Citation Nr: 21076935 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-06 758 DATE: December 28, 2021 ORDER Entitlement to an initial 30 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on limitation of flexion is granted. Entitlement to an initial, separate 10 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on lateral instability is granted. Effective January 1, 2011 (but not earlier) to August 12, 2019, entitlement to an initial 20 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint is granted. Entitlement to a disability rating in excess of 20 percent from August 13, 2019, forward for right knee tendonitis with meniscal tear based on dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint is denied. FINDINGS OF FACT 1. At worst, the Veteran's right knee right knee tendonitis with meniscal tear has been limited to 11 degrees on flexion. 2. The Veteran's right knee tendonitis with meniscal tear has manifested as slight lateral instability. 3. The Veteran sustained a meniscal tear with frequent episodes of locking, pain, and effusion into the joint from January 1, 2011, forward. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial 30 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 2. The criteria for an initial, separate 10 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on lateral instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 3. Effective January 1, 2011, to August 12, 2019, the criteria for entitlement to an initial 20 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the join have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 4. From August 13, 2019, forward, the criteria for entitlement to a disability rating in excess of 20 percent for right knee tendonitis with meniscal tear based on dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the join have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 12, 2008 to October 30, 2008, from July 2009 to August 2010, and from January 2014 to February 2015, active duty for training from June 28, 2019 to July 11, 2019, with additional active service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision. In October 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing. A transcript of that hearing is of record. The Veteran's claim for an increased disability rating for her right knee was remanded by the Board in October 2018 and February 2021 for further development. That development having been completed; the Veteran's claim has returned to the Board. Increased Disability Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations 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. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. See 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 126. In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40; see Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (holding that pain must actually affect some aspect of "the normal working movements of the body" [under] 38 C.F.R. § 4.40 in order to constitute functional loss' warranting a higher rating). With respect to disabilities of the joints, consideration is given as to whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The provisions of sections 4.40 and 4.45 thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206 -07 (1995) (holding that the provisions of 4.40 and 4.45 are not subsumed by the diagnostic codes applicable to the affected joint). The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Normal range of motion of the knee is to zero (0) degrees (full extension range of motion) to 140 degrees (full flexion range of motion). 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a noncompensable (0 percent) rating is warranted where flexion of the knee is limited to 60 degrees, and a 10 percent disability evaluation is warranted when flexion is limited to 45 degrees. A 20 percent disability rating is warranted when flexion is limited to 30 degrees, and a 30 percent rating is warranted when flexion of the leg is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable (0 percent) rating is warranted when extension of the knee is limited to 5 degrees, and a 10 percent disability rating is warranted when extension of the knee is limited to 10 degrees. A 20 percent disability rating is warranted when extension is limited to 15 degrees, and a 30 percent rating is warranted when extension limited to 20 degrees. A 40 percent disability rating is warranted when extension is limited to 30 degrees, and a 50 percent disability rating is warranted when extension of the leg is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Disability ratings under Diagnostic Code 5256 may be warranted where there is ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Under Diagnostic Code 5257 a disability rating may be assigned for subluxation or lateral instability of the knee. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, and objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Under Diagnostic Code 5258, dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5258. Under Diagnostic Code 5259, symptomatic removal of semilunar cartilage warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5259. VA's General Counsel has provided guidance concerning increased rating claims for knee disabilities. In VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997), it was held that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that any separate rating must be based upon additional disability. When a knee disability is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or DC 5261 in order to obtain a separate rating for arthritis. In VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998), the VA General Counsel clarified that when a veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. The VA General Counsel has also held that separate ratings could be provided for limitation of knee extension and flexion under Diagnostic Codes 5260 and 5261, as long as both ranges of motion meet the criteria for a compensable rating. