Citation Nr: 21077182 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-41 502 DATE: December 28, 2021 ORDER A rating in excess of 10 percent for chondromalacia of the right knee with postoperative anteromedial plica and osteoarthritis is denied. An initial, separate 10 percent rating is granted for right knee instability, subject to the law and regulations governing the award of monetary benefits. A compensable rating for a stress fracture of the right tibia is denied. A compensable rating for a stress fracture of the left tibia is denied. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's right knee disability has been productive of painful motion; it has not been productive of compensable limitation of flexion or extension, ankylosis, dislocation or removal of the semilunar cartilage with frequent episodes of pain, locking, and effusion, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. 2. For the entire period on appeal, the Veteran's right knee disability has been manifested by instability which has been no more than slight. 3. For the entire period on appeal, the Veteran's tibia stress fractures have not been productive of slight, moderate, or marked knee or ankle disability. 4. For the entire period on appeal, the Veteran's tibia stress fractures have not been productive of nonunion of the tibia and fibula with loose motion, requiring a brace. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for chondromalacia of the right knee with postoperative anteromedial plica and osteoarthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5256-5263. 2. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial, separate 10 percent rating for right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. The criteria for a compensable disability rating for a stress fracture of the right tibia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5299-5262. 4. The criteria for a compensable disability rating for a stress fracture of the left tibia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5299-5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from May 1989 to August 1992. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In June 2019, the Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. This case was previously before the Board in December 2019 and April 2021, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. In its December 2019 remand, the Board directed the AOJ to undertake additional records development and to afford the Veteran a new VA examination in connection with his claims. In its April 2021 remand, the Board found that the AOJ had substantially complied with the records development ordered in its December 2019 remand, but found that the AOJ had not afforded the Veteran a fully adequate VA examination. The Board again remanded the claims, directing the AOJ to undertake additional records development for both private and VA treatment records, and to afford the Veteran a new VA examination. In April 2021, following the issuance of the Board's decision, the AOJ sent the Veteran a letter asking him to provide a release for the records of Drs. F. and J. at Ochsner South Shore Region LA in Gretna, Louisiana, and to identify and provide an appropriate release for any other private treatment records relevant to the issues on appeal. The Veteran did not respond to that request. As such, the AOJ was unable to do anything further to develop the records. VA's duty to assist in the development and adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996); Wood v. Derwinski, 1 Vet. App. 190, 193, recon. denied, 1 Vet. App. 406 (1991) (per curiam). In April 2021, the AOJ obtained updated VA treatment records. In July 2021, the AOJ arranged to afford the Veteran a new VA examination in connection with his claims. In light of the efforts undertaken by the AOJ, the Board finds that there has been at least substantial compliance with all of its prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Higher Ratings Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If different disability ratings are warranted for different periods of time over the life of a claim, "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits compensating a veteran twice for the same symptoms or functional impairment). When an unlisted condition is encountered, it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). With any form of arthritis, painful motion is an important factor of disability; the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Painful motion is an important factor of disability, and joints that are actually painful, unstable, or malaligned due to healed injury should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 1. A rating in excess of 10 percent for chondromalacia of the right knee with postoperative anteromedial plica and osteoarthritis The Veteran contends that his right knee disability warrants a rating in excess of 10 percent. In a September 2021 Informal Hearing Presentation, his representative contended that he was entitled to a higher rating and that rating criteria do not take into consideration the negative impact the conditions have on his activities of daily living. VA's Office of General Counsel has provided guidance concerning increased rating claims for knee disorders. Among that guidance is that compensating a claimant for separate functional impairment under Diagnostic Codes 5257 and 5003 does not constitute pyramiding. See VAOPGCPREC 23-97 and VAOPGCPREC 9-98. As an initial matter, the Board notes that the rating criteria for certain musculoskeletal disabilities have been amended, effective February 7, 2021. The Board may continue to apply the old rating criteria to rating periods prior to February 7, 2021 but may apply whichever set of criteria is more favorable for the period on and after February 7, 2021. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that are more favorable to the Veteran will be applied. Prior to February 7, 2021, Diagnostic Code 5010 instructed the Board to rate traumatic arthritis as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Under the prior rating criteria, DC 5003 provided that degenerative arthritis would be rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. DC 5003 also provided for a 20 percent rating for arthritis where X-ray evidence showed involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note 1 to DC 5003 provided that the 20 and 10 percent ratings based on X-ray findings would not be combined with ratings based on limitation of motion. From February 7, 2021, DC 5010 contemplates post-traumatic arthritis, which is rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. The only substantive difference between the prior and current versions of DC 5003 is that from February 7, 2021, DC 5003 contemplates degenerative arthritis, other than post-traumatic. The appropriate diagnostic codes for rating limitation of motion of the knee are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel held that, when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation of flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitation of flexion and extension, separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Under both the former and current rating criteria, DC 5260 contemplates limitation of flexion of the leg. Limitation of knee flexion is 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and 0 (zero) percent (noncompensably) disabling where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a. Under both the former and current versions of DC 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensably disabling where extension is limited to 5 degrees. 38 C.F.R. § 4.71a. Prior to February 7, 2021, DC 5262 addressed impairment of the tibia and fibula and instructed the assignment of a 40 percent rating for nonunion of the tibia and fibula, and 10, 20, and 30 percent ratings for slight, moderate, or marked knee or ankle disabilities. Id. The words "slight," "moderate," "severe," and "marked" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just decisions." Id. From February 7, 2021, DC 5262 now provides that for malunion, the adjudicator is to evaluate under Diagnostic Code 5256, 5257, 5260, or 5261 for the knee, whichever results in the highest evaluation. A 40 percent rating is warranted for nonunion, with loose motion, requiring brace. DCs 5256, 5257, 5258, 5259, and 5263 are also pertinent to the Veteran's claims. Prior to February 7, 2021, DC 5256 provided that a 30 percent rating was warranted for ankylosis with a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. Under DC 5257, a 10 percent rating was warranted for slight recurrent subluxation or lateral instability. A 20 percent rating was warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating was warranted for severe recurrent subluxation or lateral instability. DC 5258 provided that a 20 percent rating was warranted for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. DC 5259 provided that a 10 percent rating was warranted for symptomatic removal of the semilunar cartilage. DC 5263 provided for a 10 percent rating for genu recurvatum (acquired traumatic with weakness and insecurity in weight bearing objectively demonstrated). Under the new rating criteria effective February 7, 2021, no changes were made to DCs 5256, 5258, 5259, or 5263. On the other hand, significant changes were made to Diagnostic Code 5257. Effective February 7, 2021, DC 5257 provides that for 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 walker. For recurrent subluxation or 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), crutches(es), walker) or brace for ambulation. A 20 percent rating is warranted for one of the following: a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive devices (e.g. cane(s), crutch(es), walker) for ambulation; 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), or a walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Note 2 to the new version of DC 5257 states that a surgical procedure that does not involved 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). The Veteran's right knee disability is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260. 