Citation Nr: 21077619 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 12-05 445 DATE: December 30, 2021 ORDER Entitlement to a rating of 20 percent, but no higher, for left knee residuals of arthroscopic surgery on the basis of moderate knee instability prior to October 6, 2015, is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 20 percent for left knee residuals of arthroscopic surgery on the basis of knee instability from October 6, 2015 to May 11, 2016, is denied. Entitlement to a rating of 30 percent, but no higher, for left knee residuals of arthroscopic surgery on the basis of severe knee instability from May 12, 2016, to October 5, 2017, is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 30 percent for left knee residuals of arthroscopic surgery on the basis of knee instability since October 6, 2017, is denied. Entitlement to a rating in excess of 10 percent for left knee degenerative arthritis on the basis of limitation of flexion prior to October 6, 2017 is denied. Entitlement to a rating in excess of 20 percent for left knee degenerative arthritis on the basis of limitation of flexion from October 6, 2017 to May 30, 2018, is denied. Entitlement to a rating of 30 percent, but no higher, for left knee degenerative arthritis on the basis of limitation of flexion since May 31, 2018, is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a separate 10 percent rating, but no higher, for left knee degenerative arthritis on the basis of limitation of extension from February 17, 2010 to April 23, 2017, is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to a 20 percent rating, but no higher, for left knee degenerative arthritis on the basis of limitation of extension since April 24, 2017, is granted subject to the law and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. By resolving reasonable doubt in the Veteran's favor, the Veteran's left knee residuals of arthroscopic surgery was productive of moderate instability prior to October 6, 2015. 2. The Veteran's left knee residuals of arthroscopic surgery was not productive of severe instability prior to May 12, 2016. 3. By resolving reasonable doubt in the Veteran's favor, the Veteran's left knee residuals of arthroscopic surgery was productive of severe instability since May 12, 2016. 4. The Veteran is in receipt of the maximum 30 percent rating for left knee residuals of arthroscopic surgery on the basis of severe instability since May 12, 2016. 5. The Veteran's left knee degenerative arthritis was not productive of flexion limited to 30 degrees or less prior to October 6, 2017. 6. The Veteran's left knee degenerative arthritis was not productive of flexion limited to 15 degrees or less from October 6, 2017 to May 30, 2018. 7. At its worst, the Veteran's left knee degenerative arthritis was productive of flexion limited to 5 degrees since May 31, 2018. 8. At its worst, the Veteran's left knee degenerative arthritis was productive of extension limited to 10 degrees from February 17, 2010 to April 23, 2017. 9. At its worst, the Veteran's left knee degenerative arthritis was productive of extension limited to 15 degrees since April 24, 2017. CONCLUSIONS OF LAW 1. Prior to October 6, 2015, the criteria for a rating of 20 percent for left knee residuals of arthroscopic surgery on the basis of knee instability were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 2. Prior to May 12, 2016, the criteria for a rating in excess of 20 percent left knee residuals of arthroscopic surgery on the basis of knee instability were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. Since May 12, 2016, the criteria for a rating of 30 percent, exclusive of temporary total rating periods, for left knee residuals of arthroscopic surgery on the basis of knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 4. Since May 12, 2016, the criteria for a rating in excess of 30 percent left knee residuals of arthroscopic surgery on the basis of knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 5. Prior to October 6, 2017, the criteria for a rating in excess of 10 percent for left knee degenerative arthritis with limitation of flexion were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 6. From October 6, 2017 to May 30, 2018, the criteria for a rating in excess of 20 percent for left knee degenerative arthritis with limitation of flexion were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 7. Since May 31, 2018, the criteria for a rating of 30 percent for left knee degenerative arthritis with limitation of flexion were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 8. Since February 17, 2010, the criteria for a separate 10 percent rating for left knee degenerative arthritis with limitation of extension were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 9. Since April 24, 2017, the criteria for a rating of 20 percent for left knee degenerative arthritis with limitation of extension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from May 1987 to January 1992. This matter is before the Board of Veterans' Appeals (Board) following Board Remands in August 2017, October 2018, and November 2020. This matter was originally on appeal from an August 2010 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. When, as here, the Veteran is requesting a higher rating for already established service-connected disabilities, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran contends that he is entitled to higher ratings for his service-connected left knee disabilities. The Veteran's left knee residuals of arthroscopic surgery is rated under Diagnostic Codes 5010-5257. The Veteran's left knee degenerative arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown after a hyphen. 