Citation Nr: 21072018 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 15-06 594 DATE: December 2, 2021 ORDER Entitlement to service connection for ischemic heart disease (IHD) to include as associated with herbicides is denied. Entitlement to service connection for hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to a rating in excess of 10 percent for right knee patella tendonitis with history of Osgood-Schlatter disease is denied. Entitlement to a rating in excess of 10 percent for left knee degenerative joint disease (DJD) with history of Osgood-Schlatter disease and patella tendonitis is denied. FINDINGS OF FACT 1. The Veteran's ischemic heart disease (IHD) did not have onset in service or within one year of separation from service. 2. The Veteran was not exposed to herbicides during his period of active service, including during his service in the Philippines. 3. The Veteran's bilateral hearing loss is not etiologically related to service. 4. The Veteran's tinnitus is not etiologically related to service. 5. The Veteran's right knee patella tendonitis with history of Osgood-Schlatter disease is manifested by flexion to no less than 110 degrees and full extension. 6. The Veteran's left knee degenerative joint disease (DJD) with history of Osgood-Schlatter disease and patella tendonitis is manifested by flexion to no less than 109 degrees and full extension. CONCLUSIONS OF LAW 1. The criteria for service connection for ischemic heart disease (IHD) to include as associated with herbicides have not been met. 38 U.S.C. §§ 1110, 1116, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for hearing loss have not been met. 38 U.S.C. §§ 1101 , 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303 , 3.307, 3.309, 3.385. 3. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1101 , 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303 , 3.307, 3.309. 4. The criteria for a rating in excess of 10 percent for right knee patella tendonitis with history of Osgood-Schlatter disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5024-5262. 5. The criteria for a rating in excess of 10 percent for left knee degenerative joint disease (DJD) with history of Osgood-Schlatter disease and patella tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1971 to February 1977. In April 2018, the Veteran testified at a videoconference before the undersigned. In July 2018, the issues were remanded for further development to include VA examinations and opinions. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § § 3.303 (a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 1. Entitlement to service connection for ischemic heart disease (IHD) to include as associated with herbicides The Veteran contends that his ischemic heart disease, diagnosed in 2011, is related to his military service, and specifically to herbicide exposure. The law provides that diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era will be considered to have been incurred in service. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. § 3.307 (a)(6). A veteran is presumed to have been exposed to herbicides if he or she served in Vietnam between January 9, 1962, and May 7, 1975 (Vietnam era), unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). The presumption of service connection requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307 (a)(6)(ii). If a Veteran was exposed to an herbicide agent during active military, naval, or air service, several diseases listed under 38 C.F.R. § 3.309 (e) (including early onset peripheral neuropathy) shall be service connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307 (d) are also satisfied. VA policy is that it may be established for an Air Force veteran who served on or near the perimeter of a specified Royal Thai Air Force Base (RTAFB) during the Vietnam Era. The Board notes that there is no evidence in the claims file, to include his personnel and service treatment records (STRs), that shows the Veteran served in the Republic of Vietnam or on or near the perimeter of a specified Royal Thai Air Force Base (RTAFB) during the Vietnam Era. There is also no evidence the Veteran's ischemic heart disease had onset within one year of service. As there is no evidence of service in Vietnam, on or near the perimeter of a RTAFB, or of any exposure to herbicides during active duty service, service connection for ischemic heart disease cannot be granted on a presumptive basis. The Board also finds that the weight of the evidence does not support direct service connection for ischemic heart disease. A review of the service treatment records (STRs) are absent a finding of complaints, treatment, or a diagnosis of ischemic heart disease or any heart condition. An August 2011 Ischemic Heart Disease DBQ notes the Veteran has ischemic heart disease with the diagnoses of myocardial infarction and coronary artery disease in October 2010. Post-service private treatment records show that the Veteran has been under the care of a cardiologist. An April 2018 statement from Dr. W. at Novant Health states the Veteran has been an established patient for many years and since 2016 has been assessed 58 times concerning his cardiac condition. A May 2018 statement from Dr. P. at Novant Health Heart and Vascular Institute also notes the Veteran has coronary artery disease, including a prior myocardial infarction, that put him at an increased risk for future cardiovascular events including another myocardial infarction. The Veteran's ischemic heart disease was first diagnosed in 2010, over 30 years after discharge from service. There is no evidence of complaints related to, treatment for, or diagnoses of the disability during active service, and there is no indication of symptoms, treatment, or diagnoses for the disability until decades after service separation. The evidence of record does not relate currently diagnosed ischemic heart disease to service. As such, the Board finds that the weight of the evidence shows that service connection for ischemic heart disease is not warranted. The Board has considered the lay statements made by the Veteran and others, and is sympathetic to the Veteran's current health condition, however, the medical evidence does not support the contention that the Veteran's heart condition is etiologically related to service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, a diagnosis and etiology of a heart disability falls outside the realm of common knowledge of a lay person. The Board accords his statements regarding the etiology of such disorder little probative value as he is not competent to opine on a complex medical question. For the reasons discussed above, a preponderance of the evidence is against the claim for service connection for ischemic heart disease. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for hearing loss The Veteran contends he has a bilateral hearing loss disability due to service, specifically due to military noise exposure from his job duties as a TV/radio repairman. The Veteran's military occupational specialty has been verified by his DD-214. The Veteran has reported, in a March 2012 statement, that he had hearing loss at the end of service, and it has continued since then. The Veteran testified that he was routinely exposed to noise while working on the flight line and the Board finds no reason to doubt his description of exposure to some military noise. 38 U.S.C. § 1143(a). A September 2012 VA hearing examination reflects the Veteran has bilateral sensorineural hearing loss in both ears. The examiner opined that it was less likely than not the Veteran's hearing loss was related to military noise exposure. The rationale was that the Veteran had normal hearing at separation. In July 2018, the Board found the September 2012 VA opinion to be of little probative value as the audiologist seemed to primarily rely on the Veteran having normal hearing at service discharge but did not provide any reason why the in-service acoustic trauma was not a source of, or at least a contributing factor to, his current hearing loss. See Ledford v. Derwinski, 3Vet. App.87, 89 (1992)(the absence of hearing loss at discharge from service is not a bar to service connection). The issue was remanded for a new VA examination and opinion. A June 2021 VA hearing examination report states that a diagnosis could not be made due to invalid test results. The examiner stated testing was performed for air conduction three times and bone conduction two times and between each time the Veteran was reinstructed on the task. The examiner determined the test results were not valid for rating purposes (not indicative of organic hearing loss) citing the Veteran did not follow the instructions properly. The examiner could not give an opinion due to the invalid test results. The examiner in the last examination did make a finding of sensorineural hearing loss in both ears. The Board notes that the duty to assist is not a one-way street or a blind alley. Both the RO and the Board attempted to obtain examinations that would establish the etiology of the Veteran's disability, but the Veteran was not able to produce valid test results. Based on the evidence of record, there is no causal relationship between the claimed disabilities and service. The Board has considered the Veteran's lay statements regarding a hearing loss disability. The Veteran is competent to provide evidence of which he experiences, including his symptomatology and medical history. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran did not complain of hearing loss or tinnitus at the time of discharge from service. The evidence is against a finding that a hearing loss disability manifested in service or, within one year of separation. In sum, the Board finds that the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 3. Entitlement to service connection for tinnitus The Veteran contends that he has a current diagnosis of tinnitus that is related to noise exposure he experienced on the flight line during active duty. As noted above, a September 2012 VA hearing examination reflects the Veteran has found to have bilateral sensorineural hearing loss in both ears. The Veteran reported that he had recurrent tinnitus that began in 1975 and is constant in both ears. The examiner opined that it was at least as likely as not the Veteran's tinnitus was related to his hearing loss, as tinnitus is known to be a symptom associated with hearing loss. At the June 2021 VA hearing examination, the Veteran reported recurrent tinnitus that has gotten worse, but the date and circumstances of onset were unknown. The Veteran reported a constant ringing in the right ear and intermittent in the left ear. The examiner determined a medical opinion regarding etiology of tinnitus could not be provided without resort to speculation. The reason stated was that despite testing being performed for air conduction three times and bone conduction two times, the testing results were clearly invalid because the Veteran did not follow the instructions either time. The Board notes that the duty to assist is not a one-way street or a blind alley. Both the RO and the Board attempted to obtain examinations that would establish the etiology of the Veteran's disability, but the Veteran was not able to produce valid test results. Based on the evidence of record, there is no causal relationship between the claimed disability and service. Unfortunately, the evidence is against a finding that tinnitus manifested in service or, within one year of separation. In sum, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for a tinnitus disability and the claim is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107 (b) is not applicable, as there is no approximate balance of evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The 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 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 reviewed when making disability ratings. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings are also appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). 4. Entitlement to a rating in excess of 10 percent for right knee patella tendonitis with history of Osgood-Schlatter disease The Veteran is currently in receipt of service connection for a right knee disability rated as 10 percent disabling under Diagnostic Code (DC) 5024-5262 for impairment of the tibia and fibula. Under DC 5257, ratings of 10, 20, and 30 percent are assigned where recurrent subluxation or lateral instability is slight, moderate, or severe, respectively. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." 38 C.F.R. § 4.6. The Board notes that effective February 7, 2021, the words "slight," "moderate," and "severe" were removed from the Diagnostic Code. Under DC 5260, ratings of 10, 20, and 30 percent are assigned where flexion is limited to 45, 30, or 15 degrees, respectively. Under DC 5261 for limitation of knee extension, a noncompensable rating is assigned for extension limited to 5 degrees. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Under DC 5262 for impairment of the tibia and fibula, malunion of the tibia and fibula with a slight knee or ankle disability is rated as 10 percent disabling; a moderate knee or ankle disability is rated as 20 percent disabling; and a marked knee or ankle disability is rated as 30 percent disabling. A maximum 40 percent rating is assigned for nonunion of the tibia and fibula with loose motion, requiring a brace. As noted above, effective February 7, 2021, the words "slight," "moderate," and "severe" were removed from the Diagnostic Code. Of note, separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. Specifically, when a veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. See VAOPGCPREC 09-04. 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. An August 2012 VA knee examination report shows the Veteran reported flare-ups described as described mobility due to pain. The Veteran had right knee flexion to 130 degrees and full extension with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with no additional loss of ROM. He did have functional loss and/or functional impairment of the right knee after repetitive use noted as incoordination, impaired ability to execute skilled movements smoothly. The examiner also noted pain with resistivity and on palpation. There was full muscle strength, normal joint stability, and no evidence or history of recurrent patellar subluxation/dislocation. The Veteran had a meniscal or meniscus condition in the past (1975 arthrogram showed suspected torn medial meniscus) with no current symptoms at the time of examination. The examiner stated the Veteran had prominent tibial tuberosities, that were nontender, tight patellae with positive patellar grind test, and pain with resisted extension of the knee. The Veteran reported regular use of a cane while walking due to pain and stiffness in the right knee. As for the functional impact of the Veteran's right knee on his ability to work, the Veteran stated he can't squat or kneel, and he has pain with walking more than two blocks. The examiner also noted that the diagnosis of Osgood-Schlatter disease is asymptomatic currently. A June 2021 VA knee examination showed a diagnosis of right knee patella tendonitis with Osgood-Schlatter disease. During the examination, the Veteran reported his current symptom as pain which is treated with Tramadol and Hydrocodone Oxycodone as needed. He reported flare-ups described as intermittent sharp pain, stiffness, and swelling that is of moderate severity, and precipitated by walking or standing for an extended period. The Veteran stated it lasts less than 2 minutes and is alleviated with rest and use of pain medication. Functional impairment during a flare-up was described by the Veteran as limits in walking or standing for extended periods of time. There was full muscle strength, normal joint stability, and no evidence or history of recurrent patellar subluxation/dislocation. The Veteran had right knee flexion to 110 degrees and full extension with objective evidence of painful motion. Passive range of motion was the same as active ROM with pain on both flexion and extension. There was also evidence of pain with weight-bearing on active and passive motion that did not result in/cause functional loss. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the joint. The Veteran was able to perform repetitive-use testing with no additional loss of ROM and no additional factors caused functional loss. There was no evidence that suggested pain, fatigability, weakness, lack of endurance, or incoordination that significantly limited functional ability with repeated use over time or during flare-ups. There was no muscle atrophy, ankylosis, or joint instability. Additionally, there was no recurrent patellar instability, tibia or fibular impairment, or meniscal conditions. The Veteran reported occasional use of a brace and walker to help with ambulation due to Osgood-Schlatter disease. Functional impact was noted as pain limited ambulation or standing, thereby compromising job function. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the right knee disability under Diagnostic Code 5024-5262. The Veteran's medical records show treatment for his right knee symptoms, but his medical records do not show findings consistent with higher ratings. Regarding right knee flexion, the Veteran's flexion has always exceeded the 60 degree limitation equivalent to a noncompensable rating. Accordingly, the Veteran does not meet the criteria for a rating in excess of 10 percent under DC 5260. Turning to limitation of extension, the medical evidence show that the Veteran has had normal right knee extension to 0 degrees, which exceeds the 5 degree limitation equivalent to a noncompensable rating. Accordingly, the Veteran does not meet the criteria for a rating in excess of 10 percent under DC 5261. Regarding DC, 5257,5260, and 5261, they are not relevant here as the medical record does not document any of these conditions. As for DC 5262, the evidence does not show any period of time during the appeal period when the Veteran's service-connected right knee disability with knee pain had symptoms or functional impairment that warranted an increased evaluation. As for functional loss, even considering that pain was noted on examination the pain did not cause/result in functional loss, including during flare-ups. Accordingly, based on all of the medical evidence, there is no basis for a rating in excess of 10 percent for the Veteran's right knee disability. Considering the objective medical evidence of record in light of the above criteria, the Board finds that a rating in excess of 10 percent for the Veteran's service-connected right knee disability is not warranted. 