Citation Nr: 20056719 Decision Date: 08/27/20 Archive Date: 08/27/20 DOCKET NO. 15-13 383 DATE: August 27, 2020 ORDER Entitlement to an initial rating greater than 30 percent for anxiety disorder is denied. Entitlement to an initial rating greater than 10 percent for right elbow degenerative joint disease is denied. Entitlement to an initial rating higher than 10 percent right knee patellofemoral syndrome is denied. Entitlement to a separate 10 percent disability rating, but no higher, for right knee instability, is granted. Entitlement to an initial rating higher than 10 percent left knee patellofemoral syndrome is denied. FINDINGS OF FACT 1. The preponderance of the evidence shows the Veteran’s anxiety disorder did not manifest in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationship. 2. The preponderance of the evidence shows Veteran right elbow disability did not manifest as limitation of flexion to 90 degrees or extension to 75 degrees. 3. The preponderance of the evidence shows that the Veteran’s right knee disability did not manifest as limitation of flexion to 30 degrees or extension to 15 degrees. 4. The preponderance of the evidence indicates that the Veteran’s right knee symptoms most nearly approximated slight instability. 5. The preponderance of the evidence shows that the Veteran’s left knee disability did not manifest as limitation of flexion to 30 degrees or extension to 15 degrees. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 30 percent for anxiety disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.159, 3.321, 4.130, Diagnostic Code (DC) 9413. 2. The criteria for an initial rating greater than 10 percent for right elbow degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.45, 4.59, 4.71a, DCs 5206, 5207. 3. The criteria for an initial rating higher than 10 percent right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.45, 4.59, 4.71a, DC 5260. 4. The criteria for a separate rating of 10 percent, but no greater, for right knee instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.27, 4.71a, DC 5257. 5. The criteria for an initial rating higher than 10 percent left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.45, 4.59, 4.71a, DC 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1996 to June 2013. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded these issues in July 2018 to issue a statement of the case addressing the Veteran’s claim for an increased rating for his thoracolumbar strain and to provide the Veteran with new VA examinations. The Board finds substantial compliance with the July 2018 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). These matters are properly before the Board for adjudication. Increased Rating Generally Disability evaluations (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 the 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. 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 (1991). The medical and 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. 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. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. 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. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § § 4.40. With respect to joints, in particular, the factors of disability 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; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § § 4.59 requires that “[t]he 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.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Normal range of motion of the elbow is from 0 degrees on extension to 145 degrees flexion with pronation to 80 degrees and supination to 85 degrees. 38 C.F.R. § 4.71a, Plate I. The regulations applicable to rating musculoskeletal disabilities require that VA must also consider the extent that a veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. These regulations also provide that it is the intent of the Rating Schedule to recognize painful motion with joint or periarticular pathology as productive of disability and to warrant at least the minimum compensable rating for the joint as shown by adequate pathology and evidenced by the visible behavior in undertaking motion. 1. Entitlement to an initial rating greater than 30 percent for anxiety disorder The Veteran contends his anxiety disorder should be assigned an initial rating greater than 30 percent. His service-connected anxiety disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9413. Evaluations for various psychiatric disabilities are assigned pursuant to 38 C.F.R. § 4.130 under the General Rating Formula for Mental Disorders. Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behaviour, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events), is assigned a 30 percent rating. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationship. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The evaluation of a psychiatric disability turns on the “severity, frequency, and duration” of a veteran’s symptoms and the resulting degree of social and occupational impairment. See Bankhead, 29 Vet. App. at 18 (discussing Vazquez-Claudio v. Shinseki, 713 Vet. App. 112, 116-17 (Fed. Cir. 2013)). The Board has carefully reviewed the evidence of record and finds that the Veteran is not entitled a rating greater than 30 percent for his service-connected anxiety disorder. The Veteran underwent psychological VA examinations in March 2013 and October 2018. The March 2013 VA examiner reviewed the Veteran’s claims file, medical records, lay statements, and conducted an in-person examination. The examiner stated that the Veteran was neatly groomed and dressed. He was pleasant, cooperative, polite, and he behaved normally. The Veteran’s speech was spontaneous and logical. There was no evidence of impaired impulse control, flight of ideas, loose associations, hallucinations, delusions, paranoia, homicidal ideation, suicidal ideation, depression, panic attacks, or irritability. The Veteran reported experiencing anxiety and sleep disturbances. The Veteran’s memory, concentration, judgment, and insight were normal. The examiner stated the Veteran’s prognosis was good and he was very functional. The examiner noted the Veteran’s disability manifested in anxiety and chronic sleep impairment. The Veteran stated that he drives himself crazy with anxiety and “what-ifs.” The Veteran believed that he would feel better once he decided where to attend graduate school. The examiner believed that the Veteran’s disability caused occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by medication. During the October 2018 VA examination, the Veteran reported he and his wife married in August 2015 and their relationship was extremely positive. Socially, the Veteran reported having active duty service-member friends whom he corresponds with and local friends whom he visits or talks with once a month. The Veteran talks to his parents weekly and occasionally with his brother. He enjoys family time, playgrounds, museums, and visiting extended relatives. The Veteran is employed and works for USAID. The examiner noted that the Veteran suffered from anxiety and sleep impairment. Specifically, the Veteran’s squadron was involved in a plane crash where several people died. He was speaking with the pilot who survived; however, he believed his career was effectively over. The Veteran stated he has occasional nightmares of the crash, every three to four months. He denied significant emotional distress and is able to discuss the event and fly without anxiety. The Veteran reported he avoids large groups of people and feels restless in crowds. He denied physical symptoms of anxiety, worrying thoughts, panic attacks, suicidal ideation, homicidal thoughts, and feelings of helplessness or hopelessness. The Veteran stated he felt nervous during business school and described his mood as generally positive. He was not under the care of a counselor nor prescribed medication for his service-connected disability. The October 2018 examiner opined that the Veteran’s disability caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by medication. The Board finds that a higher evaluation of 50 percent is not warranted at any time during appeal period because the Veteran’s psychiatric disorder did not manifest as occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationship. The record indicates that the Veteran’s speech was normal; he denied panic attacks; his memory was intact; he was capable of establishing and maintaining effective work and social relationships, particularly with service-members, parent’s, his brother, and spouse; and, there was no evidence of difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, or disturbances of motivation and mood. To the contrary, the March 2013 examiner noted the Veteran was of above-average intelligence and the claims file contains evidence the Veteran was accepted and enrolled in an Ivy League graduate program. Such evidence belies the notion of occupational and social impairment with reduced reliability and productivity. Private treatment records further support the Veteran’s disability warrants a rating no greater than 30 percent. Specifically, the Veteran underwent a mental status examination as part of an annual wellness visit in December 2019. There, the treating physician observed the Veteran was alert and oriented. He exhibited appropriate affect and mood. The Veteran denied suicidal and homicidal ideation, intent, or plan. He exhibited good judgment and ordered thought process. The Veteran’s speech, comprehension, and memory were intact. Consideration has been given to the Veteran’s belief that a higher rating should be assigned. The Veteran is competent to report his current psychiatric symptoms as these observations come to them through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Board finds that the medical examiners have considered Veteran’s subjective statements with regards to the severity of his psychiatric disability and provided findings which directly address the criteria under which the disability is evaluated. As such, the medical evidence is considered the most probative evidence of record. Accordingly, the Board finds that the preponderance of the evidence is against assigning an initial rating greater than 30 percent for his service-connected anxiety disorder. In reaching this determination, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, because the preponderance of the evidence is against the claim, this doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to an initial rating greater than 10 percent for right elbow degenerative joint disease The Veteran’s right elbow degenerative joint disease is assigned an initial 10 percent disability rating pursuant under 38 C.F.R. § 4.71a, DC 5206. Limitation of motion of the elbow joint is primarily rated under Diagnostic Codes 5206 (limitation of flexion of the forearm) and 5207 (limitation of extension of the forearm). These diagnostic codes contain different ratings depending on whether the affected extremity is major or minor. The Veteran is right-handed and the criteria applicable to the major extremity are therefore for application. Under DC 5206, limitation of flexion of the major forearm to 100 degrees warrants a 10 percent rating; limitation of flexion to 90 degrees warrants a 20 percent rating; limitation of flexion to 70 degrees warrants a 30 percent rating; limitation of flexion to 55 degrees warrants a 40 percent rating; and limitation of flexion to 45 degrees warrants a 50 percent rating. Under DC 5207, limitation of extension warrants a 10 percent rating; limitation of extension to 75 degrees warrants a 20 percent rating; limitation of extension to 90 degrees warrants a 30 percent rating; limitation of extension to 100 degrees warrants a 40 rating; and limitation of extension warrants a 50 percent rating. The Veteran underwent a VA examination in March 2013. He reported flare-ups which manifested as weakness, tenderness, swelling, reduced range of motion, painful joint, and pain from elbow to hand, including hand shaking. Range of motion (ROM) measurements showed normal flexion with evidence of pain at 140 degrees and right elbow ending at 15 degrees. There was no change in ROM during repetitive motion testing. The examiner noted right forearm supination ended at 85 degrees, with evidence of pain at 80 degrees; right forearm pronation ends at 80 degrees with evidence of painful motion at 75 degrees; and no change in right forearm post-test supination/pronation measurements. The examiner observed pain on palpation; however, there was no evidence of ankylosis, elbow joint replacement, or any other right elbow condition. The examiner opined that the right elbow ROM is limited by an additional 5 degrees during flare-ups or when it is used repeatedly over time. In October 2018 the Veteran underwent another VA examination. The Veteran reported flare-ups caused elbow pain and swelling with activities twice a month, lasting approximately one day. ROM tests showed flexion measured 15 to 140 degrees; extension 140 to 15 degrees; forearm supination 0 to 80 degrees; and pronation 0 to 75 degrees. Pain was noted upon flexion and extension which did not result in functional loss and pain upon palpation. There was no additional loss of function or ROM after three repetition. The examiner stated that the examination is neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use or during flare-ups. She reviewed the Veteran’s history, subjective complaints, relevant evidence of record, and stated there was no basis to offer additional losses of function or motion. The Veteran did not suffer from reduced muscle strength, muscle atrophy, ankylosis, or any other pertinent physical findings, complications, conditions, or symptoms. The examiner stated objective evidence of pain on passive motion and when the joint is used in non-weight bearing. Based on the foregoing, the Veteran is not entitled to an initial rating disability in excess of 10 percent. The record does not show that the Veteran had flexion limited to 90 degrees or that he had extension to 75 degrees. The Board has considered the March 2013 examiner’s opinion that the Veteran’s right elbow ROM is limited by an additional 5 degrees during flare-ups or when it is used repeatedly over time, however, the Veteran’s flexion and extension ROM measurements continue to exceed the necessary requirements for a 20 percent disability rating. The Board has also considered whether higher ratings for the Veteran’s right elbow disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concluded that such is not warranted. Pain on flexion and extension was noted on examination. However, limitation of flexion still measured well in excess of 90 degrees extension measures in excess of 75 degrees. The October 2018 examination noted that pain and pain on motion did not result in any additional function or loss of range of motion. The Court has also established that flare-ups must be considered. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Guidance on how to evaluate flare-ups has not been particularly clear. However, the Board finds overall wisdom in Mitchell. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because there is a regulation addressing stabilization of ratings, the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given the reports of flare-ups during the March 2013 and October 2018 VA examinations. The March 2013 VA examiner found that pain reduced range of motion by 5 degrees. The examiner did not specify whether this decrease applied to flexion or extension. Importantly, the 2018 VA examiner reviewed the Veteran’s medical records, including March 2013 VA examination report and found that the examination was neither was medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare-ups. A review of the Veteran’s records reveal that he complained of weakness, tenderness, swelling, reduced range of motion, painful joint, and pain from elbow to hand, including hand shaking. This evidence, however, does not demonstrate additional functional loss. As to the lay statements describing pain, the evidence does not demonstrate additional functional limitation more closely approximating the criteria for a higher rating. Such would not warrant a higher evaluation. The