Citation Nr: 21002033 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 13-34 578 DATE: January 12, 2021 ORDER A separate rating of 10 percent for right knee limitation of extension associated with right knee status post arthroscopy, medial meniscal tear (hereinafter, right knee limitation of extension) is granted, subject to the laws and regulations governing the payment of monetary benefits. A rating in excess of 10 percent for right knee limitation of flexion associated with right knee status post arthroscopy, medial meniscal tear (hereinafter, right knee limitation of flexion) is denied. An initial rating in excess of 10 percent prior to August 12, 2009, in excess of 20 percent from August 12, 2009, to September 15, 2014, and in excess of 30 percent thereafter for right knee instability associated with status post arthroscopy, right knee for medial meniscal tear (hereinafter, right knee instability) is denied. An initial rating in excess of 10 percent prior to January 16, 2018, and in excess of 20 percent thereafter for right knee focal neuropathy, external popliteal (common peroneal) nerve associated with status post arthroscopy, right knee for medial meniscal tear (hereinafter, right knee focal neuropathy of the common peroneal nerve) is denied. An initial rating in excess of 10 percent for right knee focal neuropathy, anterior crucial (femoral) nerve associated with status post arthroscopy, right knee for medial meniscal tear (hereinafter, right knee focal neuropathy of the femoral nerve) is denied. An initial compensable rating for ilio-inguinal nerve (right lower extremity) (hereinafter, right knee focal neuropathy of the ilio-inguinal nerve) is denied. An initial compensable disability rating for obturator nerve (right lower extremity) (hereinafter, right knee focal neuropathy of the obturator nerve) is denied. An extraschedular disability rating for the service-connected right knee status post arthroscopy, medial meniscal tear is denied. FINDINGS OF FACT 1. Throughout the pendency of the appeal, the Veteran’s right knee disability was manifested by subjective complaints of pain and giving way with extension limited to no less than 10 degrees and flexion limited to, at most, 80 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, impairment of the tibia and fibula, or genu recurvatum. 2. Prior to August 12, 2009, the Veteran’s right knee disability was manifested by no more than slight instability. 3. From August 12, 2009, to September 15, 2014, the Veteran’s right knee disability was manifested by no more than moderate instability. 4. As of September 15, 2014, the Veteran is in receipt of the maximum schedular rating for his right knee instability, and such disability does not result in symptomatology that is not contemplated by the currently assigned rating. 5. Prior to January 16, 2018, the Veteran’s right knee disability was manifested by no more than mild incomplete paralysis of the common peroneal nerve. 6. As of January 16, 2018, the Veteran’s right knee disability was manifested by no more than moderate incomplete paralysis of the common peroneal nerve. 7. Throughout the pendency of the appeal, the Veteran’s right knee disability was manifested by no more than mild incomplete paralysis of the femoral nerve. 8. Throughout the pendency of the appeal, the Veteran’s right knee disability was manifested by no more than moderate incomplete paralysis of the ilio-inguinal nerve. 9. Throughout the pendency of the appeal, the Veteran’s right knee disability was manifested by no more than moderate incomplete paralysis of the obturator nerve. 10. Throughout the pendency of the appeal, the Veteran’s right knee status post arthroscopy, medial meniscal tear was not characterized by an exceptional or unusual disability picture. CONCLUSIONS OF LAW 1. The criteria for a separate 10 percent rating for right knee limitation of extension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71A, Diagnostic Code 5261. 2. The criteria for a rating in excess of 10 percent for right knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71A, Diagnostic Code 5260. 3. Prior to August 12, 2009, the criteria for an initial rating in excess of 10 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71A, Diagnostic Code 5257. 4. From August 12, 2009, to September 15, 2014, the criteria for a rating in excess of 20 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71A, Diagnostic Code 5257. 5. As of September 15, 2014, the criteria for a rating in excess of 30 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71A, Diagnostic Code 5257. 6. Prior to January 16, 2018, the criteria for an initial rating in excess of 10 percent for right knee focal neuropathy of the common peroneal nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14. 