5. Entitlement to a rating in excess of 10 percent for left knee degenerative joint disease (DJD) with history of Osgood-Schlatter disease and patella tendonitis The Veteran is currently in receipt of service connection for a right knee disability rated as 10 percent disabling under Diagnostic Code (DC) 5003-5262 for degenerative joint disease. Degenerative arthritis is rated under Diagnostic Code 5003, and states that the severity of 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 or joints affected, which in this case would be Diagnostic Codes 5256, for ankylosis of the knee; Diagnostic Code 5257, for recurrent subluxation or lateral instability; Diagnostic Code 5258 for cartilage, semilunar, dislocated, with frequent episodes of "locking", pain, and effusion into the joint; Diagnostic Code 5259 for cartilage, semilunar, removal of, symptomatic; Diagnostic Codes 5260 and 5261 are utilized to rate limitation of flexion and extension of the knee joint; and DC 5262 for impairment of the tibia and fibula. 38 C.F.R. § 4.71a. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion diagnostic code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 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 if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Ratings under Diagnostic Code 5003 are not to be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020). An August 2012 VA knee examination report shows the Veteran reported flare-ups described as described mobility due to pain. The Veteran had left knee flexion to 130 degrees and full extension with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with no additional loss of ROM. He did have functional loss and/or functional impairment of the left knee after repetitive use noted as incoordination, impaired ability to execute skilled movements smoothly. The examiner also noted pain with resistivity and on palpation. There was full muscle strength, normal joint stability, and no evidence or history of recurrent patellar subluxation/dislocation. The Veteran had a meniscal or meniscus condition in the past (1975 arthrogram showed suspected torn medial meniscus) with no current symptoms at the time of examination. The examiner stated the Veteran had prominent tibial tuberosities, that were nontender, tight patellae with positive patellar grind test, and pain with resisted extension of the knee. As for the functional impact of the Veteran's left knee on his ability to work, the Veteran stated he can't squat or kneel, and he has pain with walking more than two blocks. The examiner also noted that the diagnosis of Osgood-Schlatter disease is asymptomatic currently. A June 2021 VA knee examination showed a diagnosis of left knee degenerative joint disease with Osgood-Schlatter disease. During the examination, the Veteran reported his current symptom as pain which is treated with Tramadol and Hydrocodone Oxycodone as needed. He reported flare-ups described as intermittent sharp pain, stiffness, and swelling that is of moderate severity, and precipitated by walking or standing for an extended period. The Veteran stated it lasts less than 2 minutes and is alleviated with rest and use of pain medication. Functional impairment during a flare-up was described by the Veteran as limits in walking or standing for extended periods of time. There was full muscle strength, normal joint stability, and no evidence or history of recurrent patellar subluxation/dislocation. The Veteran had left knee flexion to 109 degrees and full extension with objective evidence of painful motion. Passive range of motion was the same as active ROM with pain on both flexion and extension. There was also evidence of pain with weight-bearing on active and passive motion that did not result in/cause functional loss. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the joint. The Veteran was able to perform repetitive-use testing with no additional loss of ROM and no additional factors caused functional loss. There was no evidence that suggested pain, fatigability, weakness, lack of endurance, or incoordination that significantly limited functional ability with repeated use over time or during flare-ups. There was no muscle atrophy, ankylosis, or joint instability. Additionally, there was no recurrent patellar instability, tibia or fibular impairment, or meniscal conditions. The Veteran reported occasional use of a brace and walker to help with ambulation due to Osgood-Schlatter disease. Functional impact was noted as pain limited ambulation or standing, thereby compromising job function. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the right knee disability under Diagnostic Code 5003-5262. The Veteran's medical records show treatment for his left knee symptoms, but his medical records do not show findings consistent with higher ratings. Regarding right knee flexion, the Veteran's flexion has always exceeded the 60 degree limitation equivalent to a noncompensable rating. Accordingly, the Veteran does not meet the criteria for a rating in excess of 10 percent under DC 5260. Turning to limitation of extension, the medical evidence show that the Veteran has had normal left knee extension to 0 degrees, which exceeds the 5 degree limitation equivalent to a noncompensable rating. Accordingly, the Veteran does not meet the criteria for a rating in excess of 10 percent under DC 5261. Regarding DC, 5256, 5257, 5258, and 5259, they are not relevant here as the medical record does not document any of these conditions. As for DC 5262, the evidence does not show any period of time during the appeal period when the Veteran's service-connected left knee disability with knee pain had symptoms or functional impairment that warranted an increased evaluation. As for functional loss, even considering that pain was noted on examination the pain did not cause/result in functional loss, including during flare-ups. Accordingly, based on all of the medical evidence, there is no basis for a rating in excess of 10 percent for the Veteran's left knee disability. Considering the objective medical evidence of record in light of the above criteria, the Board finds that a rating in excess of 10 percent for the Veteran's service-connected left knee disability is not warranted. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Mitchell, 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.