Citation Nr: 21072141 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 12-21 982 DATE: December 2, 2021 ORDER For the rating period from September 26, 2011 to March 5, 2012, an increased disability rating in excess of 10 percent for right knee chondromalacia (right knee disability) is denied. For the rating period from March 5, 2012 forward, an increased disability rating of 20 percent, but no higher, for the right knee disability is granted. For the initial rating period from July 11, 2017 to February 7, 2021, a higher initial disability rating in excess of 10 percent for right knee instability is denied. For the initial rating period from February 7, 2021 forward, a higher initial 20 percent disability rating, but no higher, for right knee instability is granted. REMANDED Service connection for erectile dysfunction, including as secondary to the service-connected hypertension and/or benign prostatic hypertrophy (BPH), is remanded. FINDINGS OF FACT 1. For the rating period on appeal from September 26, 2011 to March 5, 2012, the right knee disability has been manifested by flexion greater than 60 degrees, extension less than 5 degrees and painful motion, without ankylosis, dislocation or removal of semilunar cartilage, nonunion or malunion of the tibia and fibular, or genu recurvatum. 2. For the rating period on appeal from March 5, 2012 forward, the right knee disability has more nearly approximated dislocated semilunar cartilage with frequent episodes of joint pain and effusion, without ankylosis, flexion limited to 15 degrees or less, extension limited to 20 degrees or more, or nonunion or malunion of the tibia and fibula. 3. For the initial rating period on appeal from July 11, 2017 to February 7, 2021, the right knee instability was not manifested by moderate recurrent subluxation or lateral instability. 4. For the initial rating period on appeal from February 7, 2021 forward, the right knee instability more nearly approximates an incomplete ligament tear causing persistent instability, and a medical provider prescribed a brace and/or assistive device for ambulation. CONCLUSIONS OF LAW 1. For the rating period on appeal from September 26, 2011 to March 5, 2012, the criteria for an increased disability rating in excess of 10 percent for the right knee disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 2. Resolving reasonable doubt in favor of the Veteran, for the rating period on appeal from March 5, 2012 forward, the criteria for an increased disability rating of 20 percent, but no higher, for the right knee disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258. 3. For the initial rating period from July 11, 2017 to February 7, 2021, the criteria for a higher initial disability rating in excess of 10 percent for the right knee instability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5257. 4. Resolving reasonable doubt in the Veteran's favor, for the initial rating period on appeal from February 7, 2021 forward, the criteria for a higher initial disability rating of 20 percent, but no higher, for the right knee instability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, served on active duty from August 1979 to December 1999. The issues of an increased disability rating for the right knee disability, a higher initial rating for right knee instability, and service connection for erectile dysfunction were previously before the Board in June 2018, along with the issues of increased ratings for residuals of a left femur fracture and left knee instability. As a result of the Board's June 2018 remand, the Regional Office (RO) issued a rating decision in May 2020, which addressed the issues of ratings for residuals of a left femur fracture and left knee instability, and granted service connection for left knee degenerative joint disease, limitation of left hip flexion, limitation of left hip extension, impairment of the left thigh, painful scar on the left thigh, linear scars on the left thigh, and special monthly compensation based on the housebound criteria. The Veteran timely appealed the May 2020 rating decision under the Appeals Modernization Act (AMA) by requesting the AMA Hearing Lane for reevaluation of the evidence considered by the Agency of Original Jurisdiction (AOJ) and additional evidence submitted within 90 days after the Veteran's Board hearing. Accordingly, the issues of increased ratings for residuals of a left femur fracture and left knee instability have been removed from the Board's instant decision under the legacy appeals process. For the reasons discussed below, the issue of service connection for erectile dysfunction requires another remand. DISABILITY RATING LEGAL CRITERIA Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. 1. Rating the right knee chondromalacia from September 26, 2011 to March 5, 2012 For the rating period on appeal from September 26, 2011 to March 5, 2012, the Veteran is in receipt of a 10 percent disability rating for the right knee chondromalacia disability under the substantive rating criteria of Diagnostic Code 5003 (10 percent for painful, noncompensable limitation of motion). 