Citation Nr: 21072987 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 14-19 890 DATE: December 7, 2021 ORDER Entitlement to a separate compensable evaluation for degenerative arthritis, left knee, limitation of extension, prior to October 25, 2018, is denied. Entitlement to an initial evaluation in excess of 30 percent for degenerative arthritis, left knee, limitation of extension, since October 25, 2018, is denied. Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis, left knee limitation of flexion, is denied. Entitlement to a separate 10 percent evaluation for left knee meniscal tear from June 6, 2011, is granted. Entitlement to an increased initial evaluation in excess of 10 percent for left knee meniscal tear is denied. Entitlement to an increased initial evaluation in excess of 10 percent for left knee instability, effective October 1, 2020 is denied. FINDINGS OF FACT 1. Prior to October 25, 2018, the Veteran's degenerative arthritis, left knee, extension manifested as limitation of extension to no worse than zero degrees. 2. Since October 25, 2018, the Veteran's degenerative arthritis, left knee, extension manifests as no worse than extension to 20 degrees. 3. Throughout the period on appeal, the Veteran's degenerative arthritis left knee, limitation of flexion has manifested by no more than pain of the left knee with flexion limited to 90 degrees. 4. Since June 6, 2011, the Veteran's left knee meniscal tear remained symptomatic, but did not show frequent episodes of "locking," pain and effusion into the joint. 5. Since October 1, 2020, the Veteran left knee disability has manifested as slight left knee instability. CONCLUSIONS OF LAW 1. The criteria for a separate compensable evaluation for degenerative arthritis, left knee limitation of extension, prior to October 25, 2018, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5261. 2. The criteria for an initial increased evaluation in excess of 30 percent for degenerative arthritis, left knee limitation of extension since October 25, 2018 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5261. 3. The criteria for an initial increased evaluation in excess of 10 percent for degenerative arthritis, left knee limitation of flexion, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.59, 4.71a, Diagnostic Codes 5003, 5260. 4. The criteria for a separate 10 percent evaluation for left knee meniscal tear from June 6, 2011 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5259. 5. The criteria for an increased initial evaluation in excess of 10 percent for left knee meniscal tear are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5259. 6. The criteria for an initial rating in excess of 10 percent for left knee instability from October 1, 2020 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1988 to March 1989, from November 1990 to May 1991 and from June 2010 to June 2011. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision by an Agency of Original Jurisdiction (AOJ) of the of the United States Department of Veterans Affairs (VA), which among other issues, granted service connection for left knee arthritis rated 10 percent disabling based on painful flexion, effective June 6, 2011, the day following separation from service. The Veteran testified at a November 2018 hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing associated with the file. In June 2019, these issues were remanded by the Board for the issuance of a supplemental statement of the case (SSOC). An SSOC and rating decision were issued in October 2020. In that decision, the AOJ granted a staged rating for left knee arthritis, assigning a 30 percent rating effective October 25, 2018, and reducing that back to 10 percent disabling effective October 1, 2020. The AOJ also indicated a separate, noncompensable evaluation for limitation of extension of the left knee arthritis was granted effective October 1, 2020. In February 2021, the Board remanded these issues again after finding that the October 2020 rating decision raised questions of pyramiding under 38C.F.R. §4.14 as two ratings appear to be assigned for impaired extension of the left knee from October 2018 to 2020. Additionally, as the AOJ potentially changed the basis for the initial rating effective October 25, 2018, an effective reduction of the initial rating had been worked. Murray v. Shinseki, 24 Vet. App. 420 (2011). The Board's remand directives required the AOJ to review the October 2020 rating decision and all the relevant evidence. The AOJ was directed to take appropriate action to clarify the assigned ratings and diagnostic codes, and correct the apparent errors identified with respect to pyramiding. The AOJ issued a supplemental statement of the case (SSOC) in February 2021. The SSOC indicated that the VA examination dated October 1, 2020 "showed a 10 percent evaluation for left knee arthritis (flexion) based upon: Limitation of flexion of 31 to 45 degrees." A review of the file shows that the AOJ did not take any action to clarify the assigned ratings and diagnostic codes, nor to correct any other errors. On the rating code sheet, dated February 17, 2021, a 30 percent rating for the Veteran's left knee from October 25, 2018, to October 1, 2020, based on Codes 5003-5261 which is a rating code associated with limitation of extension of the knee, is still reflected. Additionally, the SSOC did not address the Veteran's claims