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. See 38 C.F.R. § 4.27. The assigned Diagnostic Code 5260 suggests that the right knee disability is rated based on compensable limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that the right knee disability has been manifested, in part, by osteoarthritis and been rated based on painful noncompensable limitation of motion, and that the right knee has not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the relevant rating period (see August 2012, November 2012, May 2016, March 2020, and July 2021 VA examination reports); therefore, the diagnostic code assigned should have been Diagnostic Code 5003, to show that the bilateral knee disability with osteoarthritis was being rated based on noncompensable limitation of motion that is painful. For this reason, the Board has changed the Diagnostic Code for the right knee disability to 5003 to reflect the actual rating already assigned. 38 C.F.R. § 4.71a. After a review of all of the evidence, lay and medical, the Board finds that, even with considerations of all orthopedic limiting factors, including pain, tenderness, crepitus, and limitation on repetitive use and during flareups, the Veteran's right knee disability has not approximated the criteria for a higher, 20 percent rating, that is: limitation of flexion to 30 degrees; limitation of extension to 15 degrees, bilateral knee ankylosis; removal or dislocation of the semilunar cartilage with frequent episodes of "locking," pain, and effusion; malunion or nonunion of the tibia and fibula; or genu recurvatum. 38 C.F.R. § 4.71a. For the reasons set forth below, the Board finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for the Veteran's right knee disability, whether under the former or current criteria, as applicable. The Veteran filed his claim for increased rating for his right knee disability and tibial stress fractures in January 2012. In August 2012, an X-ray of the knees showed minimal degenerative changes, while X-rays of the tibiae and fibulae were normal. The Veteran was afforded a VA examination in connection with his claims in August 2012. The examiner found that the Veteran had chondromalacia and osteoarthritis of the right knee, as well as stress fractures of both knees and/or lower legs. The Veteran reported flareups, swelling, and pain in the right knee. On initial range of motion testing, he had right knee flexion to 120 degrees, and his right knee extension was normal. He was able to perform repetitive use testing with no additional loss of range of motion following testing, but the examiner indicated that the Veteran had functional loss and/or functional impairment of the knee and lower leg. He indicated that contributing factors of disability included less movement than normal, swelling, and interference with sitting, standing, and weight-bearing. On further examination, the Veteran's strength was full, joint stability tests (including anterior instability, posterior instability, and medial-lateral instability tests) were normal, there was no evidence or history of recurrent patellar subluxation or dislocation, and the examiner indicated that the Veteran had never had stress fractures or any other tibial and/or fibular impairment. The examiner further indicated that the Veteran had had a prior meniscus tear on the right, but that he had not had a meniscectomy, and further that there were no residual signs and/or symptoms due to a meniscectomy. He also noted that the Veteran had a small effusion in the right knee, and a positive McMurray's on the right. The examiner indicated that the Veteran did not use any assistive devices. While imaging studies documented degenerative or traumatic arthritis in the right knee, the examiner indicated that there was no X-ray evidence of patellar subluxation. The Veteran was afforded a second VA examination in connection with his claim in November 2012. The examiner found that the Veteran had right knee chondromalacia with osteoarthritis and noted that he had undergone an arthroscopic surgery of the right knee in 1992. The Veteran reported daily flareups. Initial range of motion testing showed that he had right knee flexion to 125 degrees and normal right knee extension. He was unable to perform repetitive-use testing with three repetitions. The examiner indicated that the Veteran had functional loss and/or functional impairment of the knee and lower leg, and further indicating that contributing factors of disability were less movement than normal, weakened movement, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. He added that the Veteran also had pain with climbing stairs, stooping, and bending. On further examination, the Veteran had only 4/5 strength in right knee flexion and extension, with full strength in the left knee. Joint stability tests (including, again, anterior instability, posterior instability, and medial-lateral instability tests) were normal bilaterally, and the examiner indicated that there was no evidence of recurrent patellar subluxation or dislocation. The examiner found that the Veteran had never had stress fractures or any other tibial and/or fibular impairment, that he had never had any meniscal conditions, and that he had no signs and/or symptoms due to a meniscectomy. The examiner noted that the Veteran used a brace regularly, and that imaging studies of the right knee documented degenerative or traumatic arthritis. He further noted, however, that there was no X-ray evidence