Citation Nr: 21075520 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 17-54 266 DATE: December 20, 2021 ORDER 1. The appeal seeking to establish that the reduction of the rating for the Veteran's service-connected left patellofemoral pain syndrome (left knee disability) from 30 percent to 10 percent, effective April 1, 2017, was improper is denied. 2. Entitlement to a rating in excess of 10 percent for the left knee disability from April 1, 2017, to August 25, 2021, is denied; entitlement to a 30 percent, combined (10 percent for arthritis with painful motion and 20 percent for instability) rating from August 25, 2021 is granted. FINDINGS OF FACT 1. A June 2016 rating decision proposed to reduce the rating for the Veteran's left knee disability (based on limitation of extension) from 30 percent to 10 percent; a June 30, 2016 letter with a rating decision notified him of the proposed reduction; a January 2017 rating decision implemented the reduction prospectively (effective April 1, 2017); and the reduction was based on, and supported by, the medical evidence of record, including reports of examinations demonstrating that his left knee extension was no longer limited at 20 degrees or more as it was found to be at the time of the December 2012 rating decision that granted the 30 percent rating. 2. From April 1, 2017, to August 2021, the Veteran's left knee disability was manifested by painful motion, but compensable limitations of flexion or extension, recurrent subluxation or lateral instability, a meniscus condition, malunion of tibia or fibula, genu recurvatum, or ankylosis were not shown. 3. From August 25, 2021, the Veteran's left knee disability is reasonably shown to have been manifested by arthritis with painful motion and persistent instability with crutches prescribed for ambulation; compensable degree limitations of flexion or extension, a meniscus condition, malunion of tibia or fibula, genu recurvatum, and ankylosis are not shown CONCLUSIONS OF LAW 1. The reduction of the rating for the Veteran's left knee disability from 30 percent to 10 percent, effective April 1, 2017, did not involve a due process violation, was in accordance with facts found and governing law, and was proper. 38 U.S.C. §§ 1155, 5112(a); 38 C.F.R. §§ 3.105(e), 3.344, 4.71a, Diagnostic Codes (Codes) 5003, 5256-63. 2. The Veteran's left knee disability warrants staged ratings of no higher than 10 percent from April 1, 2017, to August 25, 2021, and a combined 30 percent (10 percent under Code 5260 and 20 percent under Code 5257) from August 25, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.25, 4.59, 4.71a, Codes 5003, 5256-63. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who had active service from August 1997 to May 2000. This appeal is from a January 2017 rating decision that reduced the rating for the Veteran's service-connected left knee disability from 30 to 10 percent. A May 2000 rating decision had granted the Veteran service connection for bilateral patellofemoral syndrome, rated 10 percent. A November 2007 rating decision assigned separate, 10 percent, each) ratings for the patella femoral syndrome. In May 2011, he filed a claim for an increased rating. An August 2011 rating decision continued a 10 percent rating for the left knee disability (under Codes 5010-5260, for arthritis with limitation of flexion. The Veteran initiated an appeal of that decision, but did not perfect the appeal (by submitting a substantive appeal) following June 2012 issuance of a statement of the case (SOC) or after an interim (December 2012 DRO decision) increased the rating to 30 percent (explaining the increase was based on limitation of extension, but continuing to list the Code under which the rating was assigned as Code 5010-5260 for limitation of flexion): a supplemental statement of the case (SSOC) was also issued in December 2012 (the Veteran still did not submit a substantive appeal). An April 2014 rating decision codesheet corrected the designation of the Codes under which the left knee disability was rated to 5010-5261 (for arthritis with limitation of extension). After a scheduled routine VA examination, a September 2014 rating decision continued a 30 percent rating for the left knee disability. The Veteran filed a notice of disagreement with the September 2014 rating decision, and a March 2015 SOC was issued; he did not submit a substantive appeal following issuance of the March 2015 SOC. In July 2015, the Veteran reported that his left knee disability had worsened. A June 2016 rating decision proposed to reduce the rating for the Veteran's left knee disability from 30 to 10 percent. A June 30, 2016 VA letter notified the Veteran of the proposed reduction, that he had 60 days to present additional evidence showing that compensation should be continued at the prior level, and that he could request a hearing. He filed a notice of disagreement with the June 2016 rating decision proposal to reduce in August 2016, but he did not submit any medical evidence or request a hearing at that time. The January 2017 rating decision on appeal implemented the reduction in the rating for the left knee disability to 10 percent (under Code 5261) effective April 1, 2017. In March 2017, the Veteran filed a notice of disagreement with the reduction and stated that his left knee disability had worsened, not improved. An August 2017 SOC continued a 10 percent rating for the left knee disability. The Veteran