Citation Nr: 20031897 Decision Date: 05/06/20 Archive Date: 05/06/20 DOCKET NO. 18-28 485A DATE: May 6, 2020 ORDER A disability rating of 10 percent, and no higher, for painfully limited flexion of the left knee associated with patellofemoral pain syndrome of the left knee is granted for the entire pendency of the appeal. A separate 20 percent disability rating for instability and subluxation of the left knee is granted, effective September 11, 2019. A disability rating greater than 10 percent for patellofemoral pain syndrome of the right knee with right meniscus tear is denied. An initial disability rating of 20 percent, and no higher, for instability and subluxation of the right knee is granted for the entire pendency of the appeal. REMANDED The claim of entitlement to an effective date earlier than April 14, 2011 for the assignment of a compensable disability rating for painfully limited flexion of the left knee associated with patellofemoral pain syndrome (previously characterized as patellofemoral pain syndrome of the left knee) is remanded. The claim of entitlement to an effective date earlier than August 2, 2011 for the assignment of a compensable disability rating for instability and subluxation, right knee (previously characterized as patellofemoral pain syndrome of the right knee) is remanded. FINDINGS OF FACT 1. During the entire pendency of this appeal, the Veteran’s painfully limited flexion of the left knee associated with patellofemoral pain syndrome of the left knee has been manifested by objective evidence of painful, limited motion with flexion limited to no less than 70 degrees, even with contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups without ankylosis, lateral instability or recurrent subluxation, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 2. Beginning September 11, 2019, the Veteran’s service-connected left knee disability has demonstrated moderate instability and subluxation. 3. During the entire pendency of this appeal, the Veteran’s patellofemoral pain syndrome of the right knee with right meniscus tear has been manifested by objective evidence of painful, limited motion with flexion limited to no less than 70 degrees, even with contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups without ankylosis, lateral instability or recurrent subluxation, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. 4. The Veteran’s service-connected right knee disability has demonstrated moderate instability since the February 21, 2014 grant of service connection. CONCLUSIONS OF LAW 1. During the entire pendency of this appeal, the criteria for a disability rating of 10 percent, and no higher, for painfully limited flexion of the left knee associated with patellofemoral pain syndrome of the left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.71a, Diagnostic Code (DC) 5260. 2. Since September 11, 2019, the criteria for a separate initial disability rating of 20 percent for instability and subluxation of the left knee have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257. 3. During the entire pendency of this appeal, the criteria for a disability rating of 10 percent, and no higher, for patellofemoral pain syndrome of the right knee with right meniscus tear have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.71a, DC 5260. 4. Since the grant of service connection, the criteria for a separate initial disability rating of 20 percent, and no higher, for instability and subluxation of the right knee have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1976 to September 1976 and January 1991 to March 1991. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from July 2013 and September 2014 rating decisions of the VA Regional Office (RO) in Louisville, Kentucky. Specifically, the July 2013 rating decision granted an increased rating for the Veteran’s patellofemoral syndrome of the right knee from noncompensable to 10 percent disabling effective July 27, 2012 and continued a noncompensable disability rating for patellofemoral syndrome of the left knee. The September 2014 rating decision granted service connection for instability and subluxation of the right knee, assigning a separate 20 percent disability rating effective February 21, 2014, and increased the Veteran’s disability rating for the left knee from noncompensable to 10 percent disabling effective February 21, 2014, recharacterizing the left knee disability as painfully limited flexion of the left knee associated with patellofemoral pain syndrome off the left knee. Subsequently, by rating decision dated in April 2018, the RO granted a temporary total disability rating for the right knee effective June 17, 2011 and assigned a 10 percent disability rating effective September 1, 2011 (effectively awarding an earlier effective date for the assignment of a 10 percent disability rating). The RO also, in effect, granted an earlier effective for the assignment of a 10 percent disability rating for the left knee by assigning a 10 percent disability rating for the left knee disability effective April 14, 2011 but also assigned a noncompensable disability rating for the left knee effective January 29, 2013 and a 10 percent disability rating effective February 21, 2014. Finally, the RO granted an effective date of August 2, 2011 for the assignment of a 20 percent disability rating for instability