of patellar subluxation. The Veteran was afforded a third VA examination in connection with his claims in May 2016. The examiner found that the Veteran had stress fractures of the tibiae of both knees. The Veteran did not report flareups of his knee and/or lower leg disabilities, but reported functional impairment as having a sitting tolerance of 45 minutes. On initial range of motion testing for both knees, the Veteran had flexion to 110 degrees, and extension from 110 to 0 degrees. The examiner indicated that there was no evidence of pain with weight-bearing, and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. He found, however, that there objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with no additional loss of range of motion. The examiner opined that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. He also identified interference with sitting as an additional contributing factor of disability. The Veteran's strength was full, he had no atrophy, and there was also no ankylosis of either knee. The examiner indicated that there was no history of recurrent subluxation, lateral instability, or recurrent effusion, and joint stability tests were performed and were once again all normal. The examiner also noted that the Veteran had stress fractures of both legs but indicated that the condition did not affect range of motion of either knee or ankle. The examiner opined that there were no current signs or residuals of stress fractures of the tibiae and no tenderness along the tibiae itself, explaining that stress fractures heal and that the diagnosis was made in 1991. He also noted that the Veteran did not have and had never had a meniscal condition, but also noted the prior right knee arthroscopy and stated that residual symptoms due to the surgery included pain and decreased range of motion. The examiner indicated that the Veteran used knee braces regularly with work activity, and that imaging from May 2016 did not document degenerative or traumatic arthritis. A July 2016 VA treatment record shows that the Veteran reported daily knee pain at that time, and that he felt that his knees sometimes gave out. On examination, both knees had normal range of motion with no swelling or tenderness, and neurological testing was also normal. A July 2016 X-ray of the knees again showed no fracture or dislocation, no joint effusion, and the cartilage spaces were maintained on non-weight-bearing views. A January 2017 VA treatment shows that the Veteran had had a left meniscal repair more than ten years earlier, but under review of systems there was no swelling, paresthesias, locking, or motor weakness of either knee. On examination at that time, he had normal range of motion with no edema or tenderness, there was no joint line tenderness in either knee, anterior and posterior drawer tests were negative, there was no laxity to varus or valgus strain, and sensation to monofilament testing was normal. The Veteran was afforded a VA examination of his low back in July 2019. Knee strength and extension were noted as full, reflexes were slightly diminished in the right knee and normal in the left, and sensation was normal in the bilateral knees. The Veteran sought treatment for low back problems at the VA in July 2019. The record shows that he was noted to have an antalgic gait and that he was ambulating with a cane. There was no peripheral edema, leg flexion and extension were noted to be limited by pain bilaterally, and sensation and reflexes were normal. The record does not contain specific range of motion testing results. Another X-ray of the knees performed at that time showed bilateral patellofemoral degenerative changes and atherosclerosis. In another VA treatment record dated later in July 2019, the Veteran had an antalgic gait, used a cane as an assistive device, and was wearing a knee brace on the right. On examination, he had limited range of motion due to pain, as well as positive tibial tuberosity pain with movement. He also had pain with extension, medial rotation, and with weight-bearing, though again, specific range of motion testing results were not provided. The provider administered cortisone injections in the right knee and also recommended bilateral knee braces. In August 2019, he was issued hinged knee braces by VA. The Veteran was afforded a fourth VA examination in connection with his claim in March 2020. The examiner found that the Veteran had degenerative arthritis of both knees, chondromalacia of the right knee, and stress fractures of both tibiae. She noted that the Veteran had undergone arthroscopic surgery on his right knee in 1992, and that pain had continued since that time. She further noted the Veteran's report that he had daily knee pain and wore braces every day, and that if he did not wear the braces he felt as if he was going to fall. The Veteran also reported flareups of the right knee described as pain going to an 8 out of 10 three to four times per week, with activity making it worse. Initial range of motion testing on both knees showed that the Veteran had flexion to 110 degrees and extension from 110 to 0 degrees. The examiner indicated that range of motion itself contributed to functional loss, that there was evidence of