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. In this regard, the Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec'y of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claim. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Of note, Diagnostic code 5024 was revised to include tenosynovitis, tendinitis, tendinosis, or tendinopathy in addition to tenosynovitis. Per the note applicable to Diagnostic Code 5024 these conditions are evaluated as degenerative arthritis based on limitation of motion of the affected parts. Diagnostic Codes 5260 and 5261, applicable to limitation of motion in the knee, were unchanged by the February 2021 amendments. Diagnostic Code 5257 was amended to provide ratings for recurrent subluxation or lateral instability. A 10 percent rating is warranted 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 warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing 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 prescribing 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 prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. The amended Diagnostic Code 5257 also provides for ratings based on patellar instability. 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. Note (1) to Diagnostic Code 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) to Diagnostic Code 5257 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. 1. Entitlement to a 30 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on limitation of flexion is granted. 2. Entitlement to a separate 10 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on lateral instability is granted. When service connection was initially granted in August 2011, the Veteran's tendonitis, right knee was evaluated as noncompensable under Diagnostic Code 5099-5024 from August 12, 2010, forward. Regulations provide that, when the disability being rated is not specifically provided for in the rating schedule, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Further, the provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and "99." 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 a hyphen. Here, the hyphenated diagnostic code indicates that a condition of the musculoskeletal system (Diagnostic Code 5099) is rated under the criteria for tenosynovitis (Diagnostic Code 5024). Diagnostic Code 5024, for tenosynovitis, is rated on limitation of motion of the affected parts, as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. In a June 2020 rating decision, the Veteran's right knee disability was recharacterized as right knee tendonitis, meniscal tear, and evaluated as 20 percent disabling under Diagnostic Code 5003-5258 from August 13, 2019, forward. A July 2021 rating decision awarded a separate 10 percent disability rating for the Veteran's right knee disability from August 12, 2010, under Diagnostic Code 5260, based upon painful motion. Therefore, the primary diagnostic code utilized to evaluate the Veteran's right knee tendonitis with meniscal tear based on limitation of motion is Diagnostic Code 5260. As will be discussed below, a separate 20 percent disability rating under Diagnostic Code 5258 remained in effect from August 13, 2019. To evaluate the Veteran's right knee disability, she was afforded several examinations. A November 2010 VA examination states that the Veteran reports right knee pain that has progressively worsened since its onset. For treatment, she takes medication and participates in occupational and physical therapy. Her gait is normal. The November 2010 VA examination report states that on musculoskeletal examination, she does not have joint swelling, effusion, tenderness, or laxity. There is no joint prosthesis, ankylosis, or other objective joint abnormalities. Her right knee flexion was measured to 140 degrees and extension to 0 degrees. There was no objective evidence of pain on active motion. There was no pain on motion after at least three repetitions of range of motion. There was no additional limitation of motion after repetitive motion. She does not have Baker's cyst, tenderness, or effusion. Her reflex examination was normal. Diagnostic imaging from November 2010 showed a normal study as anteroposterior and lateral views of her right knee without previous images reveal normal osseous structures with normal relationships. Her bone mineralization is unremarkable, and the surrounding soft tissues are normal appearing without joint effusion. The November 2010 VA examination report states that the Veteran is diagnosed with tendonitis, right knee and she has associated right knee pain. Her right knee disability does not impact her ability to work. She has pain after walking and on stairs. An April 2011 addendum states that the Veteran did not have right knee ligamentous instability during the November 2010 examination. A May 2015 VA Knee and Lower Leg Conditions Disability Benefits Questionnaire states that the Veteran has diagnoses of right knee meniscal tear and degenerative arthritis. Concerning her medical history, the Veteran reported ongoing right knee pain. She completed physical therapy but continues to have right knee pain. A January 2011 MRI showed complex tears of the lateral meniscus of her right knee. In October 2011, she underwent arthroscopic debridement of her lateral meniscus. She responded well after the