of the right knee but proposed to reduce the Veteran’s disability rating for right knee instability from 20 percent to noncompensably disabling. More recently, by rating decision dated in July 2019, the RO effectuated the reduction of the Veteran’s disability rating for right knee instability from 20 percent to noncompensably disabling effective October 1, 2019. Although additional evidence has been received since the April 2018 statement of the case and has not been reviewed by the Agency of Original Jurisdiction (AOJ), a waiver of AOJ review, received in March 2020, is of record. See 38 C.F.R. § 20.1304. Increased Rating Disability ratings are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability, and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and non- weight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). By way of history, the Veteran’s service treatment records show that he was treated for bilateral knee pain during his military service which began prior to the Veteran’s second period of service. By rating decision dated in January 2010, the RO granted service connection for patellofemoral pain syndrome of the bilateral knees, assigning noncompensable disability ratings for each knee effective April 15, 2005. The Veteran disagreed with this decision and was issued a statement of the case (SOC) in December 2010 but failed to perfect an appeal of this decision. He submitted a claim for an increased rating for his bilateral knee disabilities in July 2012. As above, the July 2013 rating decision on appeal granted an increased rating for the Veteran’s patellofemoral syndrome of the right knee from noncompensable to 10 percent disabling effective July 27, 2012 and continued a noncompensable disability rating for patellofemoral syndrome of the left knee. The September 2014 rating decision, which is also on appeal, granted service connection for instability and subluxation of the right knee, assigning a separate 20 percent disability rating effective February 21, 2014, and increased the Veteran’s disability rating for the left knee from noncompensable to 10 percent disabling effective February 21, 2014, recharacterizing the left knee disability as painfully limited flexion of the left knee associated with patellofemoral pain syndrome off the left knee. The Veteran’s bilateral knee disabilities are rated pursuant to DCs 5003-5260 (pertaining to degenerative arthritis and limitation of flexion) and DC 5261 (pertaining to limitation of extension). The separate rating for laxity was established pursuant to DC 5257. Each of these DCs are established by law and found in 38 C.F.R. § 4.71a. Such separate ratings are available with these codes, because knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. While the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, and lateral instability and recurrent subluxation of the knee. DC 5260 rates based on limitation of flexion. When flexion of the leg is limited to 60 degrees, a noncompensable rating is warranted. When flexion is limited to 45 degrees, a 10 percent rating is warranted. Flexion limited to 30 degrees warrants a 20 percent rating, while flexion limited to 15 degrees warrants the maximum 30 percent rating. DC 5261 rates based on limitation of extension. That code provides that when extension is limited to 5 degrees, a noncompensable rating is assigned. Extension limited to 10 degrees warrants a 10 percent rating. When limitation of extension is at 15 degrees, a 20 percent rating is warranted. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Lastly, extension limited to 45 degrees warrants the maximum, 50 percent rating. The diagnostic criteria applicable to recurrent subluxation or lateral instability is found at 38 C.F.R. § 4.71a, DC 5257. Under that code, slight impairment is assigned a 10 percent rating, moderate impairment a 20 percent rating, and severe impairment a 30 percent rating. The terms “mild,” “moderate,” and “severe” are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “mild” or “moderate” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding a higher rating. 38 C.F.R. §§ 4.2, 4.6. Evidence relevant to the current level of severity of the Veteran’s bilateral knee disabilities includes VA examination reports dated in January 2013, February 2014, August 2014, August 2017, and September 2019. Specifically, during the January 2013 VA examination, the examiner noted diagnoses of patellofemoral pain syndrome of the knees. The Veteran reported that both of his knees give out on him and that he experiences constant pain in both of his knees. He stated that he was unable to walk because his knees “come out of the sockets” and that he wore braces on both knees. He reported that he was unable to walk and had been in a wheelchair for the last 8 years. He reported several surgeries on his right knee and multiple cortisone shots in both knees. He denied experiencing flare-ups that impact the function of the knees. On range of motion testing for the right knee he had flexion to 110 degrees and extension to 0 degrees with no objective evidence of painful motion. On range of motion testing for the left knee he had flexion to 130 degrees and extension to 0 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. With regard to functional loss, the examiner noted that the right knee disability resulted in less