for an increased rating in excess of 10 percent for left knee arthritis (flexion) for the period prior to October 25, 2018, or for the period from October 1, 2020 as was directed by the Board in its remand instructions. The Board remanded the issues again in May 2021 after finding that the AOJ failed to follow its remand instructions in not addressing all the above noted apparent errors and assigning corrected ratings under the appropriate diagnostic code or codes and did not fully consider all manifestations of the left knee disability to include flexion, extension, and instability for the entirety of the appellate period since June 2011. The AOJ issued a rating decision in July 2021 which determined clear and unmistakable errors existed in the October 25, 2018 rating decision and the October 7, 2020 rating decision. In the July 2021 decision, the AOJ corrected its previous errors and assigned ratings for each disability pursuant to the applicable diagnostic code. The decision granted an initial disability evaluation of 30 percent for degenerative arthritis, left knee limitation of extension, effective October 25, 2018; continued the previously assigned 10 percent disability evaluation for left knee arthritis with limitation of flexion effective June 6, 2011; assigned a separate evaluation for service connection for left knee meniscal tear, evaluated as 10 percent disabling effective October 25, 2018; and assigned a separate evaluation for service connection for left knee instability, evaluated as 10 percent disabling effective October 1, 2020. As the grant of the 30 percent disability evaluation for left knee limitation of extension and the continuation of the 10 percent disability evaluation for left knee limitation of flexion, the grant of a 10 percent evaluation for left knee meniscal tear, and the grant of a 10 percent evaluation for left knee instability do not constitute full grants of each benefit sought, the issues remain on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board, in its discretion, has recharacterized the issues listed on the July 2021 SSOC, as is reflected above, to accurately identify the issues on appeal. Duty to Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances...we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...."). Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 - 127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159 (a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). 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). 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. The intent of the rating schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Painful motion is considered limited motion at the point that pain begins. VAOPGCPREC 9-98. VA Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of, or overlapping with, the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994); See VAOPGCPREC 23-97 (July 1, 1997). The fact that separate ratings can be assigned where appropriate symptomatology is shown permits a VA adjudicator to change diagnostic codes, as has been done in this case. Here, the AOJ assigned separate ratings for left knee meniscal tear and left knee instability in the Jury 2021 rating decision. The Court has held that if a veteran's symptoms are distinct and separate, the veteran is entitled to separate disability ratings for the various conditions. See Murray v. Shinseki, 24 Vet. App. 420 (2011). Code 5003, for degenerative arthritis, does not permit assignment of an evaluation greater than 10 percent, and so will not be discussed further. 38 C.F.R. § 4.71a, Code 5003. There are numerous Codes which are potentially applicable to evaluation of knee disabilities. The Board notes that the rating criteria for musculoskeletal disorders were revised on February 7, 2021. The amended regulations became effective on February 7, 2021 and claims that were pending on this date must be considered under the former and revised criteria with the most favorable version applied to the claim. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (now codified at 38 C.F.R. § 4.71a, Codes 5256, 5257, 5258, 5259, 5260, 5261, 5262). Code 5256 is utilized for evaluation of ankylosis or the functional equivalent; as there is motion of the left knee, this Code is not applicable here. Code 5257 evaluates disabilities of the knee based on the degree of subluxation and instability of the joint. Under the former criteria, a 10 percent evaluation is assigned for slight, recurrent subluxation or lateral instability of the knee. A 20 percent evaluation is assigned for moderate recurrent subluxation or lateral instability of the knee. A 30 percent evaluation is assigned for severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Code 5257 (2020). Pursuant to the new criteria, Code 5257, recurrent subluxation, or lateral instability, assigns a 10 percent evaluation for 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 evaluation is assigned for either (a) 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 (b) 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 evaluation is assigned 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. 