Citation Nr: 21069320 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 14-34 453 DATE: November 18, 2021 ORDER A rating in excess of 10 percent for right knee patellofemoral syndrome and musculoligamentous strain with degenerative joint disease (DJD), manifested by limitation of motion (LOM), is denied. FINDING OF FACT The Veteran's right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM, has been characterized by pain and stiffness, particularly with flare-ups, but has not at any point approximated flexion limited to 45 degrees or extension limited to 15 degrees or greater. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1993 to October 2000. This appeal is before the Board of Veterans' Appeals (Board) from a June 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office. In February 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript is included in the claims file. In March 2019, the Board granted a rating of 10 percent, but no greater, for left shoulder musculoligamentous strain with DJD; a rating of 10 percent, but no greater, for right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM; a separate rating of 20 percent for right knee meniscal tear prior to April 21, 2014; and separate rating of 10 percent for right knee medial meniscectomy residuals beginning April 21, 2014. The Veteran appealed the decision only insofar as it denied a rating greater than 10 percent for right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM, to the United States Court of Appeals for Veterans Claims (Court). In July 2020, the Veteran, through his attorney, and the Secretary of Veterans Affairs submitted a Joint Motion for Partial Remand. In July 2020, the Court granted the motion and remanded the case to the Board. The Board remanded the appeal to the agency of original jurisdiction (AOJ) in February 2021. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. DC 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensable; flexion limited to 45 degrees is rated 10 percent; flexion limited to 30 degrees is rated 20 percent; and flexion limited to 15 degrees is rated 30 percent. 38 C.F.R. § 4.71a. DC 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensable; extension limited to 10 degrees is rated 10 percent; extension limited to 15 degrees is rated 20 percent; extension limited to 20 degrees is rated 30 percent; extension limited to 30 degrees is rated 40 percent; and extension limited to 45 degrees is rated 50 percent. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Reasonable doubt regarding the degree of disability, or any other point, is resolved in favor of the claimant. 38 U.S.C. § 5107. A rating in excess of 10 percent for right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM, is denied. VA treatment records from 2012 to 2018 reflect that the Veteran has had pain and limitation of motion in connection with his right knee patellofemoral syndrome and musculoligamentous strain with DJD, worse with walking and exercising. In April 2014, range of motion testing showed 0 degrees extension to 130 degrees flexion, with normal gait and movement noted. In September 2015, it was from 0 to 110 degrees, with pain and stiffness at the extremes and some effusion, pain, and tenderness to palpation at the medial joint line, and mild patellofemoral crepitation with range of motion. In March 2016, it was noted that the Veteran had full motor strength, 5/5, throughout range of motion, and in April 2016 it was noted that he maintained good range of motion. November 2017 and January 2018 notes reflect that the Veteran's bilateral knee range of motion was within normal limits and symmetrical, from 0 degrees extension to 120 degrees flexion. In May 2018, range of motion was noted to be within normal limits with pain reported at the end of range motion. On January 2013 VA examination, the Veteran reported worsening knee pain and flare-ups of increased right knee pain under his right knee cap occurring one day or more per year and lasting 2 minutes, where he had to stop whatever he was doing and wait for it to pass. He further reported increased right knee pain and swelling if he walked all day, 2 to 4 times a week, relieved 30 to 45 minutes after sitting down. He was reportedly unable to walk without pain. Range of motion was 0 to 110 degrees with no objective evidence of painful motion, and unchanged after repetition. The knee had full strength, 5/5, and all stability testing was normal with no evidence or history of recurrent patellar subluxation/dislocation. The examiner opined that the Veteran's right knee condition impaired his ability to perform occupational tasks that required running, jumping, repetitive squatting, or high impact activity, but that the Veteran was able to walk several miles and 8 hours per day if needed. On March 2018 VA examination, the Veteran reported right knee pain of 4 to 5/10 without activity and 8 to 10/10 with activity such as mowing the yard. He reported flare-ups whereby both knees get stiff when sitting too long and he must move, and functional impairment of being unable to sit or stand too long, being unable to run, and exercise getting harder. Range of motion was noted to be normal, 0 to 140 degrees, with pain noted on flexion but not resulting in functional loss, and no further functional loss with repetition. Muscle strength was full 5/5, and all joint stability tests were normal. The examiner opined that the Veteran's right knee osteoarthritis prevented him from kneeling or running activities, but did not prevent work of a moderately active occupation or sedentary work. On August 2021 VA examination, the Veteran reported right knee pain with flare-ups of moderate severity 2 to 3 times per month, lasting 4 to 8 hours, involving increase in right knee stiffness, sharp pains with palpation of the kneecap, and pain with walking. Precipitating factors of such flare-ups were change of weather and increased activity like walking stairs or mowing the lawn. Reported functional impairment of such flare-ups was that the Veteran could not fully straighten the knee, and it hurt to squat or lunge. Both active and passive range of motion testing showed flexion to 140 degrees and extension to 0, with pain noted in extension; such pain was in both weight-bearing and nonweight-bearing and active and passive motion, but did not result in any additional functional loss. It was noted that procured evidence (statements from the Veteran) suggested pain, fatigability, weakness, lack of endurance, or incoordination which significantly limited functional ability with flare-ups, but not with repeated use over time. Based on information procured from relevant sources including the lay statements of the Veteran, the estimate range of motion in degrees for the right knee during flare-ups was flexion to 140 degrees and extension limited to 10 degrees. The Veteran's right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM, thus warrants a rating no greater than 10 percent. Even considering all symptomology of the Veteran's knee disability including pain and stiffness with flare-ups, worse with activity, resulting in such functional impairment as inability to run, kneel, or sit, walk or stand for extended periods of time, and difficulty exercising and with other normal use of the knee, such disability does not warrant a 20 percent rating, or separate 10 percent ratings, under DC 5260 and/or DC 5261. The most to which flexion has been limited on testing has been to 110 degrees; even if the Veteran's range of motion were to be considered limited by half of that range, it would not meet the criteria under DC 5260 for even a compensable, 10 percent rating. The Veteran's right knee extension has consistently been to 0 degrees, although on August 2021 VA examination, based on information procured from relevant sources including the lay statements of the Veteran, estimated extension during flare-ups was 10 degrees. Even taking the Veteran's estimated extension during flare-ups as his extension for rating purposes, his disability warrants no greater than a 10 percent rating under DC 5261. Thus, even considering all rating factors contemplated in 38 C.F.R. §§ 4.40, 4.45, 4.59, no greater than a 10 percent rating for the Veteran's right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM, is warranted. Accordingly, a rating in excess of 10 percent for right knee patellofemoral syndrome and musculoligamentous strain with DJD, manifested by LOM, must be denied. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Andrew Mack, 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.