file a timely substantive appeal in October 2017. Accordingly, the Board has accepted jurisdiction on both the propriety of the reduction and entitlement to an increased rating for his left knee disability. In October 2020 a hearing in the matter was held before the undersigned; a transcript is in the record. In May 2021, the matter was remanded for additional development. A September 2021 rating decision increased the rating for the left knee disability to a combined 20 percent (assigning separate ratings of 10 percent rating limitation of flexion under Code 5260, 10 percent for instability under Code 5257, 0 percent for limitation of extension), effective August 25, 2021. Propriety of reduction effective April 1, 2017. Where a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons, and the agency of original jurisdiction (AOJ) must notify the veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. If no additional evidence is received within the 60-day period and no hearing is requested, final rating action will be taken, and the award will be reduced or discontinued effective the last day of the month in which the 60-day period from the date of notice to the veteran expires. 38 C.F.R. § 3.105(e). Under 38 C.F.R. § 3.344(a)(b)(c), ratings for disabilities that have continued at the same level for long periods (five years or more) are subject to procedural safeguards that include that a rating for a disease subject to episodic improvement will not be reduced based on a single examination, except in those instances where all the evidence clearly warrants the conclusion that sustained improvement has been demonstrated. When a reduction is made without compliance with applicable regulations, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999). General regulatory requirements for disability ratings must be met in deciding whether improvement is shown. Brown v. Brown, 5 Vet. App. 413 (1993). The entire recorded history of the disability must be reviewed. 38 C.F.R. §§ 4.1, 4.2. The evidence must reflect an actual change in the disability and not merely a difference in the thoroughness of the examination or in the use of descriptive terms. 38 C.F.R. § 4.13. It must further show that the disability improved in such a manner that the veteran's ability to function under the ordinary conditions of life and work has been enhanced. 38 C.F.R. §§ 4.2, 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Increased rating claim Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. The criteria for rating knee disabilities are found in 38 C.F.R. § 4.71a. Under Code 5257, a 10 percent rating is assigned for slight recurrent subluxation or lateral instability, a 20 percent rating is assigned for moderate recurrent subluxation or lateral instability, and a 30 percent rating is assigned for severe recurrent subluxation or lateral instability. Codes 5258 and 5259 pertain to ratings for a semilunar cartilage (meniscus) condition. A 20 percent rating is assigned under Code 5258 for a dislocated meniscus with frequent episodes of "locking," pain, and effusion. A 10 percent rating under Code 5259 is assigned for symptomatic removal of the meniscus. Under Code 5260 for limitation of flexion, a 0 percent rating is assigned for extension limited to 60 degrees; a 10 percent rating is assigned for flexion limited to 45 degrees; a 20 percent rating is assigned for flexion limited to 30 degrees; a 30 percent rating is assigned for flexion limited to 15 degrees. Under Code 5261 for limitation of knee extension, a 0 percent rating is assigned for extension limited at 5 degrees; a 10 percent rating is assigned for extension limited at 10 degrees; a 20 percent rating is assigned for extension limited at 15 degrees; a 30 percent rating is assigned for extension limited at 20 degrees; a 40 percent rating is assigned for extension limited at 30 degrees; and a 50 percent rating is assigned for extension limited at 45 degrees. Separate compensable ratings may be assigned for arthritis with limitation of flexion and for limitation of extension, as well as for instability, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. The criteria for evaluating musculoskeletal disorders, including Code 5257, were amended effective February 7, 2021. Under the revised criteria for rating recurrent subluxation or lateral instability, a 10 percent rating is assigned 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 rating is assigned for one of the following: (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 rating 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. For patellar instability, a 10 percent rating is assigned 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 assigned 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 assigned 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. Under Note (1), for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Under Note (2), 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). Code 5256 pertains to ratings for ankylosis of a knee. Code 5262 pertains to ratings for impairment of the tibia and fibula. Code 5263 pertains to rating genu recurvatum. The rating criteria pertaining to Code 5262 was revised effective February 7, 2021. However, as those Codes are not applicable in this matter (because the pathology or impairment required is not found), including the February 7, 2021 effective revisions and do not require further discussion. 