38 C.F.R. § 4.71a, Code 5257 (2021). Additionally, pursuant to the new criteria for Code 5257, a 10 percent evaluation is assigned for patellar instability when the condition is diagnosed and involves the patellofemoral complex with recurrent instability (with or without a history of surgical repair) that does not require a prescription from a medical provided for a brace, cane, or walker. A 20 percent evaluation is assigned for diagnosed patellar instability involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provided for one of the following: a brace, cane, or walker. A 30 percent evaluation is assigned for a diagnosed patellofemoral instability 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. Note (1) to Code 5257 for patellar instability, defines the patellofemoral complex as consisting of the quadriceps tendon, the patella, and the patellar tendon. Note (2) specifies that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). 38 C.F.R. § 4.71a, Code 5257 (2021). Code 5258 assigns a 20 percent evaluation for dislocated semilunar cartilage with frequent episodes of "locking" pain, and effusion into the joint. 38 C.F.R. § 4.71a, Code 5258. Code 5259 assigns a 10 percent evaluation for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Code 5259. For limitation of motion, there are two potentially applicable Codes; the rating criteria for these codes were unaffected by the new regulations. Code 5260 assigns evaluations based on limitation of flexion. Limitation to 60 degrees merits a noncompensable, or 0 percent, evaluation. A 10 percent evaluation is assigned for limitation to 45 degrees. Limitation to 30 degrees flexion warrants a 20 percent evaluation, and a 30 percent evaluation is assigned for limitation to 15 degrees of flexion. 38 C.F.R. § 4.71a, Code 5260. Limitation of extension is rated under Code 5261. Limitation to 5 degrees merits a noncompensable, or 0 percent, evaluation. A 10 percent evaluation is assigned for limitation to 10 degrees. Limitation to 15 degrees extension warrants a 20 percent evaluation. A 30 percent evaluation is assigned for limitation to 20 degrees of extension. A 40 percent evaluation is assigned for extension limited to 30 degrees. A 50 percent evaluation is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Code 5261. Under the former criteria for Code 5262, tibia and fibula, impairment of, a 10 percent disability evaluation is assigned for malunion of with slight knee or ankle disability. A 20 percent disability evaluation is assigned for malunion with moderate knee or ankle disability. A 30 percent evaluation is assigned for malunion with marked knee or ankle disability. A 40 percent evaluation is assigned for nonunion of the tibia and fibular with loose motion, requiring brace. 38 C.F.R. § 4.71a, Code 5262. Pursuant to the new criteria for Code 5262, for medial tibial stress syndrome (MTSS), or shin splints, a noncompensable evaluation is assigned for treatment for less than 12 consecutive months, one or both lower extremities. A 10 percent evaluation is assigned for MTSS or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities. A 20 percent evaluation is assigned for symptoms requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity. A 30 percent evaluation is assigned for symptoms requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. Malunion of tibia and fibula is evaluated under Codes 5256, 5257, 5260, or 5261 for the knee, of 5270 or 5271 for the ankle whichever results in the highest evaluation. Nonunion of tibia and fibula with loose motion, requiring brace is assigned a 40 percent evaluation. 38 C.F.R. § 4.71a, Code 5262 (2021). As discussed above, a July 2021 rating decision established separate disability evaluations for Veteran's arthritis of the left knee, one evaluation based on limitation of extension and a separate evaluation based on limitation of flexion. These manifestations had previously been rated as one disability. The Veteran is seeking an increased evaluation in excess of 30 percent for degenerative arthritis, left knee limitation of extension currently evaluated under Code 5261, for limitation of extension, and an increased evaluation in excess of 10 percent for left knee arthritis, limitation of flexion, currently evaluated under Code 5260, for limitation of flexion. The Veteran's service treatment records show that he sustained a left knee meniscal tear in January 2011 and underwent surgery to repair this tear in March 2011. The Veteran underwent a VA general medical examination in July 2011. The Veteran reported that his left knee was sore. He reported experiencing pain and weakness in the knee. A 2010 MRI showed a torn meniscus on both sides of the knee and he had arthroscopic surgery. He stated that his knee occasionally gives way. The left knee has swelling and effusion and feels hot at times. He takes hydrocodone for left knee pain. He described the pain as a 10 out of 10 in severity and as occurring once or twice per week, lasting for 3 or 4 days before it starts to relieve itself. Pain was precipitated by walking and running and is alleviated by medication. No additional limitation of motion or functional impairment during a flare-up was reported. He stated he uses crutches at times but that it had been several months since he had used them. He reported having 3 surgeries on his left knee. The Veteran was employed as a policeman. His left knee limited his ability to go down to his knees if he must. He stated he had difficulty getting in and out of bathtub and, at times, sitting on the toilet and getting up. He reported that he is able to walk for approximately one-half