4.124A, Diagnostic Code 8521. 7. As of January 16, 2018, the criteria for a rating in excess of 20 percent for right knee focal neuropathy of the common peroneal nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14. 4.124A, Diagnostic Code 8521. 8. The criteria for an initial rating in excess of 10 percent for right knee focal neuropathy of the femoral nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14. 4.124A, Diagnostic Code 8526. 9. The criteria for an initial compensable rating for right knee focal neuropathy of the ilio-inguinal nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14. 4.124A, Diagnostic Codes 8530, 8730. 10. The criteria for an initial compensable rating for right knee focal neuropathy of the obturator nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14. 4.124A, Diagnostic Codes 8528, 8728. 11. The criteria for consideration of an extraschedular disability rating for right knee status post arthroscopy, medial meniscal tear have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.321(b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1989 to December 1999 and November 2002 to March 2003. This case is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in June 2008 by a Department of Veterans Affairs (VA) Regional Office (RO), which denied a disability rating in excess of 10 percent for right knee status post arthroscopy, medial meniscal tear. In a May 2013 rating decision, the RO granted a separate 20 percent initial rating for right knee instability, effective August 12, 2009, and a separate 10 percent initial rating for right knee focal neuropathy of the common peroneal nerve, effective June 5, 2007. In September 2015, the Board denied a disability rating in excess of 10 percent for right knee status post arthroscopy, medial meniscal tear, a disability rating in excess of 20 percent for right knee instability prior to September 15, 2014, and a disability rating in excess of 10 percent for right knee focal neuropathy of the common peroneal nerve. The Board also granted an initial disability rating of 10 percent for the period prior to August 12, 2009, and a 30 percent disability rating for right knee instability as of September 15, 2014. Additionally, the Board remanded a claim for an extraschedular rating for right knee status post arthroscopy, medial meniscal tear. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2017 Court Order granting a Joint Motion for Partial Remand (JMPR) the Court vacated the Board’s September 2015 decision in part and remanded the case for further development in compliance with the directives specified in the JMPR. In November 2017, the Board remanded the case back to the RO for additional development of the record pursuant to the directives specified in the JMPR. In a February 2018 rating decision, the RO granted a separate 10 percent disability rating for right knee focal neuropathy of the femoral nerve, effective June 5, 2007, and increased the disability rating for right knee focal neuropathy of the common peroneal nerve to 20 percent, effective January 16, 2018. In June 2020, the Board again remanded the case for further development and adjudicative action. In September 2020, the RO granted service connection for right knee focal neuropathy of the ilio-inguinal nerve and right knee focal neuropathy of the obturator nerve and assigned initial noncompensable ratings for each, effective August 31, 2020. The case now returns for further appellate review, and the Board has characterized the issues in accordance with the above. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). When an appeal arises from the initially assigned disability rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms or differing levels of severity can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to a separate initial disability rating for right knee limitation of extension. 2. Entitlement to a rating in excess of 10 percent for right knee status post arthroscopy, medial meniscal tear. 3. Entitlement to an initial rating in excess of 10 percent prior to August 12, 2009, in excess of 20 percent from August 12, 2009, to September 15, 2014, and in excess of 30 percent thereafter for right knee instability. The Veteran seeks a disability rating in excess of 10 percent for his service-connected right knee limitation of flexion. Furthermore, the Veteran seeks increased disability ratings for his right knee instability, which is rated as follows: 10 percent disabling prior to August 12, 2009, 20 percent disabling between August 12, 2009, and September 15, 2014, and 30 percent disabling as of September 15, 2014. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). 