38 C.F.R. § 4.71a. The Regional Office (RO) continued the 10 percent rating for the right knee disability for limitation of flexion labeled as Diagnostic Code 5260 for the rating period from September 26, 2011 in the February 2012 rating decision on appeal; however, the reasons and bases analysis in assigning the initial 10 percent rating show that the criteria of Diagnostic Code 5003 were used (rather than compensable limitation of flexion to meet the 10 percent requirements under Diagnostic Code 5260). Diagnostic Code 5003 provides for a 10 percent rating for a major joint (includes the knee) where there is pain with noncompensable limitation of motion. 38 C.F.R. § 4.71a. The evidence in this case shows only noncompensable limitation of right knee flexion and extension; therefore, use of Diagnostic Codes 5260 or 5261 with the 10 percent rating is not appropriate until the evidence shows actual compensable limitation of motion. The appropriate diagnostic codes for rating compensable limitation of motion of the knees are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that, when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Under Diagnostic Code 5260, limitation of knee flexion is rated 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and noncompensable where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensable where extension is limited to 5 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5257 contemplates "other impairment" of the knee including recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where impairment is severe, moderate or slight, disability evaluations of 30, 20, and 10 percent are assigned, respectively. 38 C.F.R. § 4.71a. Diagnostic Code 5262 contemplates impairment of the tibia and fibula, assigning a 40 percent rating for nonunion of the tibia and fibula, and 10, 20, and 30 percent ratings for slight, moderate or marked knee or ankle disabilities. The words "slight," "moderate," "severe," and "marked" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." Id. Under Diagnostic Code 5256, disability ratings are assigned when ankylosis is present. Id. Diagnostic Code 5258 provides a 20 percent disability rating when a dislocated semilunar cartilage is present with frequent episodes of "locking," pain, and effusion into the joint. Id. Diagnostic Code 5259 provides for a 10 percent disability rating when semilunar cartilage has been removed and related symptoms are present. Id. A 10 percent disability rating is assigned under Diagnostic Code 5263 when genu recurvatum is identified. Id. Diagnostic Code 5003 provides a rating of 10 percent for a knee (major) joint where there is evidence of painful, but noncompensable limitation of motion. 38 C.F.R. § 4.71a. See also 38 C.F.R. § 4.59 (providing that painful motion should be considered limitation of motion, with a 10 percent rating as the minimum rating for a painful major joint); Burton v. Shinseki, 25 Vet. App. 1 (2011). After a review of all the lay and medical evidence of record, the Board finds that, for the rating period on appeal from September 26, 2011 to March 5, 2012, the right knee disability has been manifested by flexion greater than 60 degrees, extension less than 5 degrees and painful motion, without arthritis, ankylosis, dislocation or removal of semilunar cartilage, nonunion or malunion of the tibia and fibula, or genu recurvatum. Accordingly, the Board finds that, for the rating period on appeal from September 26, 2011 to March 5, 2012, the criteria for an increased disability rating in excess of 10 percent for the right knee disability have not been met. 38 C.F.R. §§ 4.3, 4.7, 4.71a. A February 2012 VA examination report reflects the Veteran reported intermittent, sharp, and throbbing pain in the right knee that caused difficulty climbing stairs, prolonged walking and standing, and heavy lifting. Range of motion in the right knee was measured to 120 degrees of flexion and 0 degrees of extension, with negative findings noted for additional functional loss following repetitive motion. The evidence of record shows that the Veteran had right knee flexion to 120 degrees and 0 degrees of extension, as noted in the February 2012 VA examination report, which does not more nearly approximate limitation to 30 degrees of flexion or 15 degrees of extension as needed for an increased (20 percent) rating. Therefore, a disability rating in excess of 10 percent is not warranted under either Diagnostic Code 5260 (limitation of flexion) or Diagnostic Code 5261 (limitation of extension) for the right knee, and separate 10 percent ratings for both knee flexion and knee extension are not warranted, for the rating period from September 26, 2011 to March 5, 2012. 