mile if he had to. Physical examination revealed no evidence of pain at rest. The VA examiner noted evidence of tenderness with extreme flexion of the left knee. Slight posterior-lateral tenderness on the left knee was noted. Medial anterior tenderness along the joint space was present, significantly less tenderness along the lateral anterior joint space was noted. No other tenderness was detected. There was no objective evidence of edema, effusion, instability, redness, heat, abnormal movement, guarding of movement, deformity, malalignment, drainage, or weakness. Gait appears normal. Range of motion of the left knee is flexion from 0 to 105 degrees and extension of 0 degrees. The left knee was noted to be stable. Medial and lateral collateral ligaments show no movement. Anterior and posterior cruciate ligaments are normal by Lachman's test. The medial and lateral menisci are normal by McMurray's test. The examiner noted no additional limitation of motion after repetitive motion in the left knee. Based on the findings of this examination, the AOJ granted service connection for arthritis, left knee and assigned a 10 percent disability evaluation pursuant to the criteria for Code 5260 for limitation of flexion of the left knee, effective June 6, 2011 date the Veteran's claim was received. The Veteran underwent a VA knee examination in January 2014. The VA examiner noted that there have been no orthopedic consults regarding the Veteran's knees, nor any PM&RS prosthetic consults for pain or assistive devices. The Veteran remains a patrol officer for the Waynesboro Police Department. The Veteran reported experiencing knee pain, left knee greater than right and is essentially no longer running, such as when a suspect flees on foot. He has had no surgeries or injections since his last procedures outlined in his last VA examination. He plans on requesting a knee brace from his orthopedist later at his next visit. The Veteran did not report experiencing flare-ups of his left knee. Range of motion of the left knee was flexion to 100 degrees with objective evidence of painful motion at 100 degrees, and extension to 0 degrees. Repetitive use testing did not result in any additional limitation of range of motion of the left knee. Functional loss and/or functional impairment of the left knee after repetitive use was documented as less movement than normal and pain on movement. Tenderness or pain on palpation for joint line or soft tissues of the left knee was noted. Muscle strength of the left knee was normal. There was not joint instability of the left knee and no evidence or history of recurrent patellar subluxation/dislocation of the left knee. The VA examiner noted that the Veteran had had a meniscal tear and frequent episodes of joint pain of the left knee and has undergone a left knee meniscectomy. Residual symptoms included chronic pain and discomfort, left knee worse than right knee. The VA examiner noted that x-rays revealed moderate degenerative changes of both knees showing worsening since previous study from July 2011. VA treatment records dated through January 2015 reflect the Veteran's complaints of knee pain. Private treatment records from Dr. THB dated October 2014 reflect treatment for bilateral knee pain. His reported stiffness and a tendency for his knees to lock and give way as well as swelling and making him fall. His initial surgical procedure was done by Dr. THB in November 2001, and he underwent an arthroscopy in February 2003. Notes dated April 2015 reflect treatment for complaints of knee pain, left worse than right. Examination of the left lower extremity revealed full range of motion without deformity, instability, or tenderness, no swelling was found. The Veteran underwent a VA knee examination in February 2016. The VA examiner noted the Veteran's diagnosis of left knee arthritis. The VA examiner noted he conducted the January 2014 VA examination. The VA examiner noted the Veteran was in no acute distress and ambulated with a normal gait pattern. He was not using a cane, crutch or walker and does not wear knee braces. He lives in his own residence and attends to his own activities of daily living. He does some household chores and uses a riding mower to cut the grass. He reported experiencing chronic bilateral knee pain, left worse than right with occasional daily flare-ups usually in the evening and has been known to interfere with sleep. He reported experiencing increased pain with ambulation, prolonged standing of 15 or more minutes, and stiffness when seated such as in a car or on the riding mower requiring positional changes. His functional loss is lessening of the range of motion he was used to. The Veteran was able to squat approximately halfway down. No laxity was noted on examination and he did have some mild tenderness or pain on palpation over both knees globally. He denied falling or near falls due to his knees. Range of motion of the left knee was flexion from 0 to 100 degrees, extension from 100 to 0 degrees. Pain was noted on examination, in both flexion and extension, but did not result in functional loss. Tenderness or pain on palpation was noted over both medial and lateral joint line with patellar compression. Repetitive use testing did not result in any additional functional loss or range of motion. Additional contributing factors of disability were noted as decreased range of motion with pain. Muscle