movement than normal and pain on movement. There was no functional loss of the left knee. There was tenderness or pain to palpation for joint line or soft tissue of either knee. Muscle strength and joint stability testing were normal. There was no evidence or history of recurrent patellar subluxation/dislocation. There was history of meniscal tear of the right knee for which the Veteran underwent meniscectomy in June 2011. There were no residual signs and/or symptoms due to a meniscectomy. There had been no other knee surgeries and while there was evidence of a right knee scar, the scar was not painful and/or unstable and was not greater than 39 square centimeters. There were no other pertinent physical findings. As for assistive devices, it was noted that the Veteran constantly used braces and a wheelchair. There was no functional impairment of the knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing showed degenerative or traumatic arthritis of the right knee. There was no X-ray evidence of patellar subluxation and no other significant diagnostic test findings and/or results. With regard to functional impact, the examiner noted that the Veteran’s bilateral knee disorders impacted his ability to work as he was unable to stand or walk due to his bilateral knee disabilities. During the February 2014 VA knee examination, the examiner continued a diagnosis of bilateral patellofemoral pain syndrome and also noted diagnoses of patellar subluxation and lateral meniscus tear of the right knee. He denied experiencing flare-ups that impact the function of the knees. On range of motion testing for the right knee he had flexion to 130 degrees and extension to 0 degrees with no objective evidence of painful motion. On range of motion testing for the left knee he had flexion to 130 degrees and extension to 0 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. With regard to functional loss, the examiner noted that there was pain on movement as well as interference with sitting, standing, and weight-bearing, bilaterally. There was tenderness or pain to palpation for joint line or soft tissue of the right knee. Muscle strength and joint stability testing were normal. There was no evidence or history of recurrent patellar subluxation/dislocation on the left knee but there was moderate subluxation on the right knee. There was history of meniscal tear of the right knee but there were no residual signs and/or symptoms due to a meniscectomy. There had been no other knee surgeries. As for assistive devices, it was noted that the Veteran occasionally used a wheelchair but regularly used braces and a walker. There was no functional impairment of the knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing was negative for patellar subluxation and there were no other significant diagnostic test findings and/or results. With regard to functional impact, the examiner noted that the Veteran’s bilateral knee disorders impacted his ability to work as he would not be able to do heavy labor with walking, climbing, lifting, or bending. With regard to Mitchell, the examiner noted that the Veteran had additional limitation when the joint was used repeatedly over a period of time which was manifested primarily by pain and difficulty continuing joint movement. This additional loss of motion could not be ascertained since the primary disability was related to pain and loss of repetitive use rather than loss of motion. During the August 2014 VA knee examination, the examiner continued a diagnosis of bilateral patellofemoral pain syndrome and also noted diagnoses of status post right knee lateral meniscectomy with lateral retinacular release and right knee mild medial instability. He reported experiencing constant pain as well as flare-ups that impact the function of the knees. Specifically, the Veteran reported that pain and fatigability could significantly limit function during flares. The Veteran also stated that there was additional reduction in motion with flares. Neither the Veteran not the examiner could quantify this reduction without resorting to speculation. This was due to the fact that there were no range of motion readings documented when the Veteran is flared along with range of motion readings when the Veteran was not flared to compare and determine the difference On range of motion testing for the right knee he had flexion to 90 degrees (pain beginning at 75 degrees) and extension to 0 degrees with no objective evidence of painful motion. On range of motion testing for the left knee he had flexion to 90 degrees (pain beginning at 75 degrees) and extension to 0 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. With regard to functional loss, the examiner noted that there was less movement than normal, weakened movement, excess fatigability, incoordination and impaired ability to execute skilled movements smoothly, pain on movement, as well instability of station, bilaterally. There was tenderness or pain to palpation for joint line or soft tissue. Muscle strength was normal. Joint stability testing was also normal with the exception of medial-lateral instability of the right knee. There was no evidence or history of recurrent patellar subluxation/dislocation on the left knee but there was moderate subluxation on the right knee. There was history of meniscal tear of the right knee but there were no residual