her medical record. She had two auto accidents in service, one in 1979 and one in 1984, in which she likely injured both knees. She had a left knee meniscus tear in service in 1994, and had a right knee MRI, which showed degenerative fibro cartilage in the posterior horns of the medical/lateral menisci, as per Dr. H. It was opined that her current bilateral knee problems are due to the experiences and problems that she had with her knees during military service. Dr. C.N.B. stated that her record does not contain a more likely etiology to explain her bilateral knee problems and she should be granted service connection. With regard to the feet, it was indicated that the Veteran had initial signs and symptoms of problems with this organ system during service per the lay statements and medical records. In 1997, she had bilateral heel pain, severe pronation, and x-rays documented heel spurs bilaterally per Dr. S. She broke her left 5th toe in 1982. It was opined that her current feet problems stem from her excessive pronation and heel spurs that were noted in service, noting that the record does not contain a more likely etiology to explain her bilateral foot problems. 12/03/2007 Medical Treatment Record-Non-Government Facility. An April 2010 C&P Exam reflects right knee flexion to 90 degrees on range of motion testing, with pain at 70 degrees. She had normal stability. There was no diagnosis provided as the examination pertaining to the left knee. In April 2011, the Veteran testified at a hearing before the Regional Office (RO). With regard to the right foot, she stated that she worked out a lot of stay fit and she “sustained injuries while working out, such as you know, turning my ankle, or hurting my foot.” 04/06/2011 Hearing Testimony at 7. After an auto accident, she had orthotics made by a podiatrist to help with foot stability. Id. Dr. C.N.B. testified that she was given a diagnosis of coronary syndrome of her right foot in 1987. Id. at 8. The Veteran testified that her right knee “degenerated over time” and she had arthroscopic surgery of the right knee in 1994. Dr. Bash testified that the right knee disability was due to the car accidents. There was also a suggestion of a relationship to his left knee disability. Id. at 16-17. (The Board notes that the Veteran underwent arthroscopic surgery of the left knee in 1994, not the right knee.) In April 2011, Dr. C.N.B. provided a follow-up opinion report. He stated the following: The patient has right knee and left shoulder problems which are well documented in her records. These two joints were likely injured in her initial car accidents (1979 and 1983) in service. She has had right shoulder and left knee problems, which are already rated at a high level. The fact that her right shoulder and left knee are less than 100% functional these weak joints cause abnormal forces to be placed across her other joints (left knee and right shoulder) which in turn causes them to fail prematurely. In other words, it is my opinion that her left knee and right shoulder degenerative changes are most likely due to her already damaged service connected right knee and left shoulder. It appears that Dr. C.N.B. may have been trying to opine that the Veteran’s right knee disability is due to her service-connected left knee disability. 05/12/2011 Medical Treatment Record-Non-Government Facility. In September 2011, Dr. C.N.B. opined that her right knee is most likely due to her already damaged service-connected left knee. 09/30/2011 Medical Treatment Record-Non-Government Facility. An April 2013 VA Examination reflects a diagnosis of hallux valgus of the feet. An x-ray examination reflects hallux valgus deformity and bilateral MTP joint arthropathy great toe and calcaneal spurs. The April 2013 VA examination reflects diagnoses of DJD and chondromalacia patellae with regard to the knees. The examiner opined that her right knee condition is less likely as not caused by or a result of an in-service injury/event. Review of the claims file notes no documentation of a right knee condition in active duty. Her subsequent medical records noted degenerative joint disease x-ray findings in 2001 with a 1-year history of right knee pain. With regard to a secondary relationship to her left knee, the examiner could not resolve this issue without resort to mere speculation. A diagnosis of patellae tendinitis of the left knee in December 1983 was noted, but the Veteran reportedly had been told that she had bilateral patella problems and bilateral degenerative joint disease of both knees. The examiner did not find this in the medical documentation. She had arthroscopic surgery of the left knee in 1994 and has degenerative joint disease of the left knee. She had DJD in 2001 and DJD is a common finding as we age. See 02/06/2014 C&P Exam. In February 2017, the Veteran underwent a C&P examination, wherein the examiner provided a negative etiological opinion, finding that the claims file lacks objective medical evidence to confirm a diagnosis or treatment for any right knee condition during service. Degenerative arthritis was first documented in 2006 and his separation from service was in March 1990, thus 12 years after separation from service. A negative etiological opinion was also proffered with regard to whether his right knee disability was due to his left knee disability. The examiner stated that arthritis in one joint does not cause arthritis in another joint. Medical literature does not support this, and a nexus has not been established. Another examination was sought as the examiner did not give a nexus opinion regarding his chondromalacia patella and based on the examiner’s finding that degenerative arthritis began in 2006 rather than August 2001 when it was first documented. Oddly, the file also contains