surgery and experiences only occasional twinges of right knee pain. Her right knee disability does not cause functional limitations. The May 2015 VA examination report states that the Veteran did not report flare-ups of her right knee. She did not report any functional loss or functional impairment of her right knee. She had right knee flexion to 140 degrees and extension to 0 degrees. Pain was noted on extension, but it does not result in or cause functional loss. There is no pain on weightbearing and there is no objective evidence of localized tenderness or pain on palpation of her joint or associated soft tissue. There is no objective evidence of crepitus. The Veteran is able to perform repetitive use testing with at least three repetitions and there is no additional functional loss or range of motion loss after three repetitions. Pain, weakness, fatigability, and incoordination do not significantly limit functional ability with repeated use over a period of time. The May 2015 VA examination report states that the Veteran has normal strength on flexion and extension without a reduction in muscle strength. She does not have muscle atrophy or ankylosis. The Veteran does not have recurrent subluxation or lateral instability on joint stability testing. In particular, anterior, posterior, medial, and lateral joint stability testing was normal. There was no history of recurrent effusion. The Veteran does not have and has never had recurrent patellar dislocation, "shin splints," stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The May 2015 VA examination report states that the Veteran had a meniscal tear. She was initially diagnosed with right knee tendinitis, which was ultimately proven to be a complex lateral tear requiring surgical debridement 2011. Since then, she has responded very well from the surgical intervention. She describes no limitations and only occasional momentary twinge of discomfort. She has one scar related to her surgery that measures one centimeter in length by one centimeter in width. The examination report provides that the Veteran's right knee arthroscopy scars are barely visible, soft, mobile, non-tender, and there is no evidence of any keloid or instability. The May 2015 VA examination report provides that degenerative or traumatic arthritis was shown on diagnostic testing. She has asymmetrical tibiofemoral joint space narrowing. Her right knee disability does not impact her ability to perform any type of occupational task. The Veteran was afforded a Knee and Lower Leg Conditions Disability Benefits Questionnaire in August 2019. The examination report states that the Veteran has right knee tendonitis/tendinosis and right knee meniscal tear. Concerning her recent medical history, the Veteran reported constant right knee pain that has worsened progressively in the past 18 months. She has aching pain in her knee and is unable to bend, walk, or stand without pain. She does not have any current treatment. She reported flare-ups of buckling and swelling of her knee that increases her aching, swelling, and pain that occurs three times per week, is a 9 out of 10 in severity, and lasts for two and a half hours. She does not report functional loss or functional impairment due to her right knee disability. The August 2019 examination report states that the Veteran has initial range of motion of flexion to 90 degrees and extension to 0 degrees. She has pain on flexion and extension that does not result in or cause functional loss. She has cracking when moving her knee during passive range of motion at her anterior knee that is 6 out of 10 in severity. There is pain with weightbearing and no objective evidence of crepitus. There is objective evidence of pain on passive range of motion and objective evidence of pain in non-weightbearing. The August 2019 examination report provides that the Veteran is able to perform repetitive-use testing with at least three repetitions. There is no additional loss of function or range of motion after three repetitions. On repeated use over time, the Veteran has pain, fatigue, and weakness that significantly limits functional ability with repeated use over a period of time. In terms of range of motion, the Veteran has flexion to 90 degrees and extension to 0 degrees. The August 2019 examination report states that the Veteran has pain, fatigue, and weakness that significantly limits functional ability with flare-ups. A June 22, 2021 addendum medical opinion states that the Veteran has an estimated range of motion during flare-ups of 120 degrees of flexion and 0 degrees of extension. In support, the medical opinion provides that Veteran has a history of two to three flare-ups per week that last one to two hours, which suggests that any swelling would be mild. With mild swelling, the Veteran would be expected to lose up to 20 degrees of flexion, which would make it difficult to kneel, squat, run or climb ladders or stairs. If the Veteran had moderate swelling, her flare-ups would last more than one day, and it would take at least three days for the effusion to resolve and can take up to one week with the effusion limiting flexion to about 90 to 100 degrees with extension at about 5 degrees. If the Veteran had a severe effusion, her flare-ups would last about two weeks with her estimated flexion would be approximately 70 to 80 degrees and her extension would be around 10 degrees. Since the Veteran had a short recovery period, this suggests mild swelling or mild effusion, and her active flexion during a flare-up would be estimated at 120 degrees with no effect on her extension. The August 2019 examination report demonstrates that the Veteran has disturbance of