pain with weight-bearing and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, but that there was no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions of the right knee, and the examiner indicated that there was additional functional loss or range of motion after three repetitions, with pain and lack of endurance being the factors that caused the functional loss. She described the additional functional loss in terms of range of motion as flexion limited to 100 degrees and extension limited from 100 to 0 degrees. Regarding the left knee, the Veteran was able to perform repetitive-use testing with no additional functional loss or range of motion. The examiner opined that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flareups. On further examination, the Veteran's strength was full, there was no atrophy or ankylosis, and the examiner indicated that there was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed, but as with the previous VA examinations, all stability testing was normal in both knees. The examiner further indicated that the Veteran had had stress fractures of both lower legs, but that the condition did not affect range motion of either the knees or the ankles. The examiner noted that the Veteran had never had a meniscus condition, that the 1992 right knee arthroscopic surgery had residuals including pain and decreased range of motion, and that the Veteran used a brace and a cane regularly. She stated that he used the brace for 6 hours per day and the cane for stability. Regarding X-ray evidence of arthritis, the examiner found that degenerative or traumatic arthritis was documented per the June 2019 X-ray report, and also cited to a July 1991 bone scan which showed that the Veteran had bilateral increased tibial activity consistent with stress fractures. Finally, the examiner found that there was evidence of pain on passive range of motion, but only in the left knee, that there was no evidence of pain when the joint was used in non-weight bearing in either knee, and that the opposing joint was not undamaged. A May 2020 VA treatment record indicates that another bone scan was performed in March 2020. It showed no stress or traumatic fracture involving either the tibiae or fibulae. In October 2020, the Veteran was seen for his knees at VA. On examination at that time, there were no painful or swollen joints, no decreased range of motion of any joints, and no heat or redness in any joints. In November 2020, he again underwent injections of both knees. The Veteran was afforded a fifth VA examination in connection with his claim in July 2021. The examiner found that the Veteran had osteoarthritis in both knees, chondromalacia in the right knee, and stress fractures of both tibiae. The Veteran reported that he used a brace and supports on a regular basis, that he used a cane if he had to do a lot of walking, and that he had intermittent buckling of both knees. He also reported that he had daily flareups of his knees which were moderate to severe and lasted a few hours. He did not report a history of frequent effusion of the knee. Initial range of motion testing showed that the Veteran had right knee flexion to 90 degrees and left knee flexion to 85 degrees, with extension being normal. Passive range of motion was the same as active range of motion in both flexion and extension and in both knees. The examiner indicated that there was evidence of pain with weight-bearing, in non-weight-bearing, with active motion and with passive motion, and further indicated that it caused functional loss in that pain caused decreased range of motion in both knees. The examiner further indicated that there was objective evidence of crepitus and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue in both knees, stating that the location was medial and lateral knee and anterior shin with the severity being moderate, and that the relationship to the condition was arthritis and residuals of tibial stress fractures. The Veteran was able to perform repetitive-use testing with no additional loss of function or range of motion after three repetitions in both knees, but the examiner indicated that pain and fatigability significantly limited functional ability with repeated use over time. The examiner described the additional limitation in terms of range of motion as flexion in the right knee limited to 80 degrees and in the left knee to 75 degrees. While the examiner indicated that the examination was not being conducted during a flareup, he nevertheless opined that pain and fatigability also significantly limited functional ability with flareups and estimated the additional loss in terms of range of motion as right knee flexion limited to 80 degrees and left knee flexion limited to 75 degrees. There was no atrophy or ankylosis, recurrent subluxation or persistent instability, or recurrent patellar instability of either knee, and the examiner indicated that the Veteran did not require a prescription by a medical provider for ambulation. The examiner also noted that the Veteran had had stress fractures of both lower legs and stated that current symptoms included pain and tenderness with palpation of the anterior shin, with no other symptoms noted. The examiner