38 C.F.R. § 4.27. Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. Although the rating criteria for Diagnostic Code 5257 has changed, the rating criteria for Diagnostic Code 5260 has not changed. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021. The Board will consider both the old and revised rating criteria from February 7, 2021, and the criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5257 provided the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. As of February 7, 2021, under the amended criteria, Diagnostic Code 5257 indicated that knee, other impairment of should be rated as follows: Recurrent subluxation or instability: 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, a 30 percent disability rating is warranted. For one of the following a 20 percent disability rating is warranted: (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; (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider pre-scribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. 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 10 percent disabling rating is warranted. Patellar instability: 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 a 30 percent disabling 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 20 disability 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 10 percent disability rating is warranted. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a , Plate II. 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 and, therefore, not be reflected on range-of-motion testing. 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); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran has separate ratings assigned for his left knee. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Compensating a claimant for separate functional impairment under Diagnostic Code 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997) held that arthritis and instability of the same knee may be rated separately under Diagnostic Codes 5003 and 5257. Subsequently, VAOPGCPREC 9-98 further explained that if a Veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. See also VAOPGCPREC 9-04 (holding that separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned). In determining the appropriate ratings for the Veteran's left knee, the Board is mindful that the combined ratings for disabilities of an extremity shall not exceed the rating for the amputation at the elective level were amputation to be performed. 38 C.F.R. § 4.68. Thus, the highest combined evaluation that may be assigned under the amputation rule for the knee is 60 percent. See 38 C.F.R. § 4.71a, Diagnostic Code 5152 (assigning a 60 percent rating for amputation from the lower third of the thigh). 1. The Board finds that the preponderance of the evidence supports a 20 percent rating for left knee residuals of arthroscopic surgery on the basis of knee instability prior to October 6, 2015. As noted above, a 20 percent rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. VA treatment records indicate that in July 2009, the Veteran underwent orthopedic surgery consultation at which time he reported left knee painful popping, giving out, and pain with weather changes. Physical examination of the left knee demonstrated negative McMurray's, Lachman's, and joint line tenderness. The Veteran was diagnosed as having left medial meniscus tear and patellofemoral syndrome. In September 2009, physical examination demonstrated stable varus/valgus stress, painful McMurray's, and negative Lachman's; the Veteran was treated with left knee joint injection of corticosteroid. The Veteran underwent VA examination in November 2009 at which time he reported pain, stiffness, locking, swelling, and giving way of his left knee. The Veteran reported using a cane occasionally for extended walking but not with his employment. Physical examination demonstrated normal varus/valgus of medial and lateral collateral ligaments, normal anterior and posterior cruciate ligaments, and negative McMurray's (medial and lateral meniscus). VA treatment records indicate that in February 2010, there was pain with McMurray's test in left lateral joint space, negative varus and valgus instability, and negative Lachman's. In May 2011, physical examination demonstrated pain with varus/valgus stress and with McMurray's. Private treatment records indicate that in June 2011, physical examination demonstrated positive medial McMurray's, coarse crepitus, slightly diminished strength in the left quadriceps and hamstrings. X-rays showed moderate patellofemoral degenerative joint disease and mild patellofemoral malalignment. The Veteran was diagnosed as having left patellofemoral malalignment and degenerative joint disease. VA treatment records indicate that April 2012, the Veteran described feelings of instability and loud popping. In September 2012, the Veteran reported incidents of medial/lateral instability and falls. In January 2014, the Veteran reported feelings of instability. MRI with arthrogram in August 2014 showed