Citation Nr: 21002964 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 13-32 931 DATE: January 19, 2021 ORDER Entitlement to an initial compensable rating, prior to September 11, 2013, and in excess of 10 percent from September 11, 2013 through August 10, 2014, and in excess of 30 percent thereafter, for limitation of extension due to left knee degenerative disc disease (DJD), is denied. Entitlement to an initial rating in excess of 10 percent for limitation of flexion due to knee DJD is denied. Entitlement to an initial compensable rating for left knee scars status-post repair of ACL associated with left knee DJD is denied. Entitlement to separate 10 percent rating for left knee instability is granted. FINDINGS OF FACT 1. Prior to September 11, 2013, the Veteran’s left knee disability did not manifest with compensable limited extension. Beginning September 11, 2013 through August 10, 2014, his left knee disability manifested by extension limited to 10 degrees; and extension limited to 20 degrees thereafter. 2. Throughout the period on appeal, the Veteran’s left knee disability is manifested by limitation of motion, pain, occasional swelling, and degenerative arthritis shown by X-ray findings and flexion of the left knee is limited to no less than 70 degrees with painful motion. 3. Throughout the period on appeal, the Veteran’s scars related to his left knee disability are not painful and/or unstable or greater than 39 square centimeters in area. 4. Throughout the appeal period, the Veteran has had mild left knee instability. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for limitation of extension of the left knee prior to September 11, 2013, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5010-5261. 2. The criteria for a rating in excess of 10 percent from September 11, 2013 to August 10, 2014 for limitation of extension of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5010-5261. 3. The criteria for a rating in excess of 30 percent for limitation of extension of the left knee from August 10, 2014 forward, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5003-5261. 4. The criteria for a rating in excess of 10 percent for limitation of flexion of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5003-5260. 5. The criteria for an initial compensable disability rating for left knee scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, DC 7805. 6. The criteria for a separate rating for left knee disability of 10 percent, but no higher, based on instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1966 through August 1968. This matter comes before the Board of Veterans’ Appeals (BVA or Board) on appeal from November 2011, September 2014, and October 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In a September 2015 decision, the Board denied the Veteran’s increased rating claims for left knee limitation of extension for various periods and for a compensable rating for his left knee scar. The Board also granted a separate rating 10 percent rating for limitation of flexion of the left knee. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a May 2017 Memorandum Decision, the Court vacated the September 2015 Board decision and remand these issues back to the Board for further action as consistent with the memorandum decision. The appeal has since returned to the Board. In April 2018, the Board remanded these matters to the Agency of Original Jurisdiction (AOJ) for additional development. The appeal has since returned to the Board. The Board notes that the Veteran’s claims for earlier effective dates for his Veteran’s left knee disabilities were granted while these claims were pending on appeal. See April 2019 rating decision. As the grants are consider full grants for the benefits sought, these claims are no longer before the Board. Additionally, the Board notes that a September 2020 an informal hearing presentation (IHP) of record is not responsive to the issues on appeal. The Board made attempts to obtain an IHP specifically addressing the issues presented on appeal. The Veteran’s representative failed to submit the requested IHP. As such, the Board will adjudicate the issues based on the existing record. Increased Ratings Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 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 military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability shall be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. Additionally, when evaluating a musculoskeletal disability, VA must consider functional loss due to pain, weakness, excess fatigability, or incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. See Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); see also 38 C.F.R. § 4.59 (2017). Increased Ratings for Left Knee Disabilities In a November 2011 rating decision, the RO granted service connection for the Veteran’s left knee disability causing limited flexion and assigned a 10 percent