further noted that the Veteran had not been diagnosed with a meniscus condition, noted the 1991 arthroscopic surgery of the right knee, and noted that the Veteran used a brace regularly for chondromalacia and arthritis. The July 2021 VA examiner did not perform imaging but cited to the June 2019 X-ray results noting mild patellofemoral degenerative changes. Finally, the examiner stated that the Veteran's stress fractures did not affect knee or ankle range of motion. The examiner also noted specifically that right and left knee anterior, posterior, medial, and lateral instability tests were all normal. In light of the above, the Board finds that a rating in excess of 10 percent for the Veteran's right knee disability based on painful or limited motion is not warranted. While the Board has considered the Veteran's lay statements to the effect that his right knee disability causes pain and impacts his activities of daily living, even considering additional functional impairment and limitation of motion caused by such symptoms, the evidence of record does not reflect that his disability has been manifested by flexion limited to 45 degrees or extension limited to 5 degrees. In light of the evidence of right knee osteoarthritis and otherwise noncompensable limitation of motion, a 10 percent rating under Diagnostic Code 5003 is warranted and is the most favorable code under which to rate the right knee limitation of motion, including limitation of motion due to pain and tenderness. 38 C.F.R. § 4.40, 4.45, 4.59, 4.71, DC 5003. The evidence of record reflects that, when considering additional limitations due to orthopedic (38 C.F.R. §§ 4.40, 4.45, 4.59, Deluca) factors, the Veteran has had noncompensable right knee extension to 0 degrees and noncompensable limitation of flexion of the right knee that ranged from 80 to 140 degrees, including functional loss due pain, repetitive use, and flare-ups. As noted, such limitation of motion, coupled with painful arthritis, meets the criteria for a 10 percent rating for right knee osteoarthritis with noncompensable limitation of motion under DC 5003 (degenerative arthritis prior to February 7, 2021; degenerative arthritis, other than post-traumatic from February 7, 2021). However, the criteria for a higher, 20 percent rating have not been more nearly approximated under either the old or new rating criteria (i.e., limitation of extension to at least 15, limitation of flexion to at least 30 degrees). 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, Diagnostic Codes 5260, 5261. The Board has also considered whether a separate or alternative and higher disability rating is warranted under any other diagnostic codes. As the evidence of record during the period in question does not reflect that the right knee was ankylosed; that there was removal or dislocation of the semilunar cartilage with frequent episodes of "locking," pain, and effusion; that there was malunion or nonunion of the tibia and fibula; that there was a diagnosis of genu recurvatum; that there was limitation of flexion to a compensable degree (i.e., 45 degrees); or that there was limitation of extension to a compensable degree (i.e., 5 degrees), a separate or higher disability rating is not warranted under Diagnostic Codes 5256, 5258-5263. 38 C.F.R. § 4.71a. While there was small effusion of the right knee noted at the August 2012 VA examination, that is the only instance during the nearly ten-year appeal period in which the Veteran had effusion. Four subsequent VA examinations indicated that he did not have effusion, and at the July 2021 VA examination the Veteran also expressly denied having frequent effusion. While the August 2012 VA examiner found that the Veteran had a right knee meniscal condition, that finding appears to be an error. The November 2012, May 2016, March 2020, and July 2021 VA examiners all indicated that the Veteran had never had a right knee meniscal condition, and the January 2017 VA treatment record indicates that the Veteran underwent a left meniscal repair, not a right meniscal repair, ten years earlier. Based on the foregoing, the Board finds that the service-connected chondromalacia of the right knee with postoperative anteromedial plica and osteoarthritis has not been manifested by symptomatology that more nearly approximates the criteria for a higher, 20 percent disability rating under Diagnostic Codes 5256, or 5258-5263, at any time during the period on appeal. 38 C.F.R. § 4.71a. Because the preponderance of the evidence is against a rating in excess of 10 percent, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. An initial, separate 10 percent rating for right knee instability The foregoing discussion notwithstanding, the Board finds that, for the entire period on appeal, the Veteran's right knee disability has approximated the criteria for a separate, 10 percent rating for slight knee instability. 