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 actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion (ROM) testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with ROM measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran’s right knee status post arthroscopy, medial meniscal tear is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5259-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen.  The hyphenated codes for the Veteran’s right knee status post arthroscopy, medial meniscal tear reflect that cartilage, semilunar, removal of, symptomatic is the service-connected disability under Diagnostic Code 5259 and limitation of flexion is the basis of the rating assigned under Diagnostic Code 5260. Under Diagnostic Code 5260, (limitation of flexion), a 10 percent disability rating is warranted for flexion limited to 45 degrees. Limitation of flexion to 30 degrees warrants a 20 percent disability rating. A 30 percent disability rating is assigned for flexion limited to 15 degrees or less. In order for the Veteran to receive a 10 percent rating under Diagnostic Code 5261 (limitation of leg extension), the evidence must show that his knee disability is manifested by leg extension limited to 10 degrees. A 20 percent rating under Diagnostic Code 5261 is warranted if the evidence shows leg extension limited to 15 degrees. The Veteran is entitled to a 30 percent disability rating for leg extension limited to 20 degrees. A veteran who has both compensable limitation of flexion and compensable limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (September 17, 2004). Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of the knee.  Under this diagnostic code, slight recurrent subluxation or lateral instability warrants a 10 percent disability rating.  A 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability. Severe recurrent subluxation or lateral instability warrants a 30 percent disability rating.   The words “slight,” “moderate” and “severe” are not defined in the VA 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 “moderate” or “severe” 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 an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Court recently held that nothing in Diagnostic Code 5257 provides that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee.  English v. Wilkie, 30 Vet. App. 347, 349 (2018).  During the period on appeal, the Veteran first received a VA examination of his right knee in August 2007. The Veteran reported knee swelling, redness, occasional giving way, and occasional locking. The Veteran’s right knee flexion was limited to 130 degrees, with pain starting at 110 degrees, and extension was limited to no more than 10 degrees, with pain starting at 0 degrees. The examiner estimated that incoordination would further limit right knee flexion by an additional 20 degrees following repeated use over time. There was pain on palpitation of the patella and “very small” effusion of the joint; however, there was no genu recurvatum or “locking” pain. Joint stability testing was within normal limits. The Veteran next received a VA examination for his right knee in August 2009. The Veteran indicated symptoms of pain, weakness, stiffness, swelling, redness, giving way, lack of endurance, locking, and impairment to walking, standing, bending, and kneeling. The Veteran’s right knee flexion was limited to 120, with pain starting at 0 degrees, and extension was limited to no less than 5 degrees, with pain starting at 5 degrees. There was locking pain and crepitus. Repetitive motion testing was not possible due to pain. The Veteran received another VA examination for his right knee in September 2014. The Veteran reported constant pain in his right knee that was exacerbated by “getting” and walking and remarked that the right knee “collapse[s] on me 2-3 times a day depending on how active I am.” He indicated flare-ups upon “getting up from sitting/bed and prolonged walking.” The Veteran’s right knee flexion was limited to 90 degrees, with no indication of where painful motion began, and extension was limited to no less than 10 degrees, with painful motion starting at 10 degrees. Flexion after three repetitions was limited to 80 degrees and extension was normal (to 0 degrees). Contributing factors of disability included less movement than normal, weakened movement, excess fatiguability, pain on movement, swelling, instability of station, and disturbance of locomotion. A Lachman test yielded a result of 2+, or moderate lateral instability, and a posterior drawer test yielded 1+, or slight lateral instability. The examiner noted a history of meniscal tear and frequent episodes of joint pain. The Veteran