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. In determining the degree of limitation of motion, the provisions of 38 U.S.C. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Factual Background The Veteran's treatment records show that he underwent a left knee synovectomy in January 2012. It was noted that no meniscal tears were found. By February 2012, he had almost full range of left knee motion. In March 2012, it was noted that his left knee looked totally benign, with no swelling, redness, infection, snapping, or catching. On May 2012 VA examination, left knee flexion was to 70 degrees and extension was to 25 degrees. The examiner noted that joint stability tests could not be performed. The examiner indicated that the Veteran did not have and had never had a meniscus condition, but had undergone left knee arthroscopic synovectomy. In a May 2012 addendum, the examiner reported that on testing the Veteran walked with a slight limp, but his legs were fully extended, and thus he retained left knee extension to 0 degrees. A March 2014 left knee x-ray showed mild arthritis. On July 2014 VA examination, the Veteran reported there was no improvement in his left knee disability, and that he had pain from 5 to 10 on a 10 point scale. He reported that his left knee felt unstable and would give out, but he could catch himself. On examination, left knee flexion was to 115 degrees, with pain, and extension was normal to 0 degrees, without objective evidence of pain. Repetitive used testing resulted in no additional limitation of motion. The examiner indicated that the Veteran had functional loss that included less movement than normal, pain on movement, and incoordination. Left knee muscle strength was normal (5/5). Joint stability tests were normal. The examiner indicated that the Veteran did not have, or ever have, shin splints, stress fractures, chronic exertional compartment syndrome, any other tibial and/or fibular impairment, patellar subluxation, or a meniscus condition. It was noted that the Veteran had undergone a left knee arthroscopic synovectomy in 2012. The examiner indicated that imaging studies showed left knee arthritis, and stated that the Veteran had a normal gait and did not use an assistive device. The Veteran filed the instant increased rating claim in July 2015. In July 2015 and January 2016, he stated that his left knee disability had worsened, and was . scheduled for a VA examination to determine the current severity of his left knee disability. On June 2016 VA examination, the Veteran reported a left knee constant ache with intermittent flare-ups and lockups, and that his left knee pain was aggravated by climbing stairs, squatting, and kneeling. He reported having flare-ups but denied having functional loss. On examination, left knee flexion was to 70 degrees with no pain and extension was normal (to 0 degrees), with pain. The examiner indicated that the Veteran's range of motion itself did not contribute to functional loss, and that there was no evidence of pain with weight-bearing or on palpation of the joint or associated soft tissue. Repetitive use testing did not result in additional functional loss or range of motion. The examiner stated that he was unable to say without mere speculation whether pain, weakness, fatiguability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups without sufficient evidence-based medical facts or direct observation. Left knee muscle strength was normal (5/5). It was noted that the Veteran did not have left knee joint instability, recurrent patellar dislocation, shin splits, stress fracture, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment, and that the Veteran had undergone a left knee arthroscopic synovectomy in 2012. The examiner noted that the Veteran did not have left knee ankylosis or muscle atrophy. The Veteran's treatment records show that in July 2016, he reported that his left knee would lock up. In May 2017, he had good left knee range of motion, ambulated without a limp or antalgia, and did not use an assistive device. In May 2017, his left knee had no effusion and retained good range of motion and strength. He had no distinct tenderness and ambulated without a limp or assistive device. In September 2017, left knee flexion was to 135 and extension was normal, to 0 degrees. At the October 2020 Board hearing, the Veteran testified that he had undergone left knee surgery. He testified that his left knee disability prevented him from running and limited his walking to short distances for short periods of time. He testified that his left knee locked up after sitting for 20 to 30 minutes. He testified that he had 10/10 left knee pain during flare-ups, which occurred nightly after work. In May 2021 the Board remanded this claim for further development, including a new VA examination. On August 2021 VA examination, the Veteran reported that he had to occasionally use crutches and that his knee would lock up. He reported having left knee flare-ups about once a week that lasted 12 to 24 hours and resulted in pain, limited activity, and limited range of motion. He reported functional loss of inability to walk or bend when his left knee locked up, as well as difficulty squatting and climbing stairs. He reported having a history of instability. On examination, left knee flexion was to 75 degrees, and extension was normal, to 0 degrees, both with pain. The examiner indicated that there was objective evidence of pain with weight bearing