signs and/or symptoms due to a meniscectomy. There had been no other knee surgeries. The Veteran did not use any assistive devices to aid in ambulation. There was no functional impairment of the knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing was negative for patellar subluxation and there were no other significant diagnostic test findings and/or results. With regard to functional impact, the examiner noted that the Veteran’s bilateral knee disorders impacted his ability to work in sustained moderate physical occupations or greater such as digging, climbing, sustained walking, and/or crawling/squatting but that they would not preclude sedentary occupations. During the August 2017 VA examination, the Veteran reported experiencing flare-ups of the knees which was described as increased pain and stiffness. He denied having any functional loss or functional impairment of the knees. On range of motion testing for the right knee he had flexion to 90 degrees and extension to 0 degrees. On range of motion testing for the left knee he had flexion to 90 degrees and extension to 0 degrees. There was evidence of crepitus but no evidence of pain with weight bearing or localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive-use testing with at least three repetitions and no additional loss of motion. While the Veteran’s range of motion of the knees was not examined immediately after repetitive use over time, the examiner did find that neither pain, weakness, fatigability, nor incoordination significantly limited functional ability with repeated use over a period of time. However, it was also noted that the Veteran was experiencing a flare-up at the time of the examination but that neither pain, weakness, fatigability, nor incoordination significantly limited functional ability with repeated use over a period of time. Muscle strength was nearly normal, bilaterally, described as active movement against some resistance, but there was no muscle atrophy. Joint stability testing was normal. There was a history of meniscal tear of the right knee but there were no residual signs and/or symptoms due to a meniscectomy. There had been no other knee surgeries. The Veteran did not use any assistive devices to aid in ambulation. There was no functional impairment of the knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing revealed arthritis. With regard to functional impact, the examiner noted that the Veteran’s bilateral knee disorders impacted his ability to perform any type of occupational task, specifically, the Veteran had difficulty with prolonged standing, sitting, walking, stooping, and bending due to increased pain in the bilateral knees. With regard to Correia, the examiner wrote that there was no gross evidence of pain on passive range of motion testing. There was also no evidence of pain when the joint was used in non-weight bearing and no gross evidence of opposing joint damage or abnormalities. In a February 2018 VA knee examination addendum, the examiner noted review of the August 2014 VA examination report and found that there was no instability of the left knee. While functional loss noted as instability of the left knee was based upon the Veteran’s report that he had instability of the left knee at times with weight bearing, the instability testing was done nonweight bearing and did not note any instability at the time of the examination. During the September 2019 VA knee examination, the examiner continued diagnoses of bilateral patellofemoral pain syndrome, right meniscus tear, and right knee instability. The examiner also noted a diagnosis of right knee osteoarthritis. The Veteran reported experiencing flare-ups of the knees, described as shooting pains with swelling that prevents the Veteran from moving. The Veteran also reported experiencing functional loss or impairment of the knees, described as difficulty with walking, standing, kneeling, climbing, and picking up items. On range of motion testing for the right knee he had flexion to 90 degrees and extension to 0 degrees. On range of motion testing for the left knee he had flexion to 90 degrees and extension to 0 degrees. There was no objective evidence of localized tenderness or pain on palpation of the right knee but there was evidence of pain with weight bearing as well as objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, but there was additional loss of motion, specifically, the Veteran only had flexion to 80 degrees, bilaterally due to pain and weakness. The Veteran was not examined immediately after repetitive use over time and/or during a flare-up but was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and/or during a flare-up. Significantly, it was noted that the Veteran only had flexion to 70 degrees, bilaterally due to pain and weakness with repetitive use over time and/or during a flare-up. There were no additional contributing factors to the Veteran’s knee disabilities. Muscle strength testing was almost normal, described as “active movement against gravity,” and there was no muscle atrophy. There was no ankylosis. Joint stability testing revealed moderate recurrent subluxation, lateral instability, and recurrent effusion of the knees. There was no evidence of recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fracture, chronic exertional compartment syndrome, or any other tibial or fibular