reported flare-ups are not shown to additionally limit function in a quantifiable way and are not of such length or duration that a staged rating would not violate the rule regarding stabilization of ratings. The contemporaneous treatment records contain little, if any, findings pertaining to flare-ups much less information regarding the Veteran’s functional ability during a flare-up or after repeated use over time. In sum, 38 C.F.R. § 4.1 provides that the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. The report of flare-ups in 2013 and 2018 is not quantifiable and not of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell, the spirit of 38 C.F.R. § 4.1 and the rule regarding stabilization of ratings. The Board has also considered the lay statements that the Veteran’s right elbow disability warrants a higher rating and acknowledges that the Veteran is competent to report symptoms of pain. Layno v. Brown, 6 Vet. App. 465 (1994). Lay witnesses are not, however, competent to identify a specific level of disability according to the applicable diagnostic code. Such competent evidence concerning the nature and extent of the Veteran’s service-connected right elbow disability has been provided by the VA medical professionals who examined him. The medical findings adequately address the criteria under which this disability is evaluated. The Board accords the objective medical findings greater weight than subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has considered the applicability of other rating criteria for evaluating the musculoskeletal disabilities of the right elbow under 38 C.F.R. § 4.71a; however, the Veteran at no point has been shown to have ankylosis, or impairment of the flail joint, ulna, or radius. Moreover, there was no limitation of pronation and supination found during the VA examinations. Thus, entitlement initial or separate ratings based on application of other diagnostic codes under 38 C.F.R. § 4.71a is not warranted. As the preponderance of the evidence is against a higher initial rating, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b). 3. Entitlement to an initial rating higher than 10 percent for bilateral knee patellofemoral syndrome and entitlement to separate ratings for right knee instability and meniscal condition. The Veteran’s right and left knee patellofemoral syndrome are assigned an initial 10 percent disability rating pursuant to 38 C.F.R. § 4.71a, DC 5260. DC 5260, limitation of flexion of a leg, provides a 10 percent rating if flexion is limited to 45 degrees, and a 20 percent rating if flexion is limited to 30 degrees. A maximum 30 percent rating is warranted for knee flexion that is limited to 15 degrees. 38 C.F.R. § 4.71a; DC 5260. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71; Plate II. Separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. See VAOPGCPREC 9-2004. The Veteran underwent a VA examination in March 2013. The Veteran reported right knee flare-ups that impact his right shin causing numbness. He did not report symptoms of left knee flare-ups. Right knee ROM testing showed flexion measuring 140 degrees with objective evidence of painful motion at 115 degrees and extension measured 0 degrees with no objective evidence of painful motion. Right knee post-test ROM showed no change in ROM measurements. Left knee ROM testing showed flexion measuring 140 degrees with objective evidence of painful motion at 135 degrees and extension measured 0 degrees with no objective evidence of painful motion. Left knee post-test ROM showed no change in ROM measurements. The examiner found functional loss and impairment due to pain on movement for both knees. There was no evidence of pain on palpations, instability, patellar subluxation or dislocation, or meniscal conditions. The Veteran reported bilateral shin splints. The Veteran underwent a November 2019 VA examination. The Veteran reported swelling, numbness and instability in the right knee. He also reported daily left knee flare-ups consisting of pain and popping while walking, limited left leg motion, and inability to run. Right knee ROM flexion measured 0 to 135 degrees and extension measured 135 to 0 degrees. Left knee ROM flexion measured 0 to 135 degrees and extension measured 135 to 0 degrees. The examiner found pain during flexion and extension, bilaterally, but he opined that range of motion did not contribute to functional loss. There was no evidence of localized tenderness or pain on palpation of the knees. The Veteran performed repetitive-use testing with at least three repetitions without additional loss of function or range of motion for either knee. The examiner stated that the examination is neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use and during a flare-up. The examiner reviewed the Veteran’s history, subjective complaints, relevant evidence of record, and stated there was no basis to offer additional losses of function or motion measurements. There were no additional contributing factors to the Veteran’s bilateral knee disability, reduction in muscle strength, muscle atrophy, ankylosis, instability, recurrent patellar dislocation, or other pertinent physical findings. The examiner noted the Veteran right knee status post anterior cruciate ligament repair and suffered left medial tibial stress syndrome which did not affect range of motion. The examiner found the Veteran The examiner noted that bilateral knee patellofemoral syndrome and