locomotion, interference with sitting, and interference with standing as additional contributing factors that contribute to her right knee disability. Her muscle strength was normal. She does not have muscle atrophy or ankylosis. There is no history or recurrent subluxation, lateral instability, or recurrent effusion. Right knee joint stability testing was normal on her anterior, posterior, medial, and lateral knee. She does not have and has never had recurrent patellar dislocation, "shin splints," stress fractures, chronic exertional compartment syndrome, or other tibial or fibular impairment. The August 2019 examination report states that the Veteran has had a meniscus condition as meniscal tear, frequent episodes of joint "locking" and frequent episodes of joint pain. She had arthroscopic debridement of her lateral meniscus in October 2011, and she has frequent buckling when walking and constant pain. She has a related scar that measures two centimeters in length by 0.1 centimeters in width at her right anterior knee lateral side and an additional scar that measures two centimeters in length and 0.1 centimeters in width on her right anterior knee medial side. She does not use an assistive device as a normal mode of locomotion. Her right knee disability causes functional impairment as she has lost zero to one weeks of work in the past 12 months as she is unable to stand for long periods without knee pain. Prolonged walking causes buckling, and overuse causes pain with bending. An August 2019 addendum medical opinion states that the Veteran had pain on active and passive range of motion. She had pain with weightbearing while sitting. The Veteran's range of motion has deeply decreased since her last examination in 2015. She was unable to fully bend down at the knee when asked to perform three repetitive movements. There was cracking in her right knee on passive range of motion. During a flare-up, she has right knee pain that is 9 out of 10 in severity. She has buckling, swelling, and increased aching pain that happens three times per week and lasts for two and a half hours at a time. She has decreased range of motion on a flare-up that prevents her from bending and moving. She is unable to stand for long periods of time without knee pain. Her pain limits her ability to bend, and she is unable to exercise as desired because of pain and swelling. Her knee buckling causes instability. The Veteran was afforded a January 2021 Knee and Lower Leg Conditions Disability Benefits Questionnaire. The Veteran denied right knee flare-ups. The examination report states that the Veteran has right knee flexion to 115 degrees and extension to 0 degrees. Pain was not noted on the examination and there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no pain with weightbearing. There was no objective evidence of pain on passive range of motion testing or on non-weightbearing. There was objective evidence of crepitus. The January 2021 examination report states that the Veteran is able to perform repetitive-use testing with at least three repetitions and there is no additional loss of function or range of motion after three repetitions. She is not being examined immediately after repetitive use over time. Lack of endurance significantly limits functional ability with repeated use over a period of time and when described in terms of range of motion, she has flexion to 110 degrees and extension to 0 degrees. She had normal muscle strength. She does not have muscle atrophy or ankylosis. There is no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was normal. The Veteran does not have and has never had recurrent patellar dislocation, "shin splints," stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. The January 2021 examination report states that the Veteran had a meniscal repair in 2011. Related scars were not readily seen on examination. Concerning functional impairment, the Veteran's post meniscal repair residuals cause decreased range of motion that do not significantly limit work function. The Veteran was afforded a June 3, 2021 Knee and Lower Leg Conditions Disability Benefits Questionnaire. The Veteran has diagnoses of right knee tendonitis and status post right knee meniscal tear repair with residual pain. She reported a worsening of her right knee disability with decreased range of motion and aching pain that she rates as a 6 out of 10. Concerning treatment, she takes Voltaren as needed for pain. She did not report flare-ups, functional loss, or impairment. The June 3, 2021 examination report states that the Veteran does not have a history of instability, recurrent subluxation, or frequent effusion. Her initial active range of motion was normal as she has flexion to 140 degrees and extension to 0 degrees. Passive range of motion was the same as active range of motion. There was no evidence of pain, objective evidence of crepitus, or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The June 3, 2021 examination report indicates that the Veteran was able to perform repetitive-use testing with at least three repetitions. There was no additional loss of function or range of motion after three repetitions. The Veteran was examined immediately after repeated use over time. Pain, fatigability, weakness, lack of endurance, or incoordination does not significantly limit functional ability with repeated use over time and she has an estimated range of motion of flexion to 140 degrees and extension to 0 degrees. The June 3, 2021 examination report states that the examination was not being conducted during a flare-up. Pain, fatigability, weakness, lack of endurance, or incoordination does not significantly limit