relied on regular use of a brace and occasional use of a cane. Finally, the examiner declined to estimate additional functional loss during flare-ups to avoid “mere speculation.” The Veteran received an additional VA examination for his right knee in May 2016. The Veteran indicated pain with bending and kneeling. The Veteran’s right knee flexion was recorded as normal (140 degrees) and extension was recorded as to 0 degrees. The examiner noted pain on both flexion and extension yet gave no estimate of the degree at which pain began for either flexion or extension. There was no additional functional loss after three repetitions, and the examiner further concluded that there would be no additional functional loss after repeated use over time. No contributing factors of disability were noted. Joint stability tests revealed normal results. The examiner recorded a history of meniscal tear. The Veteran reported constant use of a cane. Following the February 2017 JMPR and November 2017 Board Remand for Correia findings, the Veteran received a further VA examination for his right knee in June 2018. The Veteran reported inability to sit or stand for long and “had to stop volunteer fire fighting because he couldn’t go up ladders or carry things.” He indicated flare-ups “with overuse, [and] moderate sitting and standing.” The Veteran’s right knee flexion was limited to 100 degrees, and extension was limited to no less than 10 degrees, with pain on flexion and extension not resulting in functional loss. There was no additional functional loss after 3 repetitions. The examiner concluded that he could not estimate additional functional loss following repeated use and during flare-ups “without resorting to mere speculation.” A contributing factor of an antalgic gait favoring the right knee was noted. Joint stability tests were normal. A history of meniscal conditions without current symptoms was noted. The Veteran relied on occasional use of a cane. Regarding Correia, there was objective evidence of pain on passive ROM testing and no objective evidence of pain on non-weightbearing. The opposite, undamaged knee was also tested. Finally, following the June 2020 Board remand for Sharp estimates of additional functional loss during flare-ups, the Veteran received a VA examination in August 2020. The Veteran indicated symptoms of giving out, increased pain during storms and when transitioning from sitting to standing; he also reported functional impairments of difficulty going up and down stairs, squatting, lifting, kneeling, and walking. The examiner nevertheless recorded that the Veteran did not suffer from flare-ups in the right knee. The Veteran’s right knee flexion was limited to 110 degrees, and extension was to 0 degrees, with no pain noted. Flexion deteriorated to 105 degrees after three repetitions due to pain, weakness, and lack of endurance, with no loss of extension. The examiner estimated flexion of 100 degrees and extension to 0 degrees, after repeated use over time due to pain, weakness, and lack of endurance. She did not provide Sharp estimates because “the Veteran denies flare ups.” No additional contributing factors of disability were noted. Joint stability testing yielded normal results. The examiner noted a history of meniscal tear with no current symptoms. The Veteran did not report use of an assistive device. Based on x-ray evidence, the examiner noted a new diagnosis of right knee degenerative arthritis. Initially, the Board notes there is no evidence of ankylosis of the right knee at any point during the period on appeal. Based on the foregoing, the Board finds a separate 10 percent disability rating is warranted for right knee limitation of extension for the entire period on appeal. The examinations in August 2007, September 2014, and June 2018 each revealed extension to no less than 10 degrees, and the August 2009 examination report gave extension as limited to 5 degrees. Notably, the May 2015 examiner noted pain on extension but gave no indication of where pain began. Here, the Board finds the above examinations outweigh the August 2020 examination. As the Veteran’s limitation of extension has not been factored into prior ratings for limitation of flexion and instability, a separate rating for limitation of extension is not duplicative or overlapping with symptoms of any other disability. 38 C.F.R. § 4.14; Lyles v. Shulkin, 29 Vet. App. 107 (2017). Accordingly, resolving all doubt in the Veteran’s favor, the Board finds the criteria for a separate 10 percent disability rating for limitation of extension for the entire period on appeal have been met under Diagnostic Code 5261. 