another examination issued on the same date, by the same examiner, which reflects a positive nexus. The rationale was based on the onset of disability being shown in service. As discussed above, the service treatment records do not reflect complaints or treatment referable to the right knee. The Board thus finds that this opinion is based on an inaccurate factual premise and thus lacks probative value; it is vastly outweighed by the opposing opinion, offered by the same examiner, seemingly on the same date. With regard to the right foot, the February 2017 examiner opined that the Veteran’s right foot disability was less likely than not due to service. The examiner stated that there are no medical records available regarding the right foot that date back any earlier than 2008, which is 18 years after separation from service. As the examiner did not address the 1997 diagnosis of a calcaneal bone spur in the right foot, another examination was sought. In March 2018, a C&P examiner opined that it is less likely as not that the right heel spur is related to active duty to include the motor vehicle accident. Records from active duty are absent any showing of a right heel spur. It was not until 2000, 10 years after active duty, when an x-ray showed a right heel spur. There is nothing in the medical literature that shows a heel spur would develop due to injuries from a motor vehicle accident that did not involve the right foot/heel area. In March 2018, a C&P examiner proffered a negative etiological opinion with regard to the claimed right knee disability. The examiner stated that the condition was acute only, and there is no evidence of chronicity of care. A nexus has not been established. The examiner stated that there is no record of a right knee injury or right knee problem in service treatment records. There is no mention of a right knee condition on exit exam from military. There is no record of right knee symptoms in the medical record until August 2001, which is 11 years after separation from military service. The examiner stated that arthritis in one joint does not cause arthritis in another joint. As detailed above, while right knee and right foot disabilities have been diagnosed, such diagnoses were rendered many years after separation from service. Arthritis of the knee was diagnosed in 2001, thus 11 years after separation from service, and a heel spur was diagnosed in 2000 after he sought treatment in 1997 due to bone spur symptomatology. Service treatment records do not reflect any complaints, treatment, or diagnoses pertaining to the right knee or right foot, to include following a motor vehicle accident. Furthermore, due to the Veteran’s lay assertions of having right knee and right foot problems due to service, opinions were sought. Negative opinions on a direct basis have been provided with regard to both the right knee and right foot based on negative service treatment records and a lack of continuity of symptomatology, and negative opinions on a secondary basis have been provided with regard to the right knee. The collective opinions of the C&P/VA examiners are probative because they are based on review of an accurate medical history, consideration of the Veteran’s lay assertions, and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has given consideration to the opinions and testimony of Dr. C.N.B. but finds that the opinions of record pertaining to the right knee and right foot are not supported by the record. Dr. C.N.B. related right knee and right foot conditions to in-service motor vehicle accidents; however, the service treatment records do not reflect any such injuries due to such accidents. Indeed, if the Veteran was experiencing right foot and knee symptoms as a result of the accident it seems logical to expect that such complaints would have been reflected in the treatment reports. The absence of any such complaints suggests that symptomatology was not then present. Dr. C.N.B. discussed the Veteran’s foot disorder in his November 2007 opinion and he appears to relate her bilateral foot conditions to a left toe injury in service. Such opinion is imprecise and not adequately explained, in light of the fact that no specific right foot injury is documented in service. Dr. C.N.B. opined that the Veteran’s right knee disability was due to her left knee disability, even though he appeared to confuse the right and left knees in formulating the opinion. Such opinion, however, was not based on a physical examination, unlike the C&P/VA examinations of record. The opinions of Dr. C.N.B. appear to be based on an incomplete record and the Veteran’s self-reported medical history, which is inconsistent with service treatment records that show no complaints related to the right knee and right foot until many years following service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Consequently, the Board gives more probative weight to the C&P/VA opinions of record. The Board has also given consideration to the lay assertions by the Veteran, and the lay assertions of friends pertaining to her right knee and right foot. Due to such lay assertions, opinions were sought. While the Veteran believes that she has disabilities of the right knee and right foot due to service and/or due to a service-connected disability, she is not competent to provide a nexus opinion regarding these issues. The issues are medically complex, requiring knowledge of the interaction between multiple organ systems in the body/anatomical relationships/pathology/interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). As discussed, right knee and right foot disabilities were diagnosed several years after separation from service. The Veteran’s contentions are outweighed by the clinical findings documented several years after separation from service, and the lack of diagnosis or complaints reflected in the medical records, and the opinions of trained medical professionals. Increased Rating Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The appeal arises from the original assignment of disability evaluations following an award of service connection, thus the severity of the disabilities at issue are to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Disability ratings are determined by evaluating 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 Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The Board has reviewed all the evidence in the Virtual folders, which includes: his contentions, post-service treatment reports, and examination reports. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). For purposes of this decision, the Board notes that normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71a, Plate II. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Evaluations for limitation of extension of the knee are assigned as follows: extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The rating schedule provides for a 10 percent rating for slight recurrent subluxation or lateral instability, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Pursuant to Diagnostic Code 5003, arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joints warrants a 10 percent evaluation. See 38 C.F.R. § 4,71a, Diagnostic Code 5003. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight- bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98 (Aug. 1998). Moreover, the General Counsel also held more recently that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and under Diagnostic Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (Sept. 2004). As detailed above, the Veteran’s dislocated semilunar cartilage of the left knee is rated 20 percent disabling, effective August 25, 2006, pursuant to Diagnostic Code 5258. A separate 10 percent rating has been assigned to left knee arthritis, effective March 25, 2010, pursuant to Diagnostic Codes 5260-5003. A separate 10 percent rating has been assigned to subluxation or lateral instability, left knee, effective August 25, 2006; however, such rating is not in appellate status as the rating was granted in the April 2016 Board decision, which is final. Initially, the Board notes that pursuant to Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of “locking, pain” and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. As the Veteran is in receipt of the highest schedular rating for dislocation of semilunar cartilage, there is no basis to award a higher evaluation. Consideration will be given to other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Ankylosis of the knee is addressed per Diagnostic Code 5256, however, the evidence fails to show that the left knee is ankylosed. There is also no evidence of any impairment of the tibia or fibula or genu recurvatum to allow for application of Diagnostic Codes 5262 or 5263. A separate rating may not be assigned under Diagnostic Code 5259 as a rating has already been assigned under Diagnostic Code 5258 for the residual symptoms associated with the left knee cartilage. 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. That is, there are only two requirements for a compensable rating under Diagnostic Code 5259. First, the semilunar cartilage or meniscus must have been removed. Second, it must be symptomatic. 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 of being “symptomatic” is broad enough to encompass all symptoms, including pain, limitation of motion (including as due to joint "locking"), and effusion. The rating criteria under Diagnostic Codes 5258 and 5259 differ from each other only in that the semilunar cartilage is dislocated in DC 5258 and surgically absent in Diagnostic Code 5259. Diagnostic Code 5258 requires dislocation of the semilunar cartilage with symptoms of frequent joint locking, pain, and effusion and Diagnostic Code 5259 requires removal of the semilunar cartilage that is symptomatic; therefore, Diagnostic Codes 5258 and 5259 overlap with each other in symptoms of pain, effusion, and locking, but not as to dislocation or surgical absence. Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (stating that the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). Granting a separate rating for the same overlapping manifestations of the Veteran’s knee disability under Diagnostic Code 5259 would constitute impermissible pyramiding. 38 C.F.R. § 4.14. Moreover, the highest available rating under Diagnostic Code 5259 in this case is 10 percent; thus, Diagnostic Code 5259 does not allow for a higher rating than Diagnostic Code 5258 (which provides a single, maximum rating of 20 percent). As detailed above, a separate 10 percent rating has been assigned for degenerative arthritis of the left knee, effective March 25, 2010, which is rated based on limitation of motion. Initially, the Board has considered whether a separate compensable rating is warranted for degenerative arthritis prior to March 25, 2010. While a diagnosis of degenerative arthritis is reflected in the medical records prior to March 25, 2010, limitation of motion is not shown. Per Diagnostic Code 5003, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, however, limitation of motion is not shown prior to this date. Specifically, a June 2007 examination reflects normal range of motion, albeit with pain at 100 degrees. Even with consideration of pain, her range of motion was normal on objective examination. There is no other medical evidence that supports a finding of limitation of motion prior to a March 25, 2010 examination. With regard to the period from March 25, 2010, objective limitation of motion findings reflect that a compensable