functional ability with a flare-up as she denied flare-ups. She does not have muscle atrophy or ankylosis. She does not have recurrent subluxation, persistent instability, or recurrent patellar instability. The Veteran does not have and has never had recurrent patellar dislocation, "shin splints," stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. She does not use an assistive device. Her right knee disability does not impact her ability to perform any type of occupational task. The Veteran underwent a June 22, 2021 Knee and Lower Leg Disability Benefits Questionnaire. The examination report provides that the Veteran's right knee disability has improved since its onset. Currently, she has intermittent swelling, pain, and stiffness. For treatment, she has undergone physical therapy, hydro-tubs, sports therapy massage, right knee arthroscopic meniscectomy, and she takes Naproxen or Diclofenac. She reports flare-ups that occur every two to three days and last for one to two hours that consist of throbbing pain that is a 7 out of 10 in severity, stiffness, and mild swelling. The flare-ups are caused by long periods of driving or sitting and long distance running. Her flare-ups are alleviated by stretching, resistance bands, hydro-tubs, and Naproxen or Diclofenac. Concerning functional impairment during a flare-up, she has difficulty kneeling, squatting, running, and climbing ladders or stairs. She described general functional impairment as limited ability to squat. The June 22, 2021 examination report states that the Veteran did not report a history of instability or recurrent subluxation. She reported a history of frequent effusion of her knee as she experiences mild swelling two to three times per week. Her initial active range of motion was measured at 140 degrees of flexion and 0 degrees of extension. Her passive range of motion measurements were the same. There was no evidence of pain on weightbearing or non-weightbearing or on active or passive motion. There was no objective evidence of crepitus, objective evidence of localized tenderness, or pain on palpation of the joint or associated soft tissue. The June 22, 2021 examination report provides that the Veteran is able to perform repetitive-use testing with at least three repetitions without additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repeated use over time. Pain significantly limits functional ability with repeated use over time and her estimated range of motion after repeated use over time is flexion to 120 degrees and extension to 0 degrees. The June 22, 2021 examination report states that the Veteran is not being conducted during a flare-up. Pain significantly limits functional ability during a flare-up and her estimated range of motion during a flare-up is flexion to 120 degrees and extension to 0 degrees. She does not have muscle atrophy or ankylosis. Joint stability testing showed no recurrent subluxation or persistent instability. There has not been a ligament tear. She does not require a prescription by a medical provider for a cane, walker, crutches, or a brace for ambulation. She has not had surgical repair of her knee for patellar instability. She has not been diagnosed with recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment. The June 22, 2021 examination report indicates that the Veteran has been diagnosed with a meniscus (semilunar cartilage) condition as she had a meniscal tear, frequent episodes of joint pain, and frequent episodes of joint effusion. The residual signs or symptoms following her surgery are noted as two scars and intermittent swelling and pain. She does not use an assistive device as a normal mode of locomotion. The Veteran's VA treatment records also describe the severity of her right knee disability. An August 2010 VA treatment record states that the Veteran complains of right knee pain that occurs daily and sometimes wakes her at night. Her pain does not keep her from daily activities and that physical therapy and Naproxen were helpful. On physical examination, her right knee was mildly tender laterally and she had pain to this area on full extension of her knee. She did not have swelling or erythema. She was assessed with likely tendonitis with mild symptoms. A September 2010 VA Physical Therapy Consult states that the Veteran has constant right knee pain. She has reduced her physical activity because of her knee pain. Her right knee pain averages a 5 out of 10 and increase to 8 out of 10 at night and wakes her when she is sleeping. At times, she has buckling, but she has not fallen. She does not have locking. On physical examination, the September 2010 VA Physical Therapy Consult states that the Veteran has tenderness to palpation, flexion to 11 degrees due to pain and normal extension with pain. She has a patellar click with repetitive flexion that is painful and no clicking with inferior and lateral displacement of patella during flexion testing. She has impaired lateral flight, and a slight squishy end feeling with inferior mobility. She has negative valgus stress at 0 degrees, negative valgus stress at 30 degrees, positive varus stress for translation and patellofemoral compression, and negative anterior drawer, Lachman, posterior drawer, and posterior sag sign. She has a negative McMurray test and Apley's compression test. She was assessed with pain to right knee due to lateral collateral ligament instability, iliotibial band and patellofemoral syndrome, and patellar tendonitis with impaired strength and impaired flexibility. The examiner determined that the Veteran was appropriate for physical therapy. An October 2011 VA Surgical History and Physical Note states that the Veteran