Citation Nr: 21062332 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 05-31 922 DATE: October 7, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral pain since syndrome is denied. Entitlement to a separate initial rating of 10 percent, but no higher, from January 25, 2017 to February 10, 2019, for right knee limitation of extension is granted. Entitlement to a separate initial rating of 10 percent, but no higher, for right knee instability from March 25, 2008, is granted. FINDINGS OF FACT 1. The Veteran's right knee patellofemoral syndrome is not manifested by flexion limited to 30 degrees; moreover, there is no evidence of recurrent subluxation or lateral instability, tibia and fibula impairment, genu recurvatum, dislocated or removed semilunar cartilage, or ankylosis of the right knee. 2. From January 25, 2017 to February 10, 2019 the Veteran's right knee limitation of extension was limited to 10 degrees. Prior to January 25, 2017 and from February 11, 2019, the Veteran's right knee has demonstrated full extension, and even considering flare-ups, extension limited to 10 degrees has not been demonstrated. 3. Resolving all reasonable doubt in favor of the Veteran, from March 25, 2008, he had slight right knee instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for right knee patellofemoral pain since syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. 2. From January 25, 2017 to February 10, 2019, the criteria for an initial rating of 10 percent, but no higher, for right knee limitation of extension have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 3. From March 25, 2008, the criteria for a separate 10 percent disability rating for right knee instability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1998 to September 2002. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from an October 2002 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), that granted service connection and assigned and initial noncompensable rating for right knee patellofemoral pain syndrome, effective September 25, 2002 under Diagnostic Codes 5099-5260. In a March 2017 rating decision, a higher 10 percent rating for limitation of extension was assigned, effective January 25, 2017, under Diagnostic Code 5261. In March 2008, the Veteran testified before a Veterans Law Judge (VLJ) who is no longer employed at the Board. A transcript of the hearing is of record. In October 2019 and February 2020, the Veteran was offered an additional Board hearing. To date, the Veteran has not provided any response indicating that he would like an additional hearing. The Board first remanded the issue on appeal for additional development in September 2009, and in January and November 2013. Pursuant to an April 2014 decision, the Board denied the Veteran entitlement to a compensable rating for his service-connected right knee disability. The Veteran appealed to the Court of Appeals for Veterans Claims (CAVC or Court). In a November 2015 Memorandum Decision, the Court vacated the Board's April 2014 denial and remanded the matter for further adjudication. Pursuant to the CAVC decision, the Board remanded the matter for further development in August 2016. The Board remanded the matter again in August 2017 and May 2020, and most recently in April 2021 to afford the Veteran a new VA examination in light of the February 7, 2021 amendments to the rating criteria governing knee disabilities, to specifically include amendments to Diagnostic Code 5257 regarding patellar instability. As the actions specified in the most recent remand have been substantially complied with, the matter is again properly before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In a January 2021 rating decision, the RO granted an effective date of September 24, 2002, for the initial 10 percent rating assigned for the right knee patellofemoral pain syndrome, based on painful motion of the knee with x-ray evidence of degenerative arthritis under Diagnostic Codes 5003-5010. Lastly, the Board notes that service connection for gout has been raised by the record. See April 2014 Board decision. Should the Veteran wish to pursue a claim for service connection for gout, he may file a claim for service connection for gout using the appropriate form. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. Neither the Veteran nor the record has raised any issues regarding VA's duties to notify or assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). As such, the Board will proceed with appellate consideration of the issue on appeal. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of the assignment of different ratings for distinct periods of time, based on the facts found is required. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral pain since syndrome The Veteran generally contends that he is entitled to an increased rating for his service-connected right knee disability, diagnosed as patellofemoral pain syndrome and arthritis, because his symptoms are more severe than contemplated by his currently-assigned rating. The Veteran testified at his Board hearing that during flare-ups his knee gets weak and is not stable. He also experiences pain and swelling. The Veteran uses a brace and occasionally uses crutches. He can walk a third of a mile when his knee is not bothering him, but on a bad day he is more limited. See January 2008 Board Hearing Transcript. In an October 2002 rating decision, the RO granted service connection for right knee patellofemoral pain syndrome, and assigned a noncompensable rating under Diagnostic Codes, 5099-5260, effective September 25, 2002. In a March 2017 rating decision, the RO granted the Veteran a higher, 10 percent rating from January 25, 2017 based on limitation of extension under Diagnostic Code 5261. In a subsequent January 2021 rating decision, the RO granted a higher initial 10 percent rating for his right knee disability from September 25, 2002, returning to Diagnostic Code 5260 based on painful limitation of motion. Accordingly, the Veteran is currently in receipt of a 10 percent rating for his right knee disability under Diagnostic Codes 5003-5260, based on functional loss due to painful motion, pursuant to 38 C.F.R. § 4.59. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional code to identify the basis for the rating assigned. See 38 C.F.R. § 4.27. VA amended the criteria for rating knee disabilities effective February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. For respect to disabilities of the knee, Diagnostic Codes 5256 through 5263 set forth the relevant provisions regarding evaluating knee disabilities. However, in this case, the evidence does not demonstrate ankylosis of the knee (Diagnostic Code 5256), symptomatic removal of semilunar cartilage (Diagnostic Code 5259), or impairment of the tibia and fibula (Diagnostic Code 5262); thus, the Diagnostic Codes pertaining to such impairments are not applicable. Diagnostic Codes 5260 and 5261 were not changed by the February 7, 2021 amendments. Diagnostic Codes 5260 and 5261 provide for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the Office of General Counsel (OGC) held that separate evaluations under 38 C.F.R. § 4.71a , Diagnostic Code 5260, (limitation of knee flexion) and 38 C.F.R. § 4.71a , Diagnostic Code 5261, (limitation of knee extension) can be assigned without pyramiding. Despite the fact that knee flexion and extension both occur in the same plane of motion, limitation of flexion (bending the knee) and limitation of extension (straightening the knee) represent distinct disabilities. Prior to February 7, 2021, Diagnostic Code 5257 addresses recurrent subluxation or lateral instability of the knee. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38C.F.R. §4.71a, Diagnostic Code 5257. Effective February 7, 2021, Diagnostic Code 5257, recurrent subluxation or instability, allows a 10 percent rating for sprain, incomplete ligament tear, or complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. A 20 percent rating is warranted for either [1] sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation or [2] unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Additionally, effective February 7, 2021, VA added patellar instability to Diagnostic Code 5257. For patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. Note 1 to Diagnostic Code 5257 provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a. As the Veteran's right knee disability manifests by painful motion, the disability will be rated based on the diagnostic codes concerning limitation of motion of the knee. The Board's analysis will begin with Diagnostic Code 5260, which contemplates the criteria for limitation of flexion of the knee, but all potentially applicable rating criteria will also be considered. In considering range of motion ratings, it is important to consider whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). A minimum compensable evaluation for a joint disability is warranted for painful motion under 38 C.F.R. § 4.59. However, a rating in excess of the minimum compensable rating must be based on demonstrated functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Turning to the relevant evidence of record, the Veteran underwent a VA examination in June 2005. The Veteran did not report flare-ups. The examiner noted that the Veteran's knee pain is not debilitating and that he can perform his daily activities. The Veteran was in physical therapy. The Veteran was using Motrin and a knee brace. The examiner noted no weakness, fatigability, decreased endurance, incoordination or flare-ups. There was no tenderness to palpation, no swelling, no deformities, and no instability. Active range of motion (ROM) testing of the right knee revealed flexion of 0 to 100 degrees with full extension. Passive ROM testing revealed flexion of 0 to 130 degrees with full extension. A June 2005 VA treatment note reflects the Veteran's report of right knee pain, with his right knee giving way for the past 5 years. After examining the Veteran, his provider noted knee pain with palpation along the joint line, but an otherwise normal exam. See June 2005 VA Orthopedic Surgery Note. A May 2009 VA MRI of the Veteran's right knee revealed tenderness and an abnormal signal involving the anterior horn of the lateral meniscus of the right knee. A complex tear was suspected, along with small joint effusion. In December 2009, the Veteran underwent an additional VA examination. The Veteran reported moderate, recurrent pain and swelling since approximately 1999 or 2000. The examiner noted that no weakness, fatigability, decreased endurance, incoordination, instability or flare-ups were claimed. Active ROM testing of the right knee revealed flexion of 0 to 90 degrees with full extension. Passive ROM testing revealed flexion of 0 to 130 degrees with full extension. The examiner noted that there was no pain with repetitive motion. A July 2011 VA treatment note reflects right knee moderate effusion, mild warmth and no erythema. The Veteran's right knee was drained of fluid and injected with methylprednisolone. See July 2011 VA Primary Care note. Pursuant to the January 2012 Board remand, the Veteran was