rating would not be warranted per Diagnostic Code 5260, and a 10 percent rating would be warranted per Diagnostic Code 5261. The most severe limitation of flexion shown on any of the medical reports of record was to 85 degrees (March 2018 examination), and the most severe limitation of extension was to 10 degrees (February 2017 examination) without any additional loss of function or range of motion after repetitive-use testing. The medical evidence of record has not shown limitation of flexion to 30 degrees or less at any time, nor extension limited to 15 degrees. In fact, the February 2017 examination was the only examination that showed limitation of extension; the other examinations of record reflected normal extension. Moreover, while the above-noted February 2017 finding with respect to extension is commensurate with a 10 percent evaluation under Diagnostic Code 5261, to be awarded separate ratings for both flexion and extension of the right knee, both motions must be limited to at least a compensable degree under Diagnostic Code 5260 and 5261. Here, while a compensable rating is in effect pursuant to Diagnostic Code 5260 this is in fact based on considerations of pain, and flexion is not at any time actually limited to a compensable level under the criteria of Diagnostic Code 5260 (i.e. flexion limited to 45 degrees or worse). Therefore, the Veteran cannot be awarded a separate 10 percent rating for limitation of left knee extension for any portion of the rating period on appeal. VAOPGCPREC 9-2004 (Sept. 17, 2004). Thus, a higher or separate evaluation based on limitation of flexion and extension under the above cited rating codes is not warranted. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (holding that the Board’s choice of diagnostic code should be upheld so long as it is supported by explanation and evidence). In consideration of the DeLuca factors, there have been objective findings of pain, but the objective findings contained within the record, based on examination reports and treatment records, do not more nearly approximate the criteria for higher ratings even with consideration of pain. The 10 percent in effect for arthritis and limitation of motion symptomatology for the period from March 25, 2010, compensates him for limited and painful motion, and assigning the next higher ratings for painful motion would not accurately assess the resulting function loss, even when considering the pain. The 10 percent rating takes into consideration the Veteran’s functional loss associated with her left knee. The Board finds that 38 C.F.R. §§ 4.40, 4.45 and 4.59 do not provide a basis for an increased rating for any period contemplated by this appeal. See DeLuca, 8 Vet. App. at 204 -07. In other words, the functional loss does not most nearly approximate the criteria for the next-higher respective 20 percent evaluation. Additionally, with regard to consideration of flare-ups per Sharp v. Shulkin, 29 Vet. App. 26 (2017), the evidence of record supports a finding that the Veteran experiences flare-ups associated with her left knee disability. At a February 2014 examination, the Veteran reported that about 5 times per year her knee worsens, and she is unable to climb stairs. During such times she has to stay home from work for two days to elevate her legs. However, despite such assertions, the examiner noted that the Veteran did not experience any flare-ups of her knee. The February 2017 examination reflects that both knees were tested, and no flare-ups were noted. At the February 2018 examination the Veteran reported that every evening when she gets home from work, she has to put her feet up due to knee pain. On weekends she has to stay off her legs entirely due to intense pain throughout the week. The examiner stated that the examination was not being conducted during a flare-up and was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss as there was no conceptual or empirical basis for making such a determination without directly observing function under the flare up condition. The examiner was unable to describe in terms of range of motion without resorting to mere speculation as there is no conceptual or empirical basis for making such a determination without directly observing function under these conditions. In February 2019, a physician addressed the discrepancies in the February 2014 and February 2017 examination reports with regard to the examiners’ findings of no flare-ups, finding that the Veteran does experience flare-ups, and that it was likely that in February 2017 no flares were occurring and the 2014 examiner mistakenly omitted the flares in the later parts of the examination report. Consideration has been given to the functional effect of the Veteran’s reported flare-ups, but there is nothing specific in the record that would provide for higher ratings on this basis as there is nothing to suggest that during flare ups flexion would be limited to 30 degrees or extension limited to 15 degrees. To the extent that the examinations of record may be deemed deficient under Sharp, given the inconsistencies in the past examination reports, it does not appear likely that development to obtain a retrospective opinion as to an estimate of additional loss of motion due to flare-ups in years past would yield any probative information but rather would likely serve only to delay the appeal. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). Finally, it is noted that the Veteran has not raised any challenges with respect to any deficiencies in the examination reports. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). In sum, there is no basis for increased or separate ratings for the service-connected left knee. The appeal is therefore denied. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.