complex tear of the body and the posterior horn of the medial meniscus; significant patellar chondral disease with full-thickness fissures at the apex and severe to near complete cartilage loss along the lateral patellar facet with subchondral reactive marrow and cystic changes; and mild chondral disease involving the medial femoral condyle posteriorly. The Board has carefully considered the Veteran's reports of painful left knee popping and giving way since he filed his claim in July 2009. English, 30 Vet. App. 347, 352-53. The Board finds that the October 2015 and August 2016 VA examination reports are instructive as to the severity of the Veteran's left knee instability prior to October 6, 2016. At the time of the October 2015 VA examination, the Veteran reported that his left knee "pops and grinds"; the examiner noted that the Veteran had a history of moderate lateral instability but joint stability testing could not be performed as the Veteran was extremely tender to the touch and could not tolerate the examination. At the time of the August 2016 VA examination, the examiner, who also conducted the October 2015 examination, noted that the Veteran had a history of slight lateral instability but joint stability testing could not be performed as the Veteran was extremely tender to touch on the patellar condyle. Overall, the lay and medical evidence indicates that the Veteran's left knee instability symptoms fluctuated from slight to moderate in severity including a report in September 2012 of falls. As such, by resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran's left knee instability more nearly approximated moderate severity prior to October 6, 2015. In conclusion, the Board finds that the preponderance of the evidence supports a 20 percent rating, but no higher, prior to October 6, 2015, for the Veteran's left knee residuals of arthroscopic surgery on the basis of knee instability. In denying a higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent prior to May 12, 2016. 3. The Board finds that the preponderance of the evidence supports a rating of 30 percent from May 12, 2016, for residuals of arthroscopic surgery on the basis of knee instability. As noted above, a 30 percent rating is warranted where the recurrent subluxation or lateral instability of the knee is severe. At the time of the October 2015 VA examination, the Veteran reported that his left knee "pops and grinds"; the examiner noted that the Veteran had a history of moderate lateral instability but joint stability testing could not be performed. On May 12, 2016, the Veteran reported feelings of left knee instability. The Veteran stated that he used a cane and reported that if he did not, he would fall. Physical examination demonstrated pain with McMurray's. Later that month, he underwent left knee arthroscopy; in July 2016, the Veteran stated that four weeks earlier, he started having instability and that he was wearing a knee brace that helped with instability. At the time of the August 2016 VA examination, the examiner, who also conducted the October 2015 examination, noted that the Veteran had a history of slight lateral instability but joint stability testing could not be performed as the Veteran was extremely tender to touch on the patellar condyle. In January 2017, he reported instability and using a cane for at least 4 months. Physical examination demonstrated negative anterior drawer and negative varus instability. In June 2017, the Veteran reported instability especially when going up and down stairs causing falls. The Board has carefully considered the Veteran's reports about instability causing falls. English, 30 Vet. App. at 352-53. The Board finds that the October 2017 examination report is instructive as to the severity of the Veteran's left knee instability prior to October 6, 2016. At the time of the October 2017 VA examination, the Veteran reported that his left knee gave out on him all the time; the examiner noted that the Veteran had a history of severe lateral instability but joint stability testing demonstrated only slight anterior instability, posterior instability, medial instability, and lateral instability (1+ between zero to 5 millimeters. As such, the overall, the lay and medical evidence indicates that since May 12, 2016, the Veteran's left knee instability symptoms fluctuated from slight to severe resulting in falls if he did not use his cane. Prior to May 12, 2016, however, a history of falls was only reported in a September 2012 medical record without any indication of the frequency of such falls. The Board finds it reasonable to assume that if the Veteran was frequently suffering falls, they would have been acknowledged in other medical records. As such, by resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran's left knee instability more nearly approximated severe severity from May 12, 2016, to October 5, 2017. As the Veteran is now in receipt of the highest schedular rating for other impairment of the knee, there is no basis to award a higher evaluation. As disposition of this issue is based on the law and not the facts of the case, the issue must be denied based on a lack of entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In conclusion, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent prior to May 12, 2016, but supports a maximum 30 percent rating, but no higher, from May 12, 