afforded another VA examination in February 2012. On remand, the examiner was asked to determine whether the Veteran had a meniscal condition. The Veteran was told two years prior that he had a right meniscal tear but did not undergo surgery. The examiner noted that while the May 2009 MRI was suspicious for a lateral meniscus tear, clinical findings did not support the diagnosis. There was no evidence of symptoms of a meniscal tear. The Veteran reported current symptoms of pain when kneeling and after getting up from kneeling for a couple of minutes. He had morning pain and stiffness that resolved after moving around. He had no episodes of severe pain or swelling when taking prescription medication for his gout. He denied locking or feeling that his knee would collapse in recent months. The Veteran reported that prior to regularly taking colchicine, that he experienced flare-ups with swelling in either knee at times which required aspiration and resulted in limited flexion. The Veteran was not currently experiencing flare-ups. Initial range of motion testing of the right knee showed that the Veteran had flexion from 0 to 135 degrees, and full extension. The examiner noted no objective evidence of painful motion. Repetitive testing did not result in any additional ROM loss. The examiner noted that the Veteran had a history of bilateral shin splints when running, but not in recent years. The examiner noted that the Veteran was able to perform repetitive-use testing with at least three repetitions, but no additional loss of function or range of motion was noted for the right knee. Muscle strength testing was normal. The Veteran did not have ankylosis. Stability testing of the right knee was normal. There was no history of recurrent patellar subluxation or stress fractures, but a history of shin splints was noted. The Veteran did not use an assistive device. Pursuant to the January 2013 Board remand, the Veteran underwent an additional VA examination in July 2013. The Veteran reported intermittent swelling and pain in both knees since 1999-2000. In between episodes of gout the Veteran gets right knee pain with running and sudden twisting movements. Pain during these times is ranked as 6-7 out of 10, and improves in a few hours with ibuprofen, rest, and activity limitation. During flare-ups the Veteran reported decreased ROM and instability/giving way, but no locking. These symptoms have gotten worse since 2008. The examiner noted that since the Veteran was not currently experiencing flare that he was unable to establish the functional impact of flare-ups on the right knee. Initial range of motion testing of the right knee showed that the Veteran had flexion from 0 to 125 degrees, and full extension. The examiner noted no objective evidence of painful motion. Repetitive testing did not result in any additional ROM loss. Muscle strength testing was normal. Stability testing of the right knee was normal. There was no history of recurrent patellar subluxation, stress fractures, or shin splints. The Veteran occasionally used a brace and a cane which the examiner noted were prescribed for the Veteran's gout. The examiner noted that pain with prolonged standing impacts the Veteran's ability to work as a barber. Pursuant to the November 2013 Board remand, the Veteran underwent an additional VA examination in December 2013. The Veteran reported experiencing flare-ups with the last period of flare occurring the prior year. Flare-ups resulted in additional limitation of motion. The examiner stated that he was unable to determine ROM during a flare-up as the Veteran was not experiencing a flare at the time. These symptoms have gotten worse since 2008. The examiner noted that since the Veteran was not currently experiencing a flare-up that he was unable to assess whether pain or swelling could significantly limit functional ability during flare-ups or during repetitive use. Initial range of motion testing of the right knee showed that the Veteran had full flexion to 140 degrees, with full extension. The examiner noted no objective evidence of painful motion. Repetitive testing did not result in any additional ROM loss. Muscle strength testing was normal. Stability testing of the right knee was normal. There was no history of recurrent patellar subluxation, stress fractures, or shin splints. The examiner noted that the Veteran had a meniscus condition in the right knee with frequent episodes of joint effusion, but had not undergone a meniscectomy. The examiner noted that the Veteran did not use an assistive device. A history of intermittent gout of the right knee was noted. Pursuant to the August 2016 Board remand, the Veteran underwent an additional VA examination in January 2017. The Veteran reported current symptoms of intermittent, sharp/throbbing pain with swelling and stiffness aggravated during gout flare-ups. The Veteran reported no flare-ups related to his service-connected right knee disability. Initial range of motion testing of the right knee showed that the Veteran had flexion to 95 degrees, and extension to 10 degrees. The examiner noted pain on testing of both planes of motion causing functional loss. There was objective evidence of crepitus. Repetitive testing did not result in any additional ROM loss. Muscle strength testing of the right knee was 4/5 on flexion and extension. It was not indicated whether joint stability testing was conducted. There was no history of recurrent patellar subluxation, stress fractures, or shin splints, and no history of a meniscus condition. The Veteran occasionally used a cane and brace. The