38 C.F.R. § 4.71A. However, a separate disability rating in excess of 10 percent for right knee limitation of extension is not warranted. The evidence of record does not reflect extension limited to greater than 10 degrees at any time during the period. Regarding repeated use over time, during the June 2018 examination, extension improved to 0 degrees after three repetitions; moreover, the May 2016 examiner estimated no additional functional loss over time. Regarding flare-ups, the Veteran denied flare-ups during the August 2020 examination. However, there is no evidence that extension would be limited to beyond 10 degrees due to pain, weakness, fatiguability, and/or incoordination during flare-ups. As noted above, the Veteran’s extension has also been tested as normal (to 0 degrees) during the period on appeal. Accordingly, the Board finds the criteria for a separate disability rating in excess of 10 percent based on limitation of extension are not met. Furthermore, the Board finds a disability rating in excess of 10 percent based on limitation of flexion is not warranted at any point during the period on appeal. At most, flexion of the right knee was limited to 80 degrees, to include consideration of additional functional loss after repeated use and during flare-ups. Estimates of additional functional loss following repeated use over time have not been less than 80 degrees. The Veteran did not report flare-ups during the August 2020 examination. Although the August 2009 examiner indicated that pain on flexion began at 0 degrees, the Board finds such finding is outweighed by the VA examinations from October 2007, June 2018, and August 2020, which found either no pain on examination or pain limiting flexion not less than 80 degrees. Accordingly, the Board finds the criteria for a disability rating in excess of 10 percent based on limitation of flexion have not been met under Diagnostic Code 5260. 38 C.F.R. § 4.71A. Turning to the Veteran’s staged ratings for right knee instability, prior to August 12, 2009, the Board finds an initial disability rating in excess of 10 percent based on lateral instability is not warranted. Although there was lay evidence of right knee instability, joint stability testing during the August 2007 examination was within normal limits. Accordingly, prior to August 12, 2009, the criteria for an initial disability rating in excess of 10 percent for service-connected right knee instability have not been met. For the period between August 12, 2009, and September 15, 2014, a disability rating in excess of 20 percent based on instability is not warranted. Although the Veteran continued to report giving way and locking, there was no objective evidence of instability until the September 2014 VA examination. Here, the Board finds the Veteran’s lay statements concerning giving way and locking alone are not consistent, without more, with severe instability of the knee during this period. Accordingly, the Board finds the criteria for a disability rating in excess of 20 percent for right knee instability have not been met for the period from August 12, 2009, to September 15, 2014. For the period following September 15, 2014, the Veteran is in receipt of the maximum 30 percent disability rating for instability. As knee instability has its own code, Diagnostic Code 5257, no rating by analogy under other codes is permissible; thus, a higher rating under another code provision is not warranted. Copeland v. McDonald, 27 Vet. App. 333, 338 (2015) (held that where there is a diagnostic code that addresses the particular service-connected disability, to evaluate that disability under another code would constitute impermissible rating by analogy). The Veteran has also asserted entitlement to an extraschedular disability rating for his right knee. This contention is addressed below in a separate section. Disabilities of the knee and leg may also be evaluated under Diagnostic Codes 5256, 5258, 5259, 5262 or 5263. However, the medical and lay evidence of record does not show that the Veteran’s right knee status post arthroscopy, medial meniscal tear is manifested by ankylosis or any impairment of the tibia and fibula or genu recurvatum. Notwithstanding, the Veteran has a recorded history of meniscal conditions in the right knee, for which Diagnostic Codes 5258 (Cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint) and 5259 (Cartilage, semilunar, removal of, symptomatic) are applicable. However, the evidence does not demonstrate frequent episodes of “locking,” pain, and effusion into the joint. Furthermore, regarding Diagnostic Code 5259, the Veteran’s current ratings for right knee limitation of flexion, limitation of extension, and instability, manifested by pain, limitation of motion, and knee instability, contemplate the effects of his semilunar cartilage condition following a medial meniscal tear. As such, the Board finds a separate rating under Diagnostic Code 5259 would amount to impermissible pyramiding. 