but not with non-weight bearing, and that there was evidence of localized tenderness or pain on palpation. Repetitive use testing did not result in any additional loss of function or range of motion. The examiner indicated that pain caused functional loss with repetitive use over time and during flare-ups, further limiting the Veteran's left knee flexion to 70 degrees and extension to 5 degrees. The examiner indicated that the Veteran's left knee disability resulted in interference with sitting and standing, disturbance of locomotion, and instability of station. Left knee muscle strength was normal (5/5). It was noted that the Veteran had left knee joint instability and was prescribed crutches, and that there was no patellar instability. The examiner stated that the Veteran did not have a meniscal condition. The examiner indicated that the Veteran had undergone a left knee arthroscopic synovectomy in 2012. The examiner noted that the Veteran did not have recurrent patellar dislocation, shin splits, stress fracture, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The examiner reported that the Veteran did not have left knee ankylosis or muscle atrophy. Analyses Propriety of Reduction At the outset, the Board finds that the rating reduction in this case did not involve a violation of the due process provisions of 38 C.F.R. § 3.105(e). A June 2016 rating decision with a letter notified the Veteran of the proposed reduction, that he had 60 days to present additional evidence showing that compensation should be continued at the prior level, and that he could request a hearing. In August 2016, he filed a notice of disagreement with the June 2016 rating decision, but he did not submit any medical evidence or request a hearing (at that time). The January 2017 rating decision implemented a reduction to 10 percent effective April 1, 2017 (60 days later). In March 2017, he filed another notice of disagreement. In his October 2017 substantive appeal, he requested a Board hearing. After the October 2020 Board hearing, he was afforded another VA examination in August 2021. Given the process described above, the Board finds that the AOJ complied with the procedures required under 38 C.F.R. § 3.105(e) including notifying the Veteran of the proposed reduction and of his rights to a hearing and to submit additional evidence in response in June 2016. He was afforded the specified period of time to respond but did not submit any medical evidence in support of his claim. Accordingly, the analysis proceeds to whether the reduction was factually warranted. Regulations governing rating reductions include 38 C.F.R. § 3.344 (regarding stabilization of disability ratings). The threshold question for consideration is whether the provisions in 38 C.F.R. §§ 3.344 apply. Under 38 C.F.R. § 3.344(c) the provisions apply to ratings that have continued five years or more, and do not apply to disabilities that have not become stabilized and are likely to improve. In those cases, reexaminations disclosing improvement will warrant reduction. However, as the Veteran's left knee disability was granted a 30 percent rating effective May 8, 2012, it was in effect for less than five years when it was reduced to 10 percent effective April 1, 2017. Therefore, the procedural safeguards of 38 C.F.R. § 3.344(a) and (b) do not apply in this matter. The December 2012 rating decision assigned a 30 percent rating under Code 5261 for limitation of extension at 20 degrees. However, the rating decision was based on the initial finding of the May 2012 VA examiner (that extension was limited to 25 degrees), and did not consider an addendum submitted later that month indicated that the Veteran was able to walk with a slight limp and his leg was fully extended, and as such, the Veteran had normal extension, to 0 degrees. Furthermore, the claims file does not show limitation of extension consistent with a 30 percent rating at any time since the Veteran filed his increased rating claim in July 2015. In fact, the medical evidence of record shows that the Veteran's extension was limited, at most, at 5 degrees, even when considering repetitive use over time or during flare-ups. At the June 2016 VA examination, left knee extension was normal, to 0 degrees, with no addition limitation of motion due to repetitive use. In May 2017, he had good left knee range of motion. In September 2017, left knee extension was normal, to 0 degrees. On August 2021 VA examination, left knee extension was normal, to 0 degrees. The examiner found that considering repetitive use testing and flare-ups left knee flexion would be further limited to 70 degrees and extension would be limited to 5 degrees. The Veteran's treatment records and the findings from the May 2012, July 2014, June 2016, and August 2021 VA examinations show left knee range of motion consistent with a 0 percent rating, and the assignment of a 30 percent rating effective May 8, 2012, was in error. However, that was administrative error; the Board will not disturb the 30 percent rating that was assigned from May 8, 2012, to April 1, 2017. Considering the foregoing, the reduction in the rating was factually warranted. Accordingly, the appeal challenging the propriety of the reduction must be denied. Increased Ratings The analysis turns to the Veteran's claim for increases in the "staged" ratings assigned from April 1, 2017, the date following the reduction of the rating to 10 percent. From April 1, 