disability rating under DC 5260-5003. In a September 2014 rating decision, the RO granted an increased disability rating of 30 percent for his left knee disability causing limitation of extension under 5010-5261, effective August 11, 2014. In an October 2015 rating decision implementing the September 2015 Board decision, the Veteran was granted a separate evaluation for limited flexion due to left knee DJD with a 10 percent disability rating under DC 5003-5260, effective August 12, 2010, and a 10 percent disability evaluation for limited extension due to left knee DJD under DC 5010-5261, effective September 11, 2013. In an April 2019 rating decision, the RO implemented the Board’s April 2018 decision granting an earlier effective date of April 30, 1979 for his left knee limited flexion and limited extension disabilities. A noncompensable rating for left knee limitation of extension was assigned from April 30, 1979 through September 11, 2013.The Veteran disagrees with the ratings assigned. Applicable Statutory Law and Regulations 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. The Board will explore all possibilities in this case. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. In this case, DC 5003-5260 and 5010-5261 reflects consideration of the effects of degenerative arthritis (5010) and limited flexion and extension (5260, 5261). DCs 5003 and 5010 rate arthritic conditions. A 10 percent evaluation is warranted when there is x-ray evidence of involvement of 2 or more major joints or minor joint groups; a 20 percent evaluation is warranted when there is involvement of 2 or more major joints or minor joint groups with occasional incapacitating episodes. See 38 C.F.R. § 4.71a, DCs 5003, 5010. Additionally, a 10 percent evaluation is warranted for noncompensable limitation of motion for effected joints, provided that there is objective x-ray evidence of arthritis and objective evidence of swelling, muscle spasm, or other satisfactory evidence of painful motion. See 38 C.F.R. § 4.71a, DC 5003. Under DC 5260, limited knee flexion is assigned a 0 percent rating if it is limited to 60 degrees, 10 percent requires flexion limited to 45 degrees, and the next rating of 20 percent requires flexion limited to 30 degrees. Under DC 5261, limited knee extension is assigned a 0 percent rating where it is limited to 5 degrees, a 10 percent requires extension limited to 10 degrees, a 20 percent evaluation requires extension limited to 15 degrees, a 30 percent evaluation is required for extension limited to 20 degrees, and a 40 percent evaluation is required for extension limited to 30 degrees. 38 C.F.R. § 4.71a. Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, DC 5257. Ratings can also be assigned for impairment of the tibia or fibula, disability affecting the meniscus, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, DCs 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary 93 (30th ed. 2003). In this case, the evidence does not reflect, nor does the Veteran allege, that he has impairment of the tibia or fibula, genu recurvatum, or ankylosis of his left knee during the appeal period. As such, DC 5256, 5262, and 5263 are not for application. 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 weightbearing and non-weightbearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Evidence of Record Turning to the relevant evidence of record, the record supports that the Veteran had left knee surgery in January 1975. By February 1975, he was discharged from care with satisfactory progress and independent ambulation with minimal discomfort. The Veteran’s sought treatment several years later in June 1995 for left knee pain and give away weakness. He reported that was a Frito-Lay employee and had experienced minor episodes of instability in the past, but recently began experiencing marked episodes of instability with locking within the last week. Upon examination, he had marked pain with swelling. He could not extend his left knee within the last 10 to 15 degrees secondary to pain. He had tenderness on the lateral joint line; and his Lachman test was positive. By September 1995, the Veteran was documented as having “good ROM.” The examiner opined that the Veteran looked excellent and his lateral compartment looked very healthy. By November 1995, status post-surgery, he reported some clicking within the left knee and “a little bit” of catching, He denied swelling, locking, or giving away. In August 2010, the Veteran reported that he had been pain free since his surgery and exhibited full range of motion in his left knee. The Veteran underwent a VA examination in September 2011 for his left knee disability. He endorsed flareups that occurred weekly and was precipitated by prolonged sitting prolonged, standing, walking, and climbing stairs. During flareups, he stated that he could not continue with ordinary activities. Upon examination, his left knee flexion was to 100 degrees with objective