38 C.F.R. § 4.14. 4. Entitlement to an initial rating in excess of 10 percent prior to January 16, 2018, and in excess of 20 percent thereafter for right knee focal neuropathy of the common peroneal nerve. 5. Entitlement to an initial rating in excess of 10 percent for right knee focal neuropathy of the femoral nerve. 6. Entitlement to an initial compensable rating for right knee focal neuropathy of the ilio-inguinal nerve. 7. Entitlement to an initial compensable rating for right knee focal neuropathy of the obturator nerve. The Veteran seeks higher disability ratings for his service-connected right knee focal neuropathy of the common peroneal nerve, right knee focal neuropathy of the femoral nerve, right knee focal neuropathy of the ilio-inguinal nerve, and right knee focal neuropathy of the obturator nerve. The Veteran’s right knee focal neuropathy of the common peroneal nerve is rated as 10 percent disabling prior to January 16, 2018, and 20 percent disabling thereafter under 38 C.F.R. § 4.124a, Diagnostic Code 8521. The Veteran’s right knee focal neuropathy of the femoral nerve is currently rated as 10 percent disabling from June 5, 2007 under 38 C.F.R. § 4.124a, Diagnostic Code 8526. The Veteran’s right knee focal neuropathy of the ilio-inguinal nerve is currently rated as noncompensable, effective August 31, 2020, under 38 C.F.R. § 4.124a, Diagnostic Code 8730. The Veteran’s right knee focal neuropathy of the obturator nerve is currently rated as noncompensable, effective August 31, 2020, under 38 C.F.R. § 4.124a, Diagnostic Code 8728. Diseases of the peripheral nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. § 4.124a. The term “incomplete paralysis” indicates a degree of impaired function substantially less than the type of picture for “complete paralysis” given for each nerve.  Id. When the involvement is wholly sensory, the rating for incomplete paralysis should be for the mild, or, at most, the moderate degree. Id. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury to the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Under Diagnostic Code 8521, a 10 percent rating is warranted for mild incomplete paralysis of the common peroneal nerve. A 20 percent rating is warranted for moderate incomplete paralysis of the common peroneal nerve. A 30 percent rating is warranted for severe incomplete paralysis of the common peroneal nerve. A maximum 40 percent rating is warranted for complete paralysis of the common peroneal nerve. The rating criteria indicate that complete paralysis is present when the foot drops and there is slight drooping of first phalanges of all toes, loss of dorsiflexion of the foot, loss of extension of proximal phalanges of the toes, loss or weakness of abduction of the foot, or anesthesia covering the entire dorsum of the foot and toes. 38 C.F.R. § 4.124A, Diagnostic Code 8521. Under Diagnostic Code 8526, a 10 percent rating is warranted for mild incomplete paralysis of the femoral nerve. A 20 percent rating is warranted for moderate incomplete paralysis of the femoral nerve. A 30 percent rating is warranted for severe incomplete paralysis of the femoral nerve. Finally, a 40 percent rating is warranted where there is complete paralysis of the femoral nerve with paralysis of the quadriceps extensor muscles. 38 C.F.R. § 4.124A, Diagnostic Code 8526. Under Diagnostic Codes 8530, which provides the rating criteria for paralysis of the ilio-inguinal nerve and, 8730, which signifies neuralgia, mild or moderate paralysis of the ilio-inguinal nerve warrants a noncompensable disability rating. A maximum schedular 10 percent disability rating is warranted for severe to complete paralysis of the ilio-inguinal nerve. 38 C.F.R. § 4.124A, Diagnostic Codes 8530, 8730. Under Diagnostic Codes 8528, which provides the rating criteria for paralysis of the obturator nerve, and 8728, which signifies neuralgia, mild or moderate paralysis of the obturator warrants a noncompensable disability rating. A maximum schedular 10 percent disability rating is warranted for severe to complete paralysis of the obturator nerve. 