strength was normal. No ankylosis was present. No joint instability was present. The VA examiner noted the Veteran's occasional use of a brace to assist with locomotion. X-rays showed degenerative changes of both knees only mildly worsened since January 2014 examination. The VA examiner noted there was no weakened movement, excess fatigability and/or incoordination. VA treatment notes reflect treatment for knee pain through June 2017. The Veteran underwent a VA knee examination in May 2018. The VA examiner noted the Veteran's diagnosis of degenerative arthritis of bilateral knees. The Veteran reported he had increased knee pain bilaterally since his last VA examination. He reported that the right knee is worse than the left now. He stated that his left knee buckles sometimes now. Left knee pain was described as a 6 to 7 out of 10. He reports that he has to use a pillow at night to relieve knee pain. Pain is constant of bilateral knees. Flare-ups were described as aching when it is raining or cloudy. Pain is worse when Veteran drives. Functional loss or functional impairment of the knee was reported as an inability to walk for extended periods of time and an inability to squat down. Range of motion of the left knee was flexion from 0 to 100 degrees and extension from 100 to 0 degrees. Pain was noted on examination in flexion and extension and caused functional loss. Range of motion itself contributes to a functional loss as decreased range of motion due to pain. The Veteran has pain on the medial and lateral side of the left knee, as well as on the posterior side, bilaterally. Pain is noted on the anterior superior portion of the right knee. There was evidence of pain with weight bearing and objective evidence of crepitus. Repetitive use testing did not result in additional loss of function or range of motion. Additional contributing factors to disability were less movement than normal, weakened movement, disturbance of locomotion, interference with sitting, interference with standing. Muscle strength testing was 4 out of 5. No muscle atrophy or ankylosis was present. No joint instability was present. Symptoms of left meniscus condition included meniscal tear, frequent episodes of joint pain and frequent episodes of joint effusion. The Veteran reported frequent effusion of bilateral knees approximately 2 times per week. However, he had no effusion of either knee at the time of the examination. VA treatment records through June 2018 reflect treatment for complaints of chronic bilateral knee pain right greater than left. X-rays revealed moderately advanced bilateral knee osteoarthritis. The Veteran underwent a VA knee examination in October 2018. The VA examiner noted the Veteran's diagnosed left knee arthritis. Subjective complaints included increased pain and stiffness in both knees and frequent falls due to knees "giving out." He reported that he is following with an orthopedic and physical therapy was ordered. Weather changes and activity level determine the severity of his pain. He reported an inability to completely extend both knees. He reported experiencing constant aching, pain with stiffness in both knees and sleep disturbance. The VA examiner noted that the Veteran wears unloading right and left knee brace continuously which he says helps some. He sleeps with a pillow between his knees at night. Range of motion of the left knee was flexion from 20 degrees to 90 degrees and extension from 90 degrees to 20 degrees. Pain was noted on examination in flexion and extension, but it did not cause a functional loss. Objective evidence of mild tenderness was noted on palpation to the medial and lateral joint lines was present. There was evidence of pain with weight bearing, but no crepitus. Repetitive use testing did not result in additional loss of function or range of motion after three repetitions. Additional contributing factors of disability included less movement than normal, instability of station, disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength testing is normal. No muscle atrophy or ankylosis was present. No history of recurrent subluxation or lateral instability was noted. Diagnostic studies have shown effusions on multiple occasions. The Veteran reported intermittent episodes of swelling to both knees. Joint stability testing was performed and did not reveal joint instability. Meniscal symptoms included meniscal tear, frequent episodes of joint pain and frequent episodes of joint effusion. The Veteran experienced constant knee pain with intermittent swelling. The Veteran did not use any assistive devices as a normal mode of locomotion. At his November 2018 hearing, the Veteran testified that he had lost flexion and extension of his knees. He testified that his knees are weak and if he stands for a long period of time they hurt, if he walks for long periods of time, they get sore, and it will swell some. The Veteran testified that, one week earlier, he was coming down his steps at home and his knee buckled and he fell. He also testified that once in the yard, his knee gave out and he fell. He testified that he had three surgeries on his left knee. He testified that he had locking in the knee and that it hurts generally. The Veteran testified that his left knee hurts when he's moving it; when he sits down for a long period of time and then stands up the knee locks and he has to gradually ease it out. He testified to