38 C.F.R. § 4.71a., Diagnostic Code 5257. While acknowledging that the objective stability testing on all five of the aforementioned VA examinations was normal, the Board notes that the Veteran has also used assistive devices and reported subjective instability in the right knee throughout the period on appeal. While he was not using any assistive devices at the August 2012 VA examination, at the November 2012 VA examination he was noted to use a right knee brace regularly. At the May 2016 VA examination, the examiner indicated that the Veteran used knee braces regularly with work activity. In a July 2016 VA treatment record, the Veteran reported that he felt that his knee sometimes gave out. In a July 2019 VA treatment record, even though he was being treated for back pain rather than knee pain at that time, he was ambulating with a cane and had an antalgic gait. In another July 2019 VA treatment record regarding the knees specifically, a VA provider recommended bilateral knee braces, which were issued by VA in August 2019. At the March 2020 VA examination, the Veteran reported that he wore knee braces every day, and that if he did not wear them he felt as if he were going to fall, and the examiner indicated that he used both a brace and a cane regularly. At the July 2021 VA examination, the examiner indicated that he used a brace regularly and specified that he did so for his chondromalacia and arthritis. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's right knee disability has approximated slight lateral instability, so as to warrant a separate compensable 10 percent rating under DC 5257, for the entire period on appeal. 38 C.F.R. §§ 4.3, 4.7, 4.71a. The Board finds that a 10 percent rating, and no higher, is warranted under either the old or new rating criteria. Prior to February 7, 2021, a 10 percent rating is warranted where impairment is slight. Because objective joint stability testing has always been entirely normal, the Board finds that the Veteran's instability has been no more than slight under the old rating criteria during the entire period on appeal. From February 7, 2021, a compensable rating for recurrent subluxation or instability requires a sprain or ligament tear, and the evidence of record does not indicate that the Veteran has ever had those problems. A 10 percent rating for patellar instability under the new criteria requires a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker; higher ratings require surgical repair. While acknowledging that the Veteran underwent a right knee arthroscopic surgery in 1992, that type of surgery is expressly excluded from the definition of surgical repair in Note 2 of the new version of DC 5257. The evidence of record does not indicate that he has undergone any other right knee surgeries. Whether applying the old or new criteria, therefore, the Board finds that a separate 10 percent rating, and no higher, is warranted for the Veteran's right knee instability. 3. A compensable rating for a stress fracture of the right tibia 4. A compensable rating for stress fracture of the left tibia The Veteran contends that his tibial stress fractures warrant compensable ratings. The Veteran's tibial fractures are each rated as 0 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5299-5262. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number is "built up" with the first two digits being selected from that part of the schedule most closely identifying the part, and the last two digits being "99" for an unlisted condition. Id. Upon review of the evidence, the Board finds that the preponderance of the evidence is against the assignment of compensable disability ratings for the Veteran's right or left tibial stress fractures, whether under the former or current criteria, as applicable. Simply put, nothing in the evidence indicates that the Veteran's tibial fractures warrant compensable ratings, as there is no evidence to suggest that they have resulted in any knee or ankle impairment. While the August 2012 examiner made contradictory findings regarding stress fractures, indicating in the initial portion of the examination that the Veteran had stress fractures and in a subsequent portion that he did not, and the November 2012 VA examiner found that the Veteran did not have stress fractures, the May 2016 and March 2020 VA examiners acknowledged that he had had them. Both the May 2016 and March 2020 VA examiners, however, indicated that the past stress fractures did not impact range of motion in the knees or ankles and that they did not cause any symptoms. While the July 2021 VA examiner indicated that symptoms included pain and tenderness with palpation of the anterior shin, there is no evidence in the claims file that suggests that they are productive of any knee or ankle disability, even to a slight degree. Indeed, while a July 1991 bone scan showed that the Veteran had bilateral increased tibial activity consistent with stress fractures, an August 2012 X-ray of the tibiae was normal, a March 2020 bone scan showed no stress or traumatic fracture involving either the tibiae or fibulae, and the May 2016 VA examiner opined that there were no residual symptoms from the stress fractures, that the diagnosis was made in 1991, and that stress fractures healed. For these reasons, the Board finds that the preponderance of the evidence is against the assignment of compensable ratings for the Veteran's tibial stress fractures. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Oldroyd, Associate 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.