38 C.F.R. § 4.124A, Diagnostic Codes 8528, 8728. During the August 2007 VA examination of the Veteran’s right knee, the Veteran reported “constant numbness over the top of the kneecap and down to the toes” as a result of “surgery and a severed nerve.” At the August 2009 VA examination of the Veteran’s right knee, the examiner noted “tingling and numbness, abnormal sensation, pain and weakness” of the right knee due to a “nerve disease.” There was a sensory deficit around the right knee. Right knee and ankle reflexes were 3+. Muscle function was intact and there was no motor dysfunction. The examiner concluded that the Veteran experienced paralysis of the peroneal nerve in the right lower extremity. During the September 2014 examination of the Veteran’s right knee, the Veteran reported continued numbness of the right lower extremity. The Veteran received an initial VA examination for peripheral nerve conditions in May 2016. The Veteran reported “numbness on the lateral aspect of his knee and calf.” The examiner noted only mild right lower extremity numbness. Muscle strength and reflexes were normal. Sensation in the lower leg and ankle were decreased; in the foot and toes, sensation was normal. There were no trophic changes. The examiner noted mild incomplete paralysis of the superficial peroneal nerve and mild incomplete paralysis of the anterior crural (femoral) nerve. No paralysis of the obturator nerve or ilio-inguinal nerve was noted. Following the November 2017 Board decision, which sought to confirm whether the Veteran’s peripheral nerve disability involved two separate nerve groups, the Veteran next received a VA examination for peripheral nerve conditions in June 2018. The Veteran reported inability to feel the gas pedal while driving. The examiner noted moderate paresthesias and/or dysesthesias, mild numbness in the right lower extremity, and “constant” decreased sensation [in the] right lateral leg from [the] knee down to [the] foot and toes. Muscle strength was reduced to 4/5 for knee extension, ankle plantar flexion, and ankle dorsiflexion. Reflexes were normal. Sensation was decreased in the right lower leg and ankle and the foot and toes. There were no trophic changes. Regarding pathology and severity, the examiner found moderate incomplete paralysis of the sciatic nerve, moderate incomplete paralysis of the common peroneal nerve, and mild incomplete paralysis of the tibial nerve. Finally, the examiner noted that the bottom of the right foot was “hypersensitive … with monofilament and reflex hammer.” The Veteran most recently received a VA examination for peripheral nerve conditions in August 2020. The Veteran reported worsening numbness and tingling, indicated “his toes become extremely cold when his foot is numb.” The report indicates the Veteran’s numbness and tingling was constant, occurred daily, and worsened with activity. The examiner noted symptoms of mild intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness of the right lower extremity. Muscle strength and reflexes in the right lower extremity were normal. Sensation at the thigh and knee, lower leg and ankle, and foot and toes were decreased. Regarding pathology and severity, the examiner provided the following assessment: mild incomplete paralysis of the common peroneal nerve; mild incomplete paralysis of the superficial peroneal nerve; mild incomplete paralysis of the deep peroneal nerve, mild incomplete paralysis of the tibial nerve; mild incomplete paralysis of the posterior tibial nerve; mild incomplete paralysis of the internal saphenous nerve; and, mild incomplete paralysis of the ilio-inguinal nerve. Turning first to the rating for neuropathy associated with the common peroneal nerve, prior to January 16, 2018, the Board finds a rating in excess of 10 percent is not warranted. In this regard, the medical evidence of record shows that the Veteran’s right knee focal neuropathy of the common peroneal nerve was, at most, mild in severity, as indicated in the May 2016 examination report. Although the Veteran demonstrated sensory and reflex abnormalities during several VA examinations prior to June 2018, these findings are consistent with the mild incomplete paralysis described by the May 2016 examiner. Accordingly, prior to January 16, 2018, the criteria for an initial disability rating in excess of 10 percent for the right knee focal neuropathy of the common peroneal nerve have not been met. Furthermore, the Board finds a disability rating in excess of 20 percent for right knee focal neuropathy of the common peroneal nerve is not warranted on and after January 16, 2018. While there is evidence of 4/5 muscle strength and decreased sensation in the right foot, ankle, and knee, reflex testing at both the June 2018 and August 2020 VA examinations was normal and there is no evidence of trophic changes at any point during the period on appeal. No examiner has assessed the right knee focal neuropathy of the common peroneal nerve as resulting in severe incomplete paralysis. Accordingly, the Board finds the criteria for a disability rating in excess of 20 percent for right knee focal neuropathy of the common peroneal nerve have not been met as of January 