experiencing minimum swelling in his left knee. He testified that he has noise clicking crepitus and that sometimes it suddenly pops. VA treatment records dated January 2019 reflect treatment for chronic bilateral knee pain. Left knee examination revealed "normal temperature and color, no apparent swelling, no fullness in popliteal area, v/v stressors appeared stable, positive medial joint line tenderness, positive PFC, range of motion possible 0 -120 degrees, nv intact distally." VA treatment records dated August 2020 reflect treatment for complaints of knee pain. The clinician noted the Veteran complained of knee pain and reported edema to his knees at intervals. The Veteran underwent a VA knee examination in October 2020. The VA examiner noted arthritis of both knees and instability of the right knee. Subjective complaints include continued pain, stiffness, intermittent swelling. Current treatment is medication. Pain increases with prolonged standing longer than 10 to 15 minutes. The Veteran reported he cannot run, cannot walk for longer than 20 to 30 yards without increase in pain. Flare-ups of the left knee occur 2 times a week and are precipitated by prolonged walking/standing. The flare-ups are moderate and last up to 2 to 3 hours. Flare-ups are relieved by medication. Functional loss or functional impairment was reported as an increase in pain with prolonged standing longer than 10 to 15 minutes, cannot run, cannot walk for longer than 20 to 30 yards without increase in pain. Range of motion of the left knee was flexion from 5 to 90 degrees and extension from 90 to 5 degrees. Pain was noted on examination in both flexion and extension and caused functional loss. Range of motion itself contributed to functional loss as the Veteran could not squat down. No additional factors contributing to disability were noted. Muscle strength was normal. No muscle atrophy or ankylosis was present. The Veteran reported experiencing intermittent swelling. Left Knee, Limitation of Extension The AOJ assigned a separate 30 percent disability evaluation for left knee limitation of flexion effective October 25, 2018. The Board has carefully considered all the evidence and potentially applicable diagnostic codes, including the DeLuca factors, and finds that the disability picture of the Veteran's degenerative arthritis, left knee, limitation of extension, does not warrant a rating in excess of 30 percent pursuant to the criteria associated with Code 5261. After a careful review of the evidence of record, the Board finds that the Veteran met the criteria for a separate 30 percent evaluation, and no higher, for arthritis left knee, limitation of extension as of October 25, 2018. The Veteran's left knee limitation of extension is assigned a 30 percent disability evaluation pursuant to Diagnostic Code 5003-5261. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Code 5003 pertains to arthritis and 5261 pertains to limitation of extension of the knee. As discussed above, the rating criteria for musculoskeletal disorders were revised on February 7, 2021. However, the rating criteria for limitation of extension of the knee did not change. After a thorough review of the evidence of record, the Board finds that the 30 percent disability evaluation assigned for the Veteran's left knee arthritis, limitation of extension, effective October 25, 2018 contemplates the Veteran's symptoms of limitation of extension and properly compensates him for this symptom. Prior to October 25, 2018, the Veteran did not meet the criteria for a separate compensable evaluation for limitation of extension based on the findings of his July 2011, January 2014, February 2016, and May 2018 VA knee examinations which all revealed the Veteran had no limitation of extension. Therefore, the Board finds that the medical evidence of record does not establish that the criteria for a separate compensable evaluation for degenerative arthritis, left knee based on limitation of extension is warranted prior to October 25, 2018. At his October 2018 VA knee examination, the VA examiner noted that the Veteran's left knee extension was limited to 20 degrees. Extension limited to 20 degrees warrants a 30 percent disability evaluation. The medical evidence of record does not establish that the Veteran has experienced limitation of extension of the left knee to 30 degrees which would warrant a higher 40 percent disability evaluation. The Board has carefully considered all the evidence and potentially applicable diagnostic codes, including the DeLuca factors as described by the examiners and by the Veteran in competent and credible lay statements, and finds that the disability picture of the Veteran's degenerative arthritis left knee limitation of extension, does not more nearly approximate the rating criteria for a rating in excess of 30 percent. Therefore, the currently assigned 30 percent disability rating contemplates the Veteran's functional limitations and compensates him for such. See DeLuca. Accordingly, entitlement to a separate compensable evaluation for degenerative arthritis, left knee limitation of extension prior to October 25, 2018 and to a rating in excess of 30 percent from October 25, 2018 is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. Left Knee, Limitation of Flexion The Board has carefully considered all the evidence of record and potentially applicable diagnostic codes, including