evidence of painful motion beginning at 100 degrees. Extension was not limited. Repetitive motion testing did not cause additional limitation. Instability testing in his left knee was negative. He reported that his left knee disability resulted in his inability to squat due to pain. Climbing up and down the stairs caused him increased pain. Further, he endorsed that any type of prolonged sitting, standing, and walking all caused the pain in his left knee to increase. In September 2013, the Veteran was afforded a second orthopedic VA examination. He reported that since the surgery, his left knee pain had gotten progressively painful when he walked, sat for prolonged times, or climbed stairs. Flareups were again endorsed and occurred when it was cold or if the weather changed to rain. He would have pain for a day or two and this occurred once or twice a month. His left knee range of motion was limited to 90 degrees with painful motion beginning at 70 degrees, and extension to 10 degrees with painful motion at 5 degrees. Again, his joint stability testing was normal. The examiner opined that any additional functional limitations during repeated use over time and during flares could not be estimated without resorting to mere speculation. In a September 2014 VA examination, he reported that his left knee was more tender with a dull ache. He denied effusion but endorsed that his left knee was unstable and causing him to fall. Specifically, he endorsed lateral instability. His baseline pain was a two or three on a 10-point scale. Upon examination, his left knee flexion was to 110 degrees with pain at 100 degrees, and extension was to 20 degrees with pain beginning at 20 degrees. Repetitive motion testing caused additional loss in range of motion of flexion limited to 100 degrees. The examiner again opined that the estimated additional functional loss of range of motion, during repeated use over time and flares, could not be estimated. At his June 2015 hearing, the Veteran testified to having left knee pain and swelling, which affected his ability to move his knee. He also endorsed left knee instability with giving away, which resulted in falls. In a December 2017 VA examination, the Veteran reported current use of a cane. He endorsed some balance problems with his left knee and lack of stability. He also reported that his left knee pain was minor all the time but would increase with activity such as walking. No flareups were endorsed. His right knee range of motion was normal. His left knee flexion was limited to 100 degrees and extension 0 degrees. Pain was noted on examination but did not cause additional functional loss. He had no evidence of pain with weightbearing. There was crepitus in his left knee. His left knee muscle strength was 4 of 5. He had no left knee muscle atrophy or ankylosis. He had a meniscus condition of the left knee and had frequent episodes of joint locking, joint pain, and joint effusion. He was being examined after repeated use over time and had no additional functional loss. Since the December 2017 VA examination, the Veteran nor his representative have submitted any arguments or evidence supporting that the Veteran’s left knee disabilities have worsened. Likewise, the existing evidence of record shows no evidence of worsening since the December 2017 VA examination. Analysis 1. Entitlement to an initial compensable rating prior to September 11, 2013, and in excess of 10 percent from September 11, 2013 through August 10, 2014, and in excess of 30 percent thereafter for limitation of extension due to left knee DJD) Considering the aforementioned, increased ratings are not warranted for the Veteran’s limitation of extension under DC 5010-5261 at any point during the period on appeal. A compensable rating under DC 5261 requires limitation of extension to 10 degrees. Prior to September 11, 2013, evidence of record does not support that the Veteran’s left knee disability manifested with limitation of extension to 10 degrees or more. While June 1995 treatment notes document the Veteran’s inability to extend his knee the last 10 to 15 degrees secondary to pain, the contemporaneous evidence demonstrates that this limitation of extension and pain was a temporary exacerbation of his left knee disability. In June 1995, the Veteran reported that marked knee symptoms were only present for a week and these symptoms responded well to surgical intervention. By September 1995, treatment notes documented good range of motion. Assigning an increased rating for a temporary exacerbation of symptomatology for a limited period such as this would violate the rule against stabilization of ratings. See 38 C.F.R. § 3.344. In his September 2011 VA examination, he had normal extension and no evidence of pain with extension. Records dated earlier or thereafter likewise document no lay or medical evidence showing limitation in extension consistent with a compensable rating prior to September 