impairment. With regard to meniscal conditions, it was noted that the Veteran had a meniscal tear with frequent episodes of joint “locking,” joint pain, and joint effusion on the right side. It was noted that the Veteran underwent arthroscopic right meniscectomy in 2011 which resulted in a scar of the right knee measuring one centimeter x 0.2 centimeters. The Veteran regularly used a wheelchair and crutches and constantly use a brace. There was no functional impairment of the knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing revealed arthritis. With regard to functional impact, the examiner noted that the Veteran’s bilateral knee disorders impacted his ability to perform any type of occupational task, specifically, the Veteran had difficulty with walking, standing, kneeling, climbing, and picking up items. With regard to Correia, the examiner wrote that there was objective evidence of pain when the knees were used in non-weight bearing and passive range of motion testing revealed flexion to 90 degrees, bilaterally. Also of record is an October 2019 disability benefits questionnaire regarding the Veteran’s knees. This report shows diagnoses of bilateral degenerative arthritis, painfully limited flexion of the left knee, and right meniscus tear with arthroscopy. At that time, the Veteran reported a history of severe flare-ups which occur twice per day (each knee) and last for 15 minutes each during which he is unable to do anything and must “pop his legs up.” On range of motion testing, the Veteran had flexion to 100 degrees, bilaterally, with pain on both flexion and extension. There was evidence of pain with weight bearing but no evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions and there was no additional loss of motion. The Veteran was not examined immediately after repetitive use over time and/or during a flare-up but the examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time and/or during a flare-up. Significantly, it was noted that neither pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time and/or during a flare-up. There were no additional factors contributing to a knee disability. Muscle strength testing was normal and there was no muscle atrophy. There was no ankylosis. Joint stability testing revealed moderate recurrent subluxation or the right knee and slight recurrent subluxation of the left knee. There was no lateral instability or recurrent effusion of the knees. There was no evidence of recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fracture, chronic exertional compartment syndrome, or any other tibial or fibular impairment. With regard to meniscal conditions, it was noted that the Veteran previously had a meniscal tear of the right knee and underwent arthroscopic right meniscectomy in 2011 which resulted in a scar of the right knee measuring one centimeter x 0.2 centimeters. The Veteran occasionally used a cane/walker, regularly used a wheelchair and crutches, and constantly use a brace. There was no functional impairment of the knees such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Diagnostic testing revealed arthritis. With regard to functional impact, the examiner noted that the Veteran’s bilateral knee disorders impacted his ability to perform any type of occupational task, specifically, the Veteran had been disabled since 2001 and was unable to run, stand, and/or walk for long periods of time. With regard to Correia, the examiner wrote that there was objective evidence of pain when the knees were used in non-weight bearing and passive range of motion testing. Also of record are VA treatment records dated through April 2018 which show findings similar to those noted in the VA examination reports discussed above. 1. A disability rating of 10 percent, and no higher, for painfully limited flexion of the left knee associated with patellofemoral pain syndrome of the left knee is granted for the entire pendency of the appeal. Upon review of the medical evidence, the Board finds that a disability rating of 10 percent, and no higher, for painfully limited flexion of the left knee associated with patellofemoral pain syndrome of the left knee is granted for the entire pendency of the appeal. By way of history, the September 2014 rating decision increased the Veteran’s disability rating for the left knee from noncompensable to 10 percent disabling based on the February 2014 VA examination report which showed functional loss due to painful motion of the left knee. Significantly, it was noted that the previous VA examination in January 2013 did not show painful motion of the left knee and, as such, February 21, 2014 was the earliest date available for a 10 percent rating based on painful motion of the left knee. The April 2018 rating decision noted that there was evidence of left knee pain with patellar compression as early as an April 14, 2011 VA treatment record and, thus, granted an earlier effective date for the 10 percent rating for the left knee effective that date. However, the April 2018 rating decision also noted that the January 2013 VA examination showed no painful motion so assigned a noncompensable disability rating for the left knee from January 29, 2013 (the date of the VA examination showing no painful motion) to February 21, 2014 (the date of the VA examination showing painful left knee motion). While the January 2013 VA examination report did not specifically show painful motion of the left knee, the Veteran has arguably experienced painful motion of the left knee during the entire appeal period beginning July 2012. Significantly, as early as the Veteran’s July 2012 claim for an increased rating, he has described experiencing knee pain. As such, in affording the Veteran the benefit of the doubt, a 10 percent disability rating for painfully limited flexion of the left knee associated with patellofemoral pain syndrome of the left knee is granted for the entire pendency of the appeal. 