2016, to October 5, 2017, for the Veteran's left knee residuals of arthroscopic surgery on the basis of knee instability. In denying higher ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent since October 6, 2017, for residuals of arthroscopic surgery on the basis of knee instability. As the Veteran is in receipt of the highest schedular rating for other impairment of the knee, there is no basis to award a higher evaluation. In conclusion, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent since October 6, 2017, for the Veteran's left knee residuals of arthroscopic surgery on the basis of knee instability. In denying such higher rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for left knee degenerative arthritis on the basis of limitation of flexion prior to October 6, 2017. As noted above, a 20 percent rating is warranted for flexion limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. In July 2009, physical examination demonstrated left knee range of motion was from zero degrees to 125 degrees. In September 2009, physical examination demonstrated left knee range of motion from zero to 110 degrees. At the November 2009 VA examination, the Veteran reported pain and stiffness; physical examination demonstrated range of motion from zero to 105 degrees with no objective evidence of painful motion, edema, effusion, instability, weakness, redness, or heat; there was objective evidence of tenderness and guarding of movement. There was no additional loss of motion after repetitive use testing. The examiner diagnosed the Veteran as having left knee arthritis status post arthroscopy surgery. On February 17, 2010, the Veteran stated that corticosteroid injection decreased his pain significantly; however, this improvement only lasted three months at which time his pain worsened. Physical examination demonstrated left knee range of motion was from 10 to 45 degrees. In November 2010, the left knee demonstrated full range of motion with no tenderness, erythema, edema, or effusion. In May 2011, physical examination demonstrated full range of left knee motion, exquisite tenderness over kneecap and surrounding knee although the Veteran reported feeling "numbness" in the patellar tendon area. In June 2011, physical examination demonstrated antalgic gait, mid medial joint line tenderness, range of motion from 5 to 130 degrees. In January 2014, physical examination demonstrated full range of motion. At the October 2015 VA examination on October 15, 2015, the Veteran reported constant knee pain; he noted that he used a cane for his back and knees. Left knee range of motion was from zero to 70 degrees with pain on flexion, evidence of pain with weightbearing, and tenderness to the patellar condyle and to the medial and lateral knee. There was crepitus and deformity to the inferior patella. Muscle strength was slightly diminished; there was no muscle atrophy or ankylosis. A retrospective medical opinion received in May 2021 found range of motion from zero to 65 degrees during flare ups and from zero to 60 degrees with repeated use over time. In May 2016, physical examination demonstrated full motion, tenderness to palpation of lateral and medial joint line, pain with McMurray's. Later that month, he underwent left knee arthroscopy; in July 2016, range of left knee motion was from zero to 100 degrees with mild swelling. The Veteran underwent VA examination in August 2016 at which time he reported that his left knee surgery was not helpful and that he thought it was worse. Physical examination demonstrated range of motion from zero to 95 degrees with pain on flexion with no additional loss of motion with repetitive use testing. The examiner noted that the Veteran had moderate to severe pain along with loss of mobility that required use of a cane in most instances. The examiner was unable to determine if pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during a flare-up. There was tenderness to the patellar condyle, medial knee, and lateral knee. There was crepitus and deformity to the patellar condyle. Muscle strength testing was slightly diminished; there was no muscle atrophy or ankylosis. A retrospective medical opinion received in May 2021 found range of motion from zero to 90 degrees during flare ups and from zero to 85 degrees with repeated use over time. In September 2016, the Veteran demonstrated full extension of his left knee and further flexion to about 100 degrees. In January 2017, he rated his left knee pain located in the front of his knee below his kneecap as 9/10 and constant with nothing improving or worsening the pain. Physical examination demonstrated range of motion was from zero to 100 degrees. Although the Veteran was not tender to palpation over the tibia tubercle, he was exquisitely tender to palpation to the joint line, lateral more than medial. In April 2017, the Veteran demonstrated range of motion from 15 to 100 degrees, and he was tender to palpation at the medial and lateral knee and around the patella. In June 2017, physical examination demonstrated left knee range of motion from zero to 100 degrees; and in September 2017, the Veteran demonstrated marked limitation of motion without effusion from zero to 45 degrees. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. Prior to October 6, 2017, left knee flexion at its worst was limited to 45 degrees in September 2017. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for left knee degenerative arthritis on the basis of limitation of flexion prior to October 6, 2017. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 6. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for left knee degenerative arthritis on the basis of limitation of flexion from October 6, 2017 to May 30, 2018. As noted above, a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Veteran underwent VA examination in October 2017 at which time he reported that his left knee condition had worsened and hurt all the time. Physical examination demonstrated range of motion from zero to 40 degrees with pain on flexion and extension with additional loss of motion from zero to 25 degrees with repetitive use testing. The examiner noted that pain significantly limited functional ability with repeated use over a period of time or during a flare-up but was unable to describe in terms of range of motion. Muscle strength testing was diminished at 3/5; there was no muscle atrophy or ankylosis. A retrospective medical opinion received in May 2021 found range of motion from zero to 25 degrees during flare ups and from zero to 20 degrees after repeated use over time. In April 2018, the Veteran demonstrated full range of motion, no tenderness, no erythema, no edema, and no effusion. From October 6, 2017 to May 30, 2018, left knee flexion at its worst was limited to 20 degrees in October 2017. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for left knee degenerative arthritis on the basis of limitation of flexion from October 6, 2017 to May 30, 2018. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 7. The Board finds that the preponderance of the evidence supports a rating of 30 percent for left knee degenerative arthritis on the basis of limitation of flexion from May 31, 2018. As noted above, a maximum 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. In May 2018, the Veteran demonstrated left knee range of motion from 10 to 70 degrees with pain on the medial side of the knee. Later that month, on May 31, 2018, the Veteran was seen in the emergency department with constant left knee pain that began after it "popped" two days prior while walking and swelling. Physical examination demonstrated left knee joint swelling, limited range of motion with near complete extension and minimal flexion 5 degrees, tenderness elicited over the lateral and medial ligament, and mild to moderate tenderness over the knee cap. In June 2018, the Veteran reported that his symptoms had not been resolved and that his pain was so severe that he could not straighten his left knee any more than within 20 degrees of full extension and had only 55 degrees of knee flexion. In July 2018, physical examination demonstrated flexion limited to 75 degrees due to pain. In August 2018, the Veteran had active range of motion from zero to 130 degrees. The Veteran underwent VA examination in August 2019 at which time he reported that he could no longer go up and down stairs, run, drive manual motor vehicles, mow his law and that he had difficulty bending over, picking up things, doing household chores that required standing or walking. He also noted that he could not stand, walk, sit, or ride in the car for long periods of time. Physical examination demonstrated left knee range of motion from zero to 40 degrees with pain on all motion and no additional loss of motion on repetitive use testing. The examiner noted that pain and fatigue significantly limited functional ability with repeated use over time and during flare ups limiting the range of motion to from zero to 20 degrees. The examiner noted severe left knee pain on palpation. Muscle strength testing was diminished at 3/5 but there was no muscle atrophy or ankylosis. The examiner noted a history of slight left knee instability and a history of recurrent effusion indicating that the left knee swelled randomly when walking, standing, and sitting. The Veteran underwent VA examination in January 2021 at which time he reported that walking up and down stairs and walking for a long time were painful. Physical examination demonstrated left knee range of motion from 10 to 20 degrees with pain on all motion and no additional loss of motion on repetitive use testing. The examiner noted that pain significantly limited functional ability with repeated use over time and during flare ups limiting the range of motion from 10 to 20 degrees. The examiner noted severe left knee pain on palpation. Muscle strength testing was normal, and there was no muscle atrophy or ankylosis. The Veteran demonstrated normal left knee stability. The examiner specifically noted that at the time of the examination, there was no sign of lateral instability and that MRIs showed intact medial and collateral ligaments. Since May 31, 2018, left knee flexion at its worst was limited to 5 degrees. Accordingly, the Board concludes that the preponderance of the evidence supports a 30 percent rating for the Veteran's left knee degenerative arthritis on the basis of limitation of flexion from May 31, 2018. As the Veteran is already in receipt of the maximum 30 percent rating under Diagnostic Code 5260 for left knee flexion limited to 15 degrees or less, a schedular rating in excess of 30 percent for left knee limitation of flexion is not available and must be denied as a matter of law. 38 C.F.R. § 4.71a. As disposition of this issue is based on the law and not the facts of the case, the issue must be denied based on a lack of entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In conclusion, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent prior to October 6, 2017, in excess of 20 percent from October 6, 2017 to May 30, 2018, and in excess of 30 percent since May 31, 2018. In denying such higher ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 8. The Board finds that the preponderance of the evidence supports a separate 10 percent rating for left knee degenerative arthritis on the basis of limitation of extension from February 17, 2010 to April 23, 2017. 