11, 2013. The Board is aware that when limitation of motion is not compensable in a major joint, such as the knee, if there is painful motion of the knee with or without arthritis, a 10 percent evaluation shall be assigned. However, in this case, there is no level of disability that warrants a compensable rating under DC 5261, as permanent painful motion with extension was not demonstrated by lay or medical evidence for the relevant period. Sowers v. McDonald, 27 Vet. App. 472 (2017). Rather, any pain noted was temporary and improved post-arthroscopy. Therefore, a compensable rating for painful motion cannot be assigned in this case. Id.; 38 C.F.R. § 4.59. Further, the record does not demonstrate compensable limitation of extension prior to September 11, 2013.Thus, a higher rating for this time period is not warranted. Beginning September 11, 2013 through August 10, 2014, the record does not support that a disability rating higher than 10 percent is warranted under DC 5261. Ratings in excess of 10 percent for the Veteran’s left knee disability causing limitation of extension under DC 5261 requires extension limited to 15 degrees or more. Between September 11, 2013 through August 10, 2014, the Veteran is compensated at a 10 percent evaluation for his painful, but noncompensable limitation of extension pursuant to 38 C.F.R. § 4.59. The Veteran’s limitation of extension during this time period was not great enough to warrant a higher evaluation. Demonstratively, the Veteran’s extension during this time period was, at most, limited to 10 degrees, as reported in September 2013 VA examination. The VA treatment records support this finding as well. Thus, the preponderance of the evidence is against a rating higher than 10 percent in the Veteran’s left knee beginning September 11, 2013 through August 10, 2014. Beginning August 10, 2014, the Veteran’s left knee disability does not more nearly approximate the level of severity contemplated by a 40 percent rating under DC 5261, as at no point during the period has the medical evidence shown limitation of extension of the right knee to 30 degrees. 38 C.F.R. § 4.71a, DC 5261. Ratings in excess of 30 percent for the Veteran’s left knee disability causing limitation of extension under DC 5261 requires extension limited to 30 degrees or more. Beginning August 10, 2014, the Veteran exhibited extension limited to, at worst, to 20 degrees with pain at 20 degrees. See September 2014 VA examination. As such, a rating in excess of 30 percent is not warranted at any time during the period on appeal. Based on the aforementioned, a higher rating is not warranted for the Veteran’s limitation of extension as a result of his left knee DJD at any period on appeal. Thus, the Veteran’s claim for increased ratings for disability evaluations under DC 5010-5621 is denied. 2. Entitlement to an initial rating in excess of 10 percent for limitation of flexion due to knee DJD The preponderance of evidence is against a rating in excess of 10 percent for the Veteran’s left knee disability, based on limitation of flexion, throughout the period on appeal. For a disability evaluation in excess of 10 percent to be assigned under DC 5260, flexion of the knee must be limited to 30 degrees or less. 38 C.F.R. § 4.71a, DC 5260. The most probative evidence shows that the Veteran has flexion of the left knee well beyond 30 degrees on every occasion range of motion testing was performed during the period on appeal. Prior to September 2013, there is no medical evidence supporting that the Veteran’s left knee had flexion limited to a compensable degree. At a September 1995, a surgical follow-up treatment note documented good range of motion. Additionally, VA examinations consistently noted range of motion of at least 90 degrees or more, with pain noted at 70 degrees shown only during the September 2013 VA examination. Any loss of range of motion with repetitive usage did not result in limitation of flexion below 70 degrees. As such, the Veteran’s current 10 percent disability rating for his left knee disability based on limitation of flexion and painful motion takes into consideration and incorporates the functional loss and impairment due to pain. His left knee disability has not been shown to produce additional impairment that would warrant a rating higher than 10 percent under DC 5260. Therefore, the current functional impairment of his left knee disability and the symptoms of pain are encompassed in the 10 percent rating assigned. The preponderance of the evidence is against a rating higher than 10 percent for the Veteran’s left knee disability causing limitation in flexion throughout the period on appeal, and the claim for a higher rating is denied. 