denied locking and she does not have significant instability. She has extension to 0 degrees and flexion to 145 degrees. The Veteran underwent a right knee arthroscopic lateral meniscus debridement on October 21, 2011. An October 2011 VA Physician Discharge Note states that the Veteran has a diagnosis of right lateral meniscus tear status post right knee arthroscopic lateral meniscus debridement and that she has reached the optimal goes of an acute hospitalization. She was not placed on restrictions and ambulatory and weightbearing activities could be performed as tolerated. A November 2011 VA Orthopedic Surgery Outpatient Note provides that the Veteran is walking with a cane. She does not have pain or catching. Her right knee is sore, and her pain is improving. Her active range of motion was extension to 0 degrees and flexion to 110 degrees and 120 degrees with some discomfort. She has normal strength. A December 2011 VA Orthopedic Surgery Outpatient Note states that the Veteran is doing "awesome" six weeks status post right knee lateral meniscus debridement. She has no pain, near full flexion, and no problems with walking or range of motion. She does not utilize an assistive device and complete relief of mechanical symptoms. Her active range of motion was extension to 0 degrees and flexion to 120 degrees with very mild discomfort at extreme flexion. She has normal strength and mild subjective numbness over her anterior patella. The Veteran participated in physical therapy following her surgery. A January 2014 VA Physician Note states that the Veteran has not had knee problems since her last visit in 2012 and surgery in 2011. An October 2018 VA Physician Note states that the Veteran has intermittent right knee swelling. A July 2020 VA Physician Telephone Encounter Note states that the Veteran has left knee pain greater than right knee. The Veteran also described the severity of her right knee disability. In a January 2011 Initial Medical Review Annual Medical Certificate, the Veteran stated that she has right knee swelling and difficulty sleeping due to her right knee and as a result she takes Naproxen and sleep medication. In a November 2011 written statement, the Veteran advised of constant right knee swelling and buckling following her active service. She completed more than 8 weeks of physical therapy. She underwent surgery on her right knee in October 2011. In the Veteran's February 2016 VA Form 9, Appeal to the Board of Veterans' Appeals, she advised that she underwent right knee surgery in October 2011 due right knee pain, frequent cartilage dislocation, pain, swelling, and locking. Her pain lessened after her surgery, but it remains. She cannot perform certain exercises due to the removal of cartilage from her knee. She takes anti-inflammatory medication for right knee swelling and pain. During the October 2018 hearing, the Veteran stated that her right knee disability has worsened since her last examination in 2015. She has swelling, buckling, popping, grinding, instability, and pain. She also reported muscle atrophy and weakness. Standing for long periods of time causes her knee to buckle and she occasionally wears a brace for stability. She cannot perform a squat due to her limited range of motion as she described going "about halfway" due to clicking in her knee. She receives cortisone injections approximately two to three times per week. She changes her gait due to her right knee disability. The Board notes the Veteran is competent to report experiencing right knee symptomatology, as the onset, frequency, and duration of her swelling, buckling, popping, grinding, instability, and pain, are certainly capable of lay observation. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Further, the Board finds that the Veteran is credible in reporting her right knee symptomatology. Caluza v. Brown, 7 Vet. App. 498 (1995). The evidence demonstrates that the Veteran's right knee flexion warrants a 30 percent disability rating under Diagnostic Code 5260. A 30 percent rating requires flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Veteran's range of motion on flexion was recorded as 11 degrees in a September 2010 VA Physical Therapy Consult. Additionally, while objective testing has not shown flexion limited to this degree since September 2010, during the October 2018 hearing, the Veteran advised that she cannot perform a squat due to her limited range of motion as she described going "about halfway" due to clicking in her knee. The August 2019 addendum medical opinion states that the Veteran has decreased range of motion on a flare-up that prevents her from bending and moving. The June 22, 2021 examination report describes the Veteran's functional impairment as difficulty kneeling, squatting, running, and climbing ladders or stairs. Therefore, an initial 30 percent disability rating is warranted for the Veteran's right knee tendonitis with meniscal tear based on limitation of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5260. At worst, the Veteran's right knee extension has been measured at 0 degrees which does not meet the criteria for a 10 percent disability rating under Diagnostic Code 5261. At no point during the appeal was the Veteran's right knee extension limited to 5 degrees, satisfying the criteria for a noncompensable disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. And to assign a separate 10 percent rating for painful extension of the knee would amount to pyramiding, as the Veteran's knee pain is contemplated under Diagnostic Code 5260, as well as Diagnostic Code 5258 (as discussed in more detail below). See 38C.F.R. §4.14. In light of the foregoing, the Board also