9. The Board finds that the preponderance of the evidence supports a 20 percent rating for left knee degenerative arthritis on the basis of limitation of extension since April 24, 2017. As noted above, separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned. VAOPGCPREC 9-04. Under Diagnostic Code 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. On February 17, 2010, physical examination demonstrated left knee range of motion was from 10 to 45 degrees. Prior to that date, physical examination consistently demonstrated extension at zero degrees. Subsequent to February 17, 2010 and prior to April 24, 2017, at its worst, the Veteran's extension was limited to just 5 degrees. On April 24, 2017, physical examination demonstrated left knee range of motion from 15 to 100 degrees. Accordingly, the Board concludes that the preponderance of the evidence supports a separate 10 percent rating from February 17, 2010 to April 23, 2017, and a higher 20 percent rating since April 24, 2017, for the Veteran's left knee degenerative arthritis on the basis of limitation of extension. The preponderance of the evidence, however, is against a rating in excess of 20 percent for left knee degenerative arthritis on the basis of limitation of extension since April 24, 2017. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements would not result in limitation of motion more nearly approximating extension limited to 20 degrees or more. In conclusion, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent from February 17, 2010 to April 23, 2017, and in excess of 20 percent since April 24, 2017, for left knee degenerative arthritis on the basis of limitation of extension. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See 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 paying compensation twice for the same symptoms or functional impairment). The Board has considered the applicability of Diagnostic Code 5258 for dislocated semilunar cartilage and Diagnostic Code 5259 for residual symptoms of removal of semilunar cartilage. Separate ratings may be awarded under Diagnostic Codes 5260, 5260, and 5261 so long as assignments of separate ratings would not result in compensating the Veteran twice for the same knee symptom. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The record indicates that the Veteran has had multiple left knee surgeries for meniscal tears. The Board, however, finds that the Veteran may not be assigned a separate rating under Diagnostic Codes 5258 or 5259 as this would constitute pyramiding under 38 C.F.R. § 4.14. Diagnostic Code 5258 provides for a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a. Locking, pain and effusion are factors that may be contemplated when rating range of motion. See 38 C.F.R. §§ 4.45, 4.59. As such, the Veteran's meniscus symptomatology, which includes locking, pain, and effusion, are already contemplated and compensated by the Veteran's current disability ratings under Diagnostic Codes 5257, 5260, and 5261. With respect to the symptomatic removal of the semilunar cartilage, the plain meaning of the term "symptomatic" used in the rating criteria for Diagnostic Code 5259 means indicative, relating to, or constituting the aggregate of symptoms of disease. STEDMAN'S MEDICAL DICTIONARY, 1743 (27th ed., 2000). A symptom is any morbid phenomenon or departure from the normal in a structure, function, or sensation, experienced by a patient and indicative of disease. Id. at 1742. Thus, the requirement of being "symptomatic" is broad enough to encompass symptoms including pain, limitation of motion, and instability. In this case, the Veteran's left knee disability has been manifested by limitation of flexion and extension, including due to pain, and by instability. Those symptoms are contemplated by the rating criteria both under Diagnostic Code 5259, as residual symptoms of the semilunar cartilage removal, and under Diagnostic Codes 5257, 5260, and 5261. Accordingly, assigning separate ratings under both Diagnostic Code 5259 and Diagnostic Codes 5257, 5260, and 5261 would constitute pyramiding as it would compensate the Veteran multiple times for the same symptomatology. As such, separate ratings under Diagnostic Codes 5258 and 5259 are not warranted. (Continued on the next page) Finally, separate, compensable disability ratings for the left knee are not warranted under Diagnostic Code 5256 for ankylosis, Diagnostic Code 5262 for impairment of the tibia and fibula, and Diagnostic Code 5263 for genu recurvatum. There is no evidence of ankylosis of the right knee, genu recurvatum, or malunion or nonunion of the tibia and fibula. Robert A. Elliott II Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.