2017, to August 25, 2021, the Veteran's left knee disability was assigned a 10 percent rating for left knee arthritis with painful motion. To warrant a higher rating, flexion must be limited to 30 degrees or extension must be limited to 15 degrees. Furthermore, a separate rating could be assigned for recurrent subluxation or lateral instability, a meniscal condition, tibia and fibula impairment, or genu recurvatum; and a higher rating could be assigned for ankylosis. The evidence of record does not show left knee ankylosis, recurrent subluxation or lateral instability, a meniscal condition, a tibia and fibula impairment, or genu recurvatum from April 1, 2017, to August 25, 2021 (Codes 5256, 5257, 5258, 5259, 5262, and 5263). Regarding limitation of flexion, the record shows that the Veteran had, at worst, flexion limited to 70 degrees (on June 2016 VA examination). On a treatment visit in May 2017, he had good range of motion, and in September 2017, flexion was to 135 degrees. Regarding limitation of extension, the record shows that the Veteran had normal extension during treatment visits and on June 2016 VA examination. At a treatment visit in May 2017, he had good range of motion, and in September 2017 treatment visit, he had normal extension, to 0 degrees. Regarding a meniscal condition, although the Veteran reported left knee locking in July 2016, the evidence does not show dislocated semi-lunar or symptomatic post-removal of dislocated semilunar cartilage. The Veteran underwent left knee arthroscopic synovectomy in January 2012, but medical records at the time specifically report that he did not have a meniscus tear, and the surgery was not a meniscectomy. Medical records do not show a diagnosis of a meniscal condition. Regarding recurrent subluxation or instability, on July 2015 VA examination, the Veteran reported that his left knee would give out. However, joint stability tests were normal on both the July 2014 and June 2016 VA examinations. His medical records do not document a diagnosis of left knee recurrent subluxation or instability. Accordingly, a higher or a separate compensable rating for the Veteran's left knee disability was not warranted from April 1, 2017, to August 25, 2021, under either the previous or revised versions of the rating criteria. At the August 25, 2021 VA examination, the examiner noted that the Veteran did not have any left knee ankylosis, a meniscal condition, a tibia and fibula impairment, or genu recurvatum (Codes 5256, 5258, 5259, 5262, and 5263). Regarding flexion and extension, the Veteran had, at worse, flexion limited to 70 degrees and extension limited at 5 degrees, each consistent with a 0 percent rating. However, he has continued to have painful motion (with his left knee arthritis), and therefore a 10 percent rating under Codes 5010-5260 is warranted. Regarding recurrent subluxation or instability, the August 25, 2021 examiner noted that the Veteran had left knee joint instability and was prescribed crutches. While the AOJ assigned a 10 percent rating under Code 5257 for the Veteran's left knee instability, under the new version of the Code, as he had left knee instability and crutches were prescribed for ambulation, he is entitled to a 20 percent rating. As he was never been found to have a complete ligament tear, a 30 percent rating under Code 5257 is not warranted. Regarding a meniscal condition, as discussed above, the Veteran's medical records specifically establish that the Veteran has not had a meniscus tear; he has not undergone a meniscectomy or received a diagnosis of a meniscal condition. The Board has considered whether higher disability evaluations are warranted base on functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45 for any period on appeal. See also DeLuca, 8 Vet. App. 202 (1995). The Veteran denied having any functional loss on June 2016 VA examination. The August 2021 VA examiner noted that pain resulted in functional loss that further limited the Veteran's left knee flexion to 70 degrees and extension at 5 degrees. Even considering the functional loss from repetitive use over time and during flare-ups, the range of motion found did not warrant a compensable rating for flexion ot extension. His treatment records do not show functional limitations warranting compensable ratings for flexion or extension. Consequently, increased ratings based on functional limitations due to such factors are not warranted. While the Veteran is shown to experience left knee pain, the pain alone is not sufficient to warrant a higher rating, as it does not result in additional functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-38; see also 38 C.F.R. § 4.40. The Board has no reason to question that the Veteran's left knee disability results in the functional limitations he has reported, such as pain aggravated by climbing stairs, squatting, and kneeling, and left knee lock ups and instability. Such limitations are contemplated by the criteria for the ratings now assigned. The Board also finds that the left knee symptoms and impairment shown do not include any that are not adequately addressed by the schedular rating criteria. The disability picture presented is not shown to be (nor is it alleged to be) exceptional, so as to suggest referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321 may be warranted. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berryman, 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.