38 C.F.R. § 4.71a. The Board has considered whether a higher disability rating for the right knee chondromalacia disability 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, 4.45, and 4.59. See also DeLuca. While the right knee disability has caused pain which has restricted overall motion, and the Veteran has reported right knee pain and difficulty with walking and standing for a long period of time, even taking into account additional functional limitation due to pain, following repetitive use, and during episodes of flare ups, the lay and medical evidence, including as shown in the VA treatment records, private treatment records, and February 2012 VA examination report, indicate ranges of motion that do not more nearly approximate the 20 percent criteria, or separate 10 percent criteria for both compensable limitation of flexion with compensable limitation of extension. Based on the evidence discussed above, the degree of functional impairment does not warrant an increased rating based on limitation of motion of the right knee. 2. Rating the right knee chondromalacia from March 5, 2012 forward For the rating period on appeal from March 5, 2012 forward, the Veteran is in receipt of a 10 percent rating for the right knee chondromalacia disability. 38 C.F.R. § 4.71a. After a review of all the evidence of record, and resolving reasonable doubt in favor of the Veteran, the Board finds that, for the rating period on appeal from March 5, 2012 forward, the right knee disability has more nearly approximated dislocated semilunar cartilage with frequent episodes of joint pain, and effusion, without ankylosis, flexion limited to 15 degrees or less, extension limited to 20 degrees or more, or nonunion or malunion of the tibia and fibula. Resolving reasonable doubt in the Veteran's favor, the Board finds that a 20 percent rating under Diagnostic Code 5258 for dislocated semilunar cartilage is warranted for this period. The change in Diagnostic Code to 5258 is more appropriate because it recognizes the nature of the right knee disability (anatomical location and functional impairment), rates on the symptoms the Veteran has (dislocation of semilunar cartilage with frequent episodes of pain, effusion, and limitation of flexion and extension to a noncompensable degree), and is both potentially and actually more favorable to the Veteran in this case. As noted above, the Veteran was in receipt of a 10 percent rating (ostensibly under Diagnostic Code 5260 but actually under the criteria of Diagnostic Code 5003). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as it is supported by reasons and bases as well as the evidence. Butts, 5 Vet. App. at 538. One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See also Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the diagnostic code associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). Because the Board is granting a 20 percent rating under Diagnostic Code 5258, the 10 percent rating under Diagnostic Code 5260 (substantive criteria of Diagnostic Code 5003) will be discontinued because assigning separate ratings under both Diagnostic Codes 5260 (or Diagnostic Code 5003) and 5258 would constitute pyramiding; both Diagnostic Codes 5260 and 5258 overlap in symptoms or findings of pain and knee pain as a cause of limitation of motion, such that assigning separate ratings under both codes would violate the prohibition against pyramiding because it would compensate the Veteran twice for the same symptomatology. 38 C.F.R. § 4.14 (directing that the evaluation of the same disability or the same manifestation under various diagnoses is to be avoided); see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (holding that, for purposes of determining whether separate evaluations violate VA's anti-pyramiding provisions, the critical element is that none of the symptoms for any one of the conditions is duplicative of or overlapping with the symptomatology of the other conditions); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). Moreover, this change in Diagnostic Code does not amount to a reduction, as the rating of the Veteran's right knee disability increases from 10 percent to 20 percent as a result of this decision. A March 2012 private treatment record is the earliest evidence showing an MRI of the right knee that revealed a subtle meniscal tear involving the anterior horn and trace amounts of effusion. Additionally, VA and private treatment records throughout the rating period on appeal show the Veteran reported frequent episodes of joint pain and popping in the right knee. See e.g., July 2017 VA examination report; February 2018 private treatment record; April 2019 VA examination report. Based on the foregoing, and resolving reasonable doubt in favor of the Veteran, the Board finds that symptoms of the right knee disability more closely approximate the criteria under Diagnostic Code 5258 of dislocated semilunar cartilage with frequent episodes of joint pain and effusion; therefore, a 20 percent disability rating is warranted under Diagnostic Code 5258 from March 5, 2012. 