Veteran underwent an additional VA examination in February 2019. The Veteran reported experiencing flare-ups with worsening pain precipitated by increased weightbearing due to standing or walking. Flare-ups resulted in limited mobility and standing. The examiner stated that he was unable to determine ROM during a flare-up as the Veteran was not experiencing a flare at the time. The examiner noted that since the Veteran was not currently experiencing a flare-up that he was unable to assess whether pain or swelling could significantly limit functional ability during flare-ups or during repetitive use. Initial range of motion testing of the right knee showed that the Veteran had full flexion to 140 degrees, and full extension. The examiner noted no objective evidence of painful motion. Repetitive testing did not result in any additional ROM loss. Stability testing of the right knee was normal. There was no history of recurrent patellar subluxation, stress fractures, or shin splints, and no history of a meniscus condition. The examiner noted that the Veteran occasionally used a brace when experiencing severe stiffness. Pursuant to the May 2020 Board remand, the Veteran underwent an additional VA examination in January 2021. The Veteran reported that he had been bed ridden for the prior 3 days due to pain, swelling, and decreased ROM of his right knee. The Veteran also reported experiencing flare-ups 2-3 times per month "severe" in nature, lasting 3-4 days per week. Flare-ups are precipitated by prolonged standing, heavy lifting, and carrying activities and alleviated by medication, resting, laying in bed, limiting activities, and gently bending the knee. Initial range of motion testing of the right knee showed that the Veteran had flexion to 110 degrees, with full extension. The examiner noted pain on testing of both planes of motion causing functional loss. There was objective evidence of localized tenderness or pain on palpation in the anterior and posterior areas of the right knee, with the Veteran rating severity at 9 of 10. The Veteran experienced pain on weightbearing. There was no objective evidence of crepitus. Repetitive testing did not result in any additional ROM loss, but did result in additional functional loss caused by pain, weakness and lack of endurance. The exam was conducted during a flare-up, with the Veteran experiencing ROM loss to 90 degrees on flexion testing, but maintaining full extension. The examiner noted that pain, weakness, and lack of endurance significantly limit functional ability during flare-ups. Muscle strength testing of the right knee was 3/5 on flexion and extension. Joint stability testing was not conducted due to the Veteran's reported pain of 9/10. There was no history of recurrent patellar subluxation, stress fractures, or shin splints, and no history of a meniscus condition. The examiner noted weakened movement due to swelling of the knee, increased pain, and instability of locomotion. The Veteran regularly used a right hand crutch for knee stability and to prevent falls due to his right knee osteoarthritis. Pursuant to the Board's most recent April 2021 remand, the Veteran underwent an additional VA examination in July 2021. The Veteran reported current symptoms of worsening, throbbing/aching right knee pain, with swelling. The Veteran denied experiencing flare-ups. Initial range of motion testing of the right knee showed that the Veteran had flexion to 140 degrees, with full extension. There was no objective evidence of pain, but there was objective evidence of crepitus. Repetitive testing did not result in any additional ROM loss, but did result in additional functional loss caused by pain. Joint stability testing was normal, and the Veteran had no recurrent patellar instability. There was no history of recurrent patellar subluxation, stress fractures, or shin splints, and no history of a meniscus condition. The Veteran did not use any assistive device. There is no evidence that any of the examiners were not competent or credible. The findings provided in the examination reports are adequate to decide the claim. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). Having reviewed the evidence of record, medical and lay, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's right knee disability based on limitation of flexion at any time during the period on appeal. Throughout the period on appeal, the Veteran has been assigned a 10 percent rating for the right knee for functional loss due to painful motion. This 10 percent rating for painful motion has been assigned pursuant to 38 C.F.R. § 4.59, which allows for a compensable rating available for limitation of motion for a joint if there is acknowledged painful motion. Thus, the Board finds that an initial rating in excess of 10 percent for painful limitation of flexion motion under Diagnostic Codes 5003-5260 is not warranted at any time since the effective date of the grant of service connection. However, the Board finds that during the period from January 25, 2017 to February 11, 2019, the Veteran's right knee disability has resulted in limitation of extension sufficient to meet the requirements for a separate 10 rating under Diagnostic Code 5261. In this regard, on VA examination in January 2017, the Veteran was shown to have extension limited to 10 degrees at worst. Subsequent VA examinations beginning on February 11, 2019, and every examination thereafter, the Veteran has demonstrated full extension on examination. Even after repeated range of motion testing and with consideration of flare-ups. Thus, for the period from