the DeLuca factors, and finds that the disability picture of the Veteran's degenerative arthritis, left knee limitation of flexion does not warrant a rating in excess of 10 percent pursuant to the criteria associated with Code 5260. The Veteran's range of motion was limited to 90 degrees, at most, with some functional impairment due to constant pain as noted upon the VA examinations. Even with consideration of the DeLuca factors, the Veteran's range of motion on flexion was not limited to 30 degrees which would warrant a higher evaluation of 20 pursuant to Code 5260, and based on the severity of his symptoms, the evidence does not support that a rating in excess of 10 percent is warranted. Left Knee, Meniscal Tear In its July 2021 rating decision, the AOJ assigned a 10 percent evaluation for left knee meniscal tear, effective October 25, 2018. The AOJ stated that the evaluation was assigned from October 25, 2018 - the date the condition was diagnosed. A review of the record reveals the condition had its onset in service, in January 2011. The Board notes that the appellate period herein begins June 6, 2011, the day following the Veteran's discharge from service. Therefore, the Veteran is entitled to a separate evaluation for a left knee meniscal tear effective June 6, 2011, the day following his discharge from service. The AOJ assigned a 10 percent evaluation pursuant to the criteria for Code 5259. As indicated above, this is the highest evaluation for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Code 5259. A higher 20 percent evaluation is available under Code 5258 for dislocated semilunar cartilage with frequent episodes of "locking" pain, and effusion into the joint. 38 C.F.R. § 4.71a, Code 5258. The Board has carefully considered all the evidence of record and potentially applicable Codes, including the DeLuca factors, and finds that the disability picture of the Veteran's left knee meniscal tear most closely approximates the criteria associated with a 10 percent disability evaluation pursuant to Code 5259. This is the maximum disability provided for removal of semilunar cartilage, symptomatic. The Veteran has reported experiencing intermittent swelling; however, VA examinations did not document any swelling. Private medical records from Dr. THB noted no swelling. At his November 2018 hearing, the Veteran reported his knee would lock. Consideration has been given to assigning a higher evaluation under a different Code; however, the Veteran has been assigned a separate evaluation for instability of the left knee, limitation of extension and limitation of flexion. Therefore, the currently assigned 10 percent disability rating for left knee meniscal tear contemplates the Veteran's diagnosed condition and functional limitations and compensates him for such. See DeLuca. Accordingly, entitlement to an increased rating in excess of 10 percent for left knee meniscal tear is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. Thus, the Board finds that the Veteran's symptoms documented in the evidence of record are consistent with the 10 percent disability evaluation assigned for left knee meniscal tear which adequately compensates him for his symptoms. Left Knee Instability In its July 2021 rating decision, the AOJ assigned a 10 percent evaluation for left knee instability, effective October 1, 2020. The AOJ stated that the evaluation was assigned from October 1, 2020 the date the condition was diagnosed. The AOJ assigned a 10 percent evaluation pursuant to the criteria for Code 5257. As indicated above, a 10 percent evaluation is assigned for slight lateral instability of the knee. 38 C.F.R. § 4.71a, Code 5257. A 20 percent evaluation is assigned for moderate symptoms. A 30 percent evaluation is assigned for severe symptoms. 38 C.F.R. § 4.71a, Code 5258. The Board has carefully considered all the evidence of record and potentially applicable Codes, including the DeLuca factors, and finds that the disability picture of the Veteran's left knee instability most closely approximates the criteria associated with a 10 percent disability evaluation pursuant to Code 5257. The Veteran's VA examinations conducted in July 2011, January 2014, February 2016, May 2018, and October 2018 did not document left knee instability. Left knee instability was first noted in his October 2020 VA examination when the October 2020 VA examiner noted a history of slight lateral instability. Joint stability testing results were normal. The evidence does not show that the Veteran meets the criteria for a 20 percent rating pursuant to Code 5257 because the Veteran does not have moderate recurrent subluxation or moderate lateral instability of the left knee. Therefore, the currently assigned 10 percent disability rating for left knee instability contemplates the Veteran's diagnosed condition and functional limitations and compensates him for such. See DeLuca. Accordingly, entitlement to an increased rating in excess of 10 percent for left knee instability is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. Thus, the Board finds that the Veteran's symptoms documented in the evidence of record is consistent with the 10 percent disability evaluation assigned for left knee instability which adequately compensates him for his symptoms. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Margaret M. Lunger, 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.