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258. The Board further finds that a rating in excess of 20 percent for the right knee chondromalacia disability is not warranted for the rating period from March 5, 2012. The evidence of record shows that, for the entire rating period from March 5, 2012, the right knee disability did not manifest in symptoms of ankylosis or nonunion or malunion of the tibia and fibula. See July 2017 VA examination report; April 2019 VA examination report. The record includes an August 2018 private examination report from Dr. B.T. that reveals severe right knee symptoms such as limitation of flexion to only 45 degrees in passive motion with the onset of pain at 40 degrees, and limitation of extension to 15 degrees in active motion with the onset of pain at 10 degrees, with positive findings for moderate right knee instability. However, it is unclear from the August 2018 private examination report whether the Veteran was examined in person by Dr. B.T. Furthermore, both VA and private treatment records before and after the August 2018 private examination report consistently reflect symptoms and limitation of motion that are far less severe than those reported in the August 2018 private examination report. See e.g., March 2018 private treatment record (finding no right knee effusion or instability); July 2017 VA examination report (flexion limited to 100 degrees in right knee and extension limited to 10 degrees following repetitive use and during episodes of flare ups); April 2019 VA examination report flexion limited to 90 degrees in the right knee and extension limited to 0 degrees during episodes of flare ups). Because the findings contained in the August 2018 private examination report are aberrational from the overall disability picture shown by prior and subsequent VA and private treatment records, the Board finds that the August 2018 private examination report characterizations as to severity are outweighed by the July 2017 VA examination report, April 2019 VA examination report, and the other VA and private treatment records throughout the rating period on appeal from March 5, 2012. Instead, the Board finds that the competent and probative evidence of record shows that right knee flexion was, at most, limited to 90 degrees with extension limited to 10 degrees. See July 2017 VA examination report; April 2019 VA examination report. Therefore, the criteria for an increased rating in excess of 20 percent under Diagnostic Codes 5256, 5260, 5261, and 5262 have not been met or more nearly approximated for the period from March 5, 2012. 38 C.F.R. §§ 4.3, 4.7, 4.45, 4.59, 4.71a. 3. Rating right knee instability from July 11, 2017 to February 7, 2021 For the initial rating period from July 11, 2017 to February 7, 2021, the Veteran is in receipt of an initial 10 percent rating for right knee instability under Diagnostic Code 5257. 38 C.F.R. § 4.71a. As noted above, Diagnostic Code 5257 contemplates "other impairment" of the knee including recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where impairment is severe, moderate, or slight, disability ratings of 30, 20, and 10 percent are assigned, respectively. 38 C.F.R. § 4.71a. After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence shows the right knee had not more nearly approximated symptoms of moderate right knee instability for a higher 20 percent initial disability rating under Diagnostic Code 5257 for the period from July 11, 2017 to February 7, 2021. A July 2017 VA examination report first diagnosed right knee instability when the VA examiner found slight right knee instability based on the results of joint stability testing. A March 2018 private treatment record reflects negative findings for instability in the right knee. An April 2019 VA examination report likewise reflects negative findings for right knee instability based on joint stability testing conducted during the examination. The record includes the August 2018 private examination report, discussed above, which reflects findings of moderate instability or subluxation in the right knee; however, it is unclear from the August 2018 private examination report whether joint stability testing was performed, or the clinical basis for the private examiner's characterization of moderate right knee instability. Additionally, the August 2018 private examiner's finding of moderate right knee instability is inconsistent with, and outweighed by, the overall disability picture of the right knee instability reflected in prior and subsequent VA and private treatment records. Accordingly, the Board finds that the August 2018 private examiner's finding of moderate right knee instability is outweighed by the other competent and more probative evidence of record. Based on the foregoing, the Board finds that the weight of the evidence is against finding that symptomatology of right knee instability more nearly approximates a "moderate" impairment of right knee functionality; therefore, a higher initial disability rating in excess of 10 percent for right knee instability is not warranted under Diagnostic Code 5257. 38 C.F.R. §§ 4.3, 4.7, 4.71a. 4. Rating right knee instability from February 7, 2021 For the initial rating period from February 7, 2021 forward, the Veteran is in receipt of an initial 10 percent rating for right knee instability under Diagnostic Code 5257. 