16, 2018. Finally, the Veteran’s neuropathy was noted to involve other branches associated with the sciatic nerve, including the sciatic, superficial peroneal, deep peroneal, tibial, and posterior tibial nerves, as defined in the VA Adjudication Procedures Manual (M21-1). See M21-1, Pt. III, Subpt. iv, 4.N.e.f. While the M21-1 is not binding on the Board, the Board “is required to discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons and bases.” Overton v. Wilkie, 30 Vet. App. 257, 264 (2018). As the nerves described above are both in the sciatic branch, the functions and symptomatology associated with the nerves are not separate and distinct. Accordingly, assignment of separate ratings for multiple nerves within the sciatic branch constitutes impermissible pyramiding. See 38 C.F.R. § 4.14. Turning next to the rating for neuropathy associated with the femoral nerve, the Board finds a disability rating in excess of 10 percent is not warranted at any point during the period on appeal. In this regard, no examiner has estimated the Veteran’s incomplete paralysis of the femoral nerve to be greater than mild in severity. While the August 2020 examiner noted sensation in the thigh was decreased, this finding was found to be consistent with mild incomplete paralysis. Accordingly, the criteria for a disability rating in excess of 10 percent for the right knee focal neuropathy of the femoral nerve have not been met. As noted above, the August 2020 examiner noted involvement of the internal saphenous nerve, another nerve defined as within the femoral nerve branch. See M21-1, Pt. III, Subpt. iv, 4.N.e.f. As the functions and symptomatology associated with the femoral and internal saphenous nerves are not separate and distinct, assignment of separate ratings for the femoral and internal saphenous nerves would amount to impermissible pyramiding. See 38 C.F.R. § 4.14. Regarding the rating for neuropathy of the ilio-inguinal nerve, the Board finds a compensable initial disability rating is not warranted. At no point during the period on appeal was the paralysis of the ilio-inguinal nerve noted to be greater than mild in severity. Furthermore, no paralysis of ilio-inguinal nerve was noted during any VA examination, or elsewhere in the evidence of record, prior to August 2020. Accordingly, the criteria for an initial compensable disability rating for the right knee focal neuropathy of the ilio-inguinal nerve have not been met. Finally, regarding the rating for neuropathy of the obturator nerve, the Board finds a compensable initial disability rating is not warranted. At no point during the period on appeal was the paralysis of the obturator nerve noted to be greater than mild in severity. Furthermore, no paralysis of obturator nerve was noted during any VA examination, or elsewhere in the evidence of record, prior to August 2020. Accordingly, the criteria for an initial compensable disability rating for the right knee focal neuropathy of the obturator nerve have not been met. 8. Entitlement to an extraschedular disability rating for right knee status post arthroscopy, medial meniscal tear. The Veteran has contended that his service-connected right knee status post arthroscopy, medial meniscal tear is entitled to an extraschedular rating. See October 2020 Informal Hearing Presentation. (Continued on the next page)   Under Thun v. Peake, 22 Vet, App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran’s disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” Third, if the rating schedule is inadequate to evaluate a Veteran’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran’s disability picture requires the assignment of an extraschedular rating. In this case, the Board finds the symptoms associated with the Veteran’s right knee disability have not been shown to cause any impairment that is not already contemplated by the Ratings Schedule. The record as a whole provides evidence of musculoskeletal pain, limitation of motion, disturbances of locomotion, sitting, standing, and carrying, and instability of the knee; regarding the neurological aspect of the disability, there is evidence of neuropathic pain, paresthesias and dysesthesias, numbness, and sensory and reflex deficits. These aspects are either explicitly set forth in the Rating Schedule or are downstream effects of the symptoms in the rating criteria, such that they are contemplated by the ratings assigned. See, e.g., Doucette v. Shulkin, 28 Vet. App. 366 (2017). Thus, the Board finds referral for an extraschedular rating is not warranted under 38 C.F.R. § 3.321(b)(1). M. M. Celli Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Small, Attorney Advisor 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.