38 C.F.R. § 4.59. The evidence does not support the assignment of a rating in excess of 10 percent for the left knee. Notably, the reported loss of flexion has been noncompensable while no loss of extension has been reported. In this regard, the Veteran had flexion to 130 degrees during the January 2013 VA examination; flexion to 130 degrees during the February 2014 VA examination; flexion to 90 degrees during the August 2014 VA examination; flexion to 90 degrees during the August 2017 VA examination; and flexion to 90 degrees (70 degrees during flare-ups) during the September 2019 VA examination. As noted above, a loss of flexion to 90 degrees or more does not constitute compensable limitation of motion under DC 5260. Even so, the Veteran has been assigned a 10 percent rating under such diagnostic code in light of his painful, noncompensable limited motion. See DC 5003, 38 C.F.R. § 4.59; Burton, supra. Also, the Veteran’s reported extension of 0 degrees in each of the above VA examination reports does not constitute compensable limitation of motion under DC 5261. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran’s left knee disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran’s symptoms are supported by pathology consistent with the assigned 10 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain in his left knee with limited motion and an examiner opined that there was significant functional impairment; the examiner was unable to describe additional limitation of motion during flare-ups and the Veteran has also not described additional limitation of motion during flare-ups. With regard to a higher rating under another diagnostic code, as there was no evidence of ankylosis (i.e., where the joint fixed in place), impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5262, and 5263 are not for application. As for the potential of a separate compensable rating for instability of the left knee pursuant to DC 5257, the Board notes that there is no evidence of left knee instability in the January 2013, February 2014, August 2014, and August 2017 VA examination reports. However, the September 2019 VA examination report shows instability of both knees. As such, the Board finds that a separate 10 percent disability rating for left knee instability and subluxation is warranted effective September 11, 2019 pursuant to DC 5257. 2. A disability rating greater than 10 percent for patellofemoral pain syndrome of the right knee with right meniscus tear is denied. Upon review of the medical evidence, the Board finds that the evidence does not support the assignment of a rating in excess of 10 percent for patellofemoral pain syndrome of the right knee with right meniscus tear. Notably, the reported loss of flexion has been noncompensable while no loss of extension has been reported. In this regard, the Veteran had flexion to 110 degrees during the January 2013 VA examination; flexion to 130 degrees during the February 2014 VA examination; flexion to 90 degrees during the August 2014 VA examination; flexion to 90 degrees during the August 2017 VA examination; and flexion to 90 degrees (70 degrees during flare-ups) during the September 2019 VA examination. As noted above, a loss of flexion to 90 degrees or more does not constitute compensable limitation of motion under DC 5260. Even so, the Veteran has been assigned a 10 percent rating under such diagnostic code in light of his painful, noncompensable limited motion. See DC 5003, 38 C.F.R. § 4.59; Burton, supra. Also, the Veteran’s reported extension of 0 degrees in each of the above VA examination reports does not constitute compensable limitation of motion under DC 5261. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, an increased evaluation for the Veteran’s right knee disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran’s symptoms are supported by pathology consistent with the assigned 10 percent rating, and no higher. In this regard, the Board observes that the Veteran has complained of pain in his right knee with limited motion and an examiner opined that there was significant functional impairment; the examiner was unable to describe additional limitation of motion during flare-ups and the Veteran has also not described additional limitation of motion during flare-ups. With regard to a higher rating under another diagnostic code, as there was no evidence of ankylosis (i.e., where the joint fixed in place), impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5262, and 5263 are not for application. 