38 C.F.R. § 4.71a. Effective February 7, 2021, VA revised the portion of the Schedule for Rating Disabilities that addresses the musculoskeletal system. The amendments divided Diagnostic Code 5257 into two subsections recurrent subluxation or instability and patellar instability, each with its own criteria. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). For recurrent subluxation or instability, three ratings are available. A 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent is warranted under one of two scenarios: sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. For patellar instability, three ratings are available. 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. Two Notes accompany the revised Diagnostic Code 5257. Note 1 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note 2 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). After a review of all the lay and medical evidence of record, the Board finds that for the rating period from February 7, 2021 the evidence more nearly approximates an incomplete ligament tear causing persistent right knee instability, and a medical provider prescribes a brace and/or assistive device for ambulation. As discussed above, the March 2012 private treatment record reflects an incomplete ligament tear involving the anterior horn in the right knee. The July 2017 VA examination report shows the Veteran endorsed constant use of knee braces and occasional use of a cane for ambulation. The April 2019 VA examination report reflects the Veteran now uses both the knee braces and the cane constantly. Based on the foregoing, the Board finds that, for the initial rating period from February 7, 2021 forward, a higher initial 20 percent rating is warranted for right knee instability under the revised criteria for Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board further finds that the lay and medical evidence is against assigning a higher initial rating in excess of 20 percent for right knee instability for the initial rating period from February 7, 2021. The weight of the evidence of record demonstrates that the right knee instability did not manifest in severe recurrent subluxation or lateral instability, unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes both an assistive device and bracing for ambulation, or 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. While the medical evidence of record shows the Veteran was prescribed knee braces and a cane, the evidence does not show an unrepaired or failed repair of a complete ligament tear. Furthermore, the April 2019 VA examiner noted negative findings for recurrent subluxation and lateral instability, and clinical testing showed normal joint stability in all planes tested in the right knee. Based on the foregoing, the Board finds that the weight of the evidence is against finding that the right knee instability had manifested in severe recurrent subluxation or lateral instability. The April 2019 VA examiner found no recurrent subluxation or lateral instability in the right knee or any other form of joint instability. Other VA and private treatment records throughout the rating period on appeal from February 7, 2021 also do not reflect findings of severe instability of the right knee joint measuring between 10 and 15 millimeters (required for a 30 percent rating under Diagnostic Code 5257). VA and private treatment records throughout the initial rating period on appeal from February 7, 2021 do not reflect findings of unrepaired or failed repair of complete ligament tear (requirement for a 30 percent rating under revised Diagnostic Code 5257). As such, the Board finds that a higher initial disability rating in excess of 20 percent for right knee instability is not warranted under either the old or revised Diagnostic Code 5257 for the initial rating period from February 7, 2021. 38 C.F.R. § 4.71a. REASONS FOR REMAND 5. Service connection for erectile dysfunction is remanded. As noted above, the issue of service connection for erectile dysfunction, including as secondary to the service-connected hypertension and/or BPH, was previously before the Board in June 2018. The Board remanded the matter for the RO to obtain a new VA addendum opinion. Although a VA addendum opinion was obtained in April 2019, the RO has not readjudicated the issue of service connection for erectile dysfunction either by a rating decision or by providing the Veteran and representative with a Supplemental Statement of the Case (SSOC); therefore, the issue of service connection for erectile dysfunction is being remanded for the issuance of a SSOC. See September 2020 Correspondence. The issue of service connection for erectile dysfunction is REMANDED for the following action: Issue a SSOC that addresses the issue of service connection for erectile dysfunction, including as secondary to the service-connected hypertension and/or BPH. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Choi, 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.