finds that a separate 10 percent disability rating is warranted for slight right knee instability under the prior version of Diagnostic Code 5257. Full consideration has been given to the Veteran's statements made throughout the appeal period that she has right knee instability and buckling that is contained in her treatment records, examination reports, hearing testimony, and written statements. Again, the Veteran is competent to report that which she has personally experienced, such as the above knee symptomatology. See Layno, 6 Vet. App. at 470. Further, an August 2019 addendum medical opinion states that the Veteran's knee buckling causes instability. The Veteran also advised that she wears a knee brace. However, a rating in excess of 10 percent is not warranted under either the prior or revised version of Diagnostic Code 5257, as the evidence does not support a finding of moderate recurrent subluxation or lateral instability under the prior version of Diagnostic Code 5257. A rating in excess of 10 percent is also not warranted under the revised version of Diagnostic Code 5257 as there is no evidence that the Veteran's right knee had 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 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. There have been no objective findings of right knee subluxation or patellar instability. The Board again acknowledges the Veteran's complaints of instability and buckling. However, the VA treatment records and examination reports spanning a period of over ten years consistently show that stability testing of her right knee was normal. Objective evidence of instability is not necessarily required to satisfy the criteria for a rating under Diagnostic Code 5257. English, 30 Vet. App. at 353. Nevertheless, the Board finds that the Veteran's subjective complaints are not sufficient to show that her right knee is manifested by moderate lateral instability, in light of the repeated objective medical findings of no recurrent subluxation or instability. The medical evidence documented for more than 10 years is found to carry greater probative weight than the Veteran's lay statements. Therefore, a disability rating in excess of 10 percent under the former version of Diagnostic Code 5257 is not warranted as her right knee disability has not manifested as moderate recurrent instability. In sum, the Board finds that the evidence supports the assignment of a separate 10 percent disability rating, but not higher, under the prior version of Diagnostic Code 5257 for the entire appellate period. The Board has considered the applicability of Diagnostic Codes 5256, 5259, 5262, and 5263. The Board finds that the remaining diagnostic codes are inapplicable to the Veteran's right knee. Of note, the evidence does not indicate that the Veteran experiences ankylosis, has had cartilage removed, tibia and fibula impairment, or genu recurvatum. Lastly, the Board also notes that the Veteran is already separately rated for her surgical scars, and that issue is not presently before the Board. 1. Effective January 1, 2011 (but not earlier) to August 12, 2019, entitlement to an initial 20 percent disability rating, but not higher, for right knee tendonitis with meniscal tear based on dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint is granted. 2. Entitlement to a disability rating in excess of 20 percent from August 13, 2019, forward for right knee tendonitis with meniscal tear based on dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint is denied. The Veteran has been assigned a 20 percent disability rating under Diagnostic Code 5258 from August 13, 2019, forward. Based on the evidence above, an initial 20 percent disability rating is warranted for the Veteran's right knee disability under Diagnostic Code 5258, effective January 1, 2011, to August 12, 2019. Diagnostic Code 5258 provides for assignment of a 20 percent rating for dislocation of the semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. A January 2011 VA MRI showed that the Veteran has a right meniscal tear described as complex tear involving the anterior horn of the lateral meniscus with a horizontal component extending posteriorly to involve the body, and there is also a small associated meniscal cyst; small radial tear involving the free edge of the anterior horn of the lateral meniscus. The August 2019 examination report states that the Veteran has had a meniscus condition as meniscal tear, frequent episodes of joint "locking" and frequent episodes of joint pain. The June 22, 2021 examination report indicates that the Veteran has been diagnosed with a meniscus (semilunar cartilage) condition as she had a meniscal tear, frequent episodes of joint pain, and frequent episodes of joint effusion. In the Veteran's February 2016 VA Form 9, Appeal to the Board of Veterans' Appeals, she advised that she experiences frequent cartilage dislocation, pain, swelling, and locking. (Continued on the next page) As such, an initial 20 percent disability rating is warranted for the Veteran's right knee disability under Diagnostic Code 5258, effective January 1, 2011, the first day of the month in which diagnostic testing revealed a meniscus tear, to August 12, 2019. A 20 percent disability rating is the maximum rating available under Diagnostic Code 5258; therefore, a rating in excess of 20 percent is not warranted at any time during the appellate period from January 1, 2011, forward. Further, prior to January 1, 2011, a separate rating is not warranted under DC 5258, as there was no evidence of a meniscus tear. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mussey, Sean 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.