3. An initial disability rating of 20 percent, and no higher, for instability and subluxation of the right knee is granted for the entire pendency of the appeal. Upon review of the medical evidence, the Board finds that an initial disability rating of 20 percent, and no higher, for instability and subluxation of the right knee is granted for the entire pendency of the appeal. By way of history, the September 2014 rating decision granted service connection for instability and subluxation of the right knee based on the February 2014 VA examination report which showed moderate instability of the right knee, assigning a 20 percent disability rating effective February 21, 2014. However, the subsequent VA examination in August 2017 was negative for instability of the right knee. As such, in an April 2018 rating decision, the RO granted an earlier effective date for the 20 percent rating for instability of the right knee to August 2, 2011, the date of a VA treatment record showing right patellar subluxation, and proposed to reduce the Veteran’s disability rating for right knee instability from 20 percent to noncompensable. This reduction was effectuated in a July 2019 rating decision, effective October 1, 2019. However, the September 2019 VA examination report, again, shows moderate instability of the right knee. As such, an initial disability rating of 20 percent, and no higher, for instability and subluxation of the right knee is granted for the entire pendency of the appeal. REASONS FOR REMAND 4. The claims of entitlement to an effective date than April 14, 2011 for the assignment of a compensable disability rating for painfully limited flexion of the left knee associated with patellofemoral pain syndrome (previously characterized as patellofemoral pain syndrome of the left knee) and entitlement to an effective date than August 2, 2011 for the assignment of a compensable disability rating for instability and subluxation, right knee (previously characterized as patellofemoral pain syndrome of the right knee) are remanded. By way of history, in a January 2010 rating decision, the RO granted service connection for patellofemoral pain syndrome of the bilateral knees, assigning noncompensable disability ratings for each knee effective April 15, 2005. The Veteran disagreed with this decision and was issued an SOC in December 2010 but failed to perfect an appeal of this decision. He submitted a claim for an increased rating for his bilateral knee disabilities in July 2012. As above, the July 2013 rating decision on appeal granted an increased rating for the Veteran’s patellofemoral syndrome of the right knee from noncompensable to 10 percent disabling effective July 27, 2012 and continued a noncompensable disability rating for patellofemoral syndrome of the left knee. The September 2014 rating decision, which is also on appeal, granted service connection for instability and subluxation of the right knee, assigning a separate 20 percent disability rating effective February 21, 2014, and increased the Veteran’s disability rating for the left knee from noncompensable to 10 percent disabling effective February 21, 2014, recharacterizing the left knee disability as painfully limited flexion of the left knee associated with patellofemoral pain syndrome off the left knee. In October 2016, the Veteran entered a notice of disagreement (NOD) with the agency of original jurisdiction (AOJ) with regard to both the disability ratings and effective date assigned for the increased ratings of these disabilities. Subsequently, by rating decision dated in April 2018, the RO granted earlier effective dates for the assignment of increased disability ratings for the Veteran’s bilateral knee disabilities. Specifically, the RO granted an effective date of August 2, 2011 for the assignment of a 20 percent disability rating for instability of the right knee. The RO also, in effect, granted an earlier effective for the assignment of a 10 percent disability rating for the left knee by assigning a 10 percent disability rating for the left knee disability effective April 14, 2011. In response to the April 2018 rating decision, the Veteran submitted another NOD, specifically requesting that he be assigned an effective date earlier than August 2, 2011 for the assignment of a 20 percent disability rating for instability of the right knee. When there has been an initial AOJ adjudication of a claim and a notice of disagreement as to its denial, the claimant is entitled to an SOC. See 38 C.F.R. § 19.26. While the Veteran was issued an SOC regarding the appeal for higher disability ratings for these disabilities, he was never issued an SOC with regard to an earlier effective date for the assignment of disability ratings for these disabilities. Thus, remand for issuance of an SOC on these issues is necessary. Manlincon v. West, 12 Vet. App. 238 (1999). However, these issues will be returned to the Board only if the Veteran perfects an appeal after receiving the SOC. The matters are REMANDED for the following action: Issue an SOC regarding the effective dates assigned for the 20 percent rating for instability and subluxation of the right knee and 10 percent rating for painfully limited flexion of the left knee associated with patellofemoral pain syndrome. He should be advised of the time period in which to perfect his appeal. Only if the Veteran’s appeal as to these issues are perfected within the applicable time period, then such should return to the Board for appellate review Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board April Maddox, 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.