3. Entitlement to an initial compensable rating for left knee scars status-post repair of ACL associated with left knee DJD In September 2014, the Veteran was granted service connection for left knee scars status-post repair of ACL with a noncompensable disability rating under DC 7805, effective August 11, 2014. In an April 2019 rating decision, the Veteran was granted an earlier effective date of April 30, 1979 for his left knee scars. The Veteran disagrees with the rating assigned. During the course of the appeal, the regulations pertaining to the evaluation of skin disabilities were amended. See 67 Fed. Reg. 49,590 (July 31, 2002) (effective August 30, 2002); 73 Fed. Reg. 54,710 (September 23, 2008) (effective October 23, 2008). Where laws or regulations change while a claim is pending, the version most favorable to the Veteran applies, absent contrary Congressional or Secretarial intent. See Dudnick v. Brown, 10 Vet. App. 79 (1997); Karnas v. Derwinski, 1 Vet. App. at 312-13 (1991). The Veteran’s claim was pending at the time of the 2002 and 2008 amendments, and there is no VA or legislative limitation of the effective date of these amendments. As such, he is entitled to application of the criteria that are the most favorable to his claim. However, an award based on the amended regulations may not be made effective before the effective date of the change. 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114. Accordingly, the Board will evaluate the Veteran’s left knee scars under the criteria in effect prior to August 30, 2002, then the criteria in effect from August 30, 2002 to October 23, 2008, and then the criteria from October 23, 2008 forward keeping in mind that the revised criteria may not be applied prior to the effective date of the change. The Board notes that the diagnostic criteria for disorders of the skin are found at 38 C.F.R. § 4.118, DCs 7800 to 7805. As the evidence of record indicates that the Veteran’s scars are not on his head, face, or neck, and that he does not have any disfigurement of the head, face, or neck, consideration under DC 7800 is not warranted. 38 C.F.R. § 4.118, DC 7800. Under the pre-August 2002 version of Diagnostic Code 7800, a 10 percent rating is warranted for disfigurement of the head, face, or neck when the skin disability is moderately disfiguring. 38 C.F.R. § 4.118 (2001). Under Diagnostic Code 7801, a 10 percent rating is warranted for a third degree burn or scar in an area or areas exceeding 6 square inches (38.7 sq. cm.). Under Diagnostic Code 7802, a 10 percent rating is warranted for a second degree burn scar with an area approximating 1 square foot. Under Diagnostic Code 7803, a 10 percent rating is warranted for a superficial scar, poorly nourished, with repeated ulceration. Under Diagnostic Code 7804, a 10 percent rating is warranted for a superficial scar, tender and painful on objective demonstration. Finally, under Diagnostic Code 7805, a scar can be rated on limitation of function of the affected part. 38 C.F.R. § 4.118 (2001). Under the pre-October 2008 version of Diagnostic Code 7800, a 10 percent rating is warranted for disfigurement of the head, face, or neck when the skin disability has one characteristic of disfigurement. Under Diagnostic Code 7801, a 10 percent rating is warranted for a scar on other than the head, face, or neck, that is deep (associated with underlying soft tissue damage) or that causes limited motion with area or areas exceeding 6 square inches (39 sq. cm.). Under Diagnostic Code 7802, a maximum 10 percent rating is warranted if a scar on other than the head face or neck is superficial (not associated with soft tissue damage) and does not cause limited motion, affecting an area or areas of 144 square inches (929 sq. cm.) or greater. Under Diagnostic Code 7803, a superficial and unstable (involving frequent loss of covering of skin over the scar) scar may be assigned a maximum 10 percent rating. Under Diagnostic Code 7804, a scar that is superficial and painful on examination may be assigned a maximum 10 percent rating. Finally, under Diagnostic Code 7805, scars are rated according to limitation of function of the affected part. See 38 C.F.R. § 4.118 (2008). Under the post-October 2008 version of Diagnostic Code 7800, a 10 percent rating is warranted for burn scars of the head, face, or neck; or scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck - when the skin disability has one characteristic of disfigurement. See 38 C.F.R. § 4.118 (2016). Under Diagnostic Code 7801, a 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear, at least 39 sq. cm. in area but less than 77 sq. cm. (or between 6 sq. inches and 12 sq. inches). Under Diagnostic Code 7802, a maximum 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are superficial (not associated with soft tissue damage) and nonlinear, affecting an area or areas of 144 square inches (929 sq. cm.) or greater. Id. Under DC 7804, which applies to scars that are unstable or painful, a 10 percent evaluation is warranted for one or two scars that are unstable or painful. A 20 percent evaluation is warranted for three or four scars that are unstable or painful. A maximum 30 percent evaluation is warranted for five or more scars that are unstable or painful. Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provides that if one or more scars are both unstable and painful, 10 percent should be added to the evaluation that is based on the total number of unstable or painful scars. Note 3 provides that scars evaluated under DC 7800, 7801, 7802, and 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, DC 7804. DC 7805 applies to other scars (including linear scars) and other effects of scars evaluated under DC 7800, 7801, 7802 and 7804. Any disabling effects not considered in a rating provided under DC 7800 through 7804 should be evaluated under an appropriate diagnostic code. Upon review, the evidence of record does not warrant an initial disability rating greater than 10 percent for the left knee scars under all three sets of skin criteria as discussed further below. 38 C.F.R. § 4.7. Additionally, under all three sets of skin criteria, the Veteran does not contend, and the objective evidence does not demonstrate disfigurement of the head, face, or neck when the skin disability is moderately disfiguring; burn scars, scars due to other causes, or disfigurement on the head, face, or neck with one characteristic of disfigurement (Diagnostic Code 7800). Compare 38 C.F.R. § 4.118 (2016) with 38 C.F.R. § 4.118 (2008) with 38 C.F.R. § 4.118 (2001). Turning to the available evidence of record, the record does not document complaints or objective findings concerning left knee scars prior to September 2011. Specifically, the record is devoid of any evidence of documenting nonlinear, unstable, or painful scars on his left knee prior to September 2011. At a September 2011 VA examination, the Veteran’s left knee surgical scars were documented. He was noted to have two scars with one located on the inferior aspect measuring 6.5 cm by 0.3 cm linear, and another on the outer aspect measuring 2 cm by.3cm. The scars were described as well-healed, hypo-pigmented, superficial, non-adherent, caused no limitation in range of motion, and there was no evidence of keloid or ulcerations. The Veteran specifically reported that his scars did not cause any problems. At the September 2013 VA examination, the Veteran did not have left knee scars that were painful and/or unstable, nor having the total area of all related scars greater than 39 scar cm. Subsequent VA examinations in September 2014 and December 2017 noted similar results. There are no treatment notes showing further limitations or a more severe presentation of the Veteran’s scars than represented in the VA examinations. Neither the Veteran, nor his representative, have submitted specific arguments to support increased ratings for his scars. In light of the foregoing, the Board finds that the Veteran’s scars warrant a noncompensable under DC 7805 throughout the period on appeal. Under the pre-August 2002 criteria, the probative evidence of record does not demonstrate: a third degree burn or scar in an area or areas exceeding 6 square inches (38.7 sq. cm.) (Diagnostic Code 7801); a second degree burn scar with an area approximating 1 square foot (Diagnostic Code 7802); a superficial scar, poorly nourished, with repeated ulceration (Diagnostic Code 7803); or a scar with limitation of function of the affected part (Diagnostic Code 7805). Under the pre-October 2008 criteria, the probative evidence of record does not demonstrate: a deep scar or one that causes limited motion exceeding 39 square cm. (Diagnostic Code 7801); a superficial scar 929 sq. cm. or greater in area (Diagnostic Code 7802); a superficial scar that is unstable (involving frequent loss of covering of skin over the scar) (Diagnostic Code 7803); or, left knee scars causing limitation of function of an affected part (Diagnostic Code 7805). Under the post-October 2008 criteria, the probative evidence of record does not demonstrate burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear, at least 39 sq. cm. in area but less than 77 sq. cm. (Diagnostic Code 7801); burn scars or scars due to other causes, not of the head, face, or neck, that are superficial (not associated with soft tissue damage) and nonlinear, affecting an area or areas of 144 square inches (929 sq. cm.) or greater (Diagnostic Code 7802); or, a separate rating for any disabling effects not considered under Diagnostic Codes 7800-7804 (Diagnostic Code 7805). All of the Veteran’s scars are linear and stable, are not deep or exceed 39 square cms, or are burn scars or exceeds 6 square inches, and does not cause limitation of function or motion. Thus, under all three rating criteria and applicable diagnostic codes, a compensable rating is not warranted for the Veteran’s left knee scars. The claim is denied. 