the January 2017 VA examination to February 10, 2019, a 10 percent rating, but no higher, for limitation of extension is warranted. However, a higher rating is not warranted for additional functional limitation of motion. The Board acknowledges the Veteran's reports of symptoms such as pain, swelling, tenderness, limited mobility, weakness, instability of locomotion, and increased pain with prolonged standing and walking. However, pain itself does not rise to the level of functional loss applicable to the musculoskeletal system. Mitchell v. Shinseki. Physical examination of the Veteran consistently indicated no additional limitation of motion that was commensurate with a higher rating. As such, a higher rating for additional limitation of motion is not warranted. See DeLuca v. Brown, 8 Vet. App. at 202. Additionally, the Veteran is already compensated for his right knee pain; specifically, he has been assigned a 10 percent rating because of pain in his right knee pursuant to 38 C.F.R. § 4.59. Sharp v. Shulkin, 29 Vet. App. 26, 3436 (2017). However even with consideration of all pertinent disability factors, there remains no basis for assignment of a higher rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. See also Sharp v. Shulkin, 29 Vet. App. 26, 3436 (2017). Lastly, resolving all reasonable doubt in favor of the Veteran, the Board finds that throughout the period on appeal, the evidence is at least in equipoise, that a separate 10 percent disability rating for right knee instability is warranted under the pre- February 7, 2021 version of Diagnostic Code 5257. While the VA examinations of record show that the Veteran does not have instability, objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257. As such, objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352 - 53 (2018). In this case, the Veteran first reported having issues with right knee instability during his March 2008 hearing, and July 2013 and January 2021 VA examinations. The Board finds that the Veteran's reports of his right knee instability are credible and competent. Without objective evidence on examination though, the Board finds that such reports support a finding of, at most, slight instability under Diagnostic Code 5257. However, the preponderance of the evidence is against a rating in excess of 10 percent for right knee instability. The Board has carefully considered the Veteran's reports about instability, but overall, the lay and medical evidence indicates that the instability symptoms occur infrequently and do not suggest the presence of symptoms more nearly approximating moderate severity. Moreover, out of all of the medical evidence of record, only the January 2021 examination resulted in physical findings of instability of locomotion. There have been no other physical findings of instability, which would reasonably be expected if instability were more severe. Under the amended 5257 rating criteria, while the Veteran has regularly used a right-hand crutch for stability at times during the period on appeal, but has not been found to have persistent instability or patellar instability. Thus, the amended version of Diagnostic Code 5257 does not provide for a higher rating. The Board has considered whether the Veteran is eligible for separate ratings under any other potentially applicable diagnostic code. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). There is no evidence that the Veteran had frequent episodes of "locking," pain, and effusion as a result of semilunar cartilage dislocation or removal. Thus, ratings under Diagnostic Codes 5258 or 5259 are not warranted. Moreover, there is no evidence during the period on appeal of ankylosis, removed semilunar cartilage, tibia and fibula impairment, or genu recurvatum in the right knee. As such, the Board finds that separate ratings under Diagnostic Codes 5256, 5262, or 5263 are not warranted. Finally, the Board notes that the Veteran has a current diagnosis of right knee arthritis; as such, the Board has considered whether he is eligible for an increased rating under Diagnostic Code 5003 for arthritis. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Veteran is already in receipt of a 10 percent disability rating for his right knee disability on the basis of painful limitation of motion pursuant to 38 C.F.R. §§ 4.59. Therefore, the Board is unable to assign a separate 10 percent rating pursuant to Diagnostic Code 5003 under essentially the same manifestation of symptoms, as such would violate the rule against pyramiding in 38 C.F.R. § 4.14. Moreover, the objective medical evidence of record also does not show that an increased 20 percent rating is warranted under Diagnostic Code 5003 for arthritis because the Veteran's arthritis of the right knee does not involve two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. (Continued on the next page) In summary, the Board finds that the Veteran's right knee disability is not entitled to an initial rating in excess of 10 percent at any point since the effective date of the grant of service connection under Diagnostic Codes 5003-5260. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). However, from January 25, 2017 to February 11, 2019, a separate 10 percent disability rating, but no higher, for limitation of extension is granted under Diagnostic Code 5261. Likewise, from March 25, 2008 forward, a separate 10 percent disability rating, but no higher, for right knee instability is granted under Diagnostic Code 5257. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Gates 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.