left leg shin splints caused difficulty walking for a long period of time. Furthermore, there was objective evidence of pain on passive motion testing and when the joint is used in non-weight bearing. Based on the foregoing, the Veteran is not entitled to an initial rating disability in excess of 10 percent for either the right or left knee disability. ROM testing has consistently shown flexion measurements exceeding 30 degrees. There is also no basis for the assignment of a separate compensable rating based on limitation of extension. Limitation of extension to 15 degree was not shown. To the contrary, even with consideration of pain, pain on motion, and functional loss, extension would only be limited to 135 degrees. The Board has also considered whether higher ratings for the Veteran’s knee disabilities are appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concluded that such is not warranted. Pain on flexion and extension was noted on examination. However, limitation of flexion still measured well in excess of 30 degrees and extension measures in excess of 15 degrees for both knees. See 38 C.F.R. § 4.71a; DC 5261. The Court has also established that flare-ups must be considered. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Guidance on how to evaluate flare-ups has not been particularly clear. However, the Board finds overall wisdom in Mitchell. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because there is a regulation addressing stabilization of ratings, the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given the reports of flare-ups during the March 2013 and November 2019 VA examinations. The March 2013 VA examiner found that pain reduced range of motion by 5 degrees. The examiner did not specify whether this decrease applied to flexion or extension. Importantly, the 2019 VA examiner reviewed the Veteran’s medical records, including March 2013 VA examination report and found that the examination was neither was medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare-ups. A review of the Veteran’s records reveal that he experienced pain after walking for a long time and left shin splints, pain of the left knee generally does not prevent the Veteran from using and moving his legs. This evidence, however, does not demonstrate additional functional loss. As to the lay statements describing pain, the evidence does not demonstrate additional functional limitation more closely approximating the criteria for a higher rating. Such would not warrant a higher evaluation. The reported flare-ups are not shown to additionally limit function in a quantifiable way and are not of such length or duration that a staged rating would not violate the rule regarding stabilization of ratings. The contemporaneous treatment records contain little, if any, findings pertaining to flare-ups much less information regarding the Veteran’s functional ability during a flare-up or after repeated use over time. In sum, 38 C.F.R. § 4.1 provides that the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. The report of flare-ups in 2013 and 2018 is not quantifiable and not of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell, the spirit of 38 C.F.R. § 4.1 and the rule regarding stabilization of ratings. The Board has also considered the lay statements that the Veteran’s bilateral knee disability warrants a higher rating and acknowledges that the Veteran is competent to report symptoms of pain. Layno v. Brown, 6 Vet. App. 465 (1994). Lay witnesses are not, however, competent to identify a specific level of disability according to the applicable diagnostic code. Such competent evidence concerning the nature and extent of the Veteran’s service-connected left knee disability has been provided by the VA medical professionals who examined him. The medical findings adequately address the criteria under which this disability is evaluated. The Board accords the objective medical findings greater weight than subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has considered the applicability of DCs 5257 and 5258. Regarding DC 5257, the Board finds that a separate 10 percent rating, but no greater, for right knee instability is warranted. Here, the Veteran submitted private treatment records from December 2019 indicating he suffered from chronic instability. Specifically, the physician noted 2+ instability to anterior drawer testing, indicating slight instability. The Board has considered the applicability of other rating criteria for evaluating the musculoskeletal disabilities of the left knee under 38 C.F.R. § 4.71a; however, there is no basis for assigning a higher or separate compensable rating under an alternate diagnostic code such as DCs 5256, 5258, 5259, 5262 or 5263. There is simply no evidence of ankylosis of the left knee, dislocated cartilage with frequent episodes of “locking”, pain with effusion in the joint, removal of symptomatic cartilage, impairment of the tibia or fibula, or genu recurvatum. Such was specified by the VA examiner. Accordingly, the Board finds that the claim of entitlement to an evaluation in excess of 10 percent for service-connected right and left knee patellofemoral syndrome must be denied. The Board also finds that the Veteran is entitled to a separate 10 percent rating, but no greater, for right knee instability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mohammad Mahmoudi, Associate 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.