Citation Nr: 21005603 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 14-36 868 DATE: February 2, 2021 ORDER From February 16, 2010, to May 4, 2010, entitlement to a disability rating of 30 percent for severe subluxation is granted. Prior to May 4, 2010, entitlement to a disability rating greater than 10 percent