4. Entitlement to separate rating for left knee instability with a 10 percent disability rating Separate ratings may be assigned for limitation of motion and for instability of the knee under DC 5257. VAOPGCPREC 23-97 (July 1, 1997). Separate ratings may also be assigned for both limitation of flexion (DC 5260) and limitation of extension (DC 5261). VAOPGCPREC 9-04 (September 17, 2004). In addition, the Court recently made clear that separate ratings may be assigned for meniscal injury under DC 5258 or 5259, instability under DC 5257, and/or limitation of motion under DC 5260 and/or 5261, if there are non-overlapping symptoms to warrant each rating. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Board has considered the rating criteria under DC 5257, which provides ratings for recurrent subluxation or lateral instability of the knee. The Board acknowledges the Veteran’s report of instability of his left knee. See September 2014 VA medical examination. For example, the Veteran has complained of his left knee locking and giving way. See June 1995 private treatment notes. He also reported a history of minor episodes of instability in his left knee at the June 1995 doctor visit. He further stated that his left knee condition impacts his daily activities and that he must be very careful when walking. See September 2011 VA medical examination report. In addition, he has reported occasional use of a cane as an assistive device for normal locomotion beginning in 2013. See September 2013 and September 2014 VA medical examination reports. The Veteran endorsed the inability to flex his left knee at times. He has asserted that his left knee is a laterally unstable. He has also endorsed falls due to knee instability. As the evidence of record demonstrates intermittent notations of instability, a separate rating under DC 5257, recurrent subluxation or lateral instability, must be considered. While no instability of the left knee was documented on objective testing at VA examinations throughout the period of issue, the Veteran has consistently reported symptoms consistent with instability, such as give away in his left knee and falls. That stated, given the Veteran’s competent and credible lay accounts of intermittent falls, and prior history of instability documented in private treatment notes, the Board finds that the evidence of record is in equipoise as to whether instability of the left knee is shown by the record throughout the appeal period. Resolving all doubt in the Veteran’s favor, a separate 10 percent disability rating under DC 5257 based on slight instability, is warranted. Considerations Under Mitchell v. Shinseki In evaluating ratings for the Veteran’s left knee disabilities, the Board has considered any additional limitation that the Veteran may have during flareups and with repeated use over time. The guidance on how to evaluate flareups has not been particularly clear. As a consequence, it is determined that the holding in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), will be expanded and flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. As addressed above, the Veteran’s reports of flareups have been considered. However, the statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher ratings would not violate the rule regarding stabilization of ratings.  In particular, the VA examiners attempted to elicit information from the Veteran in this regard, and he stated that flares would decrease his activity level. Notably, the Veteran was examined during repeated use over time at the December 2017 VA examination. The examiner opined that repeated use over time did not cause significant functional limitations and the range of motion exhibited did not prompt higher ratings under DC 5260, 5261, or 5257. Moreover, repetitive use testing resulted in a reduction of limitation of flexion to only 70 degrees. Otherwise, repetitive use testing did not result in additional limitation to range of motion. In sum, 38 C.F.R. § 4.1 provides that the degrees of disability specified by the ratings in particular diagnostic codes 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. Here, the Veteran’s reports of exacerbation or flareups for his left knee disabilities are not quantifiable and not of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell, 38 C.F.R. § 4.1, and the rule regarding stabilization of ratings.  Although the Veteran contends that his left knee disabilities warrants a higher rating, he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of any disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which his disability is evaluated. As such, the Board finds these records to be more probative than the Veteran’s subjective complaints of increased symptomatology. (CONTINUED ON NEXT PAGE) Conclusion The preponderance of the evidence is against finding increased ratings for the Veteran’s left knee and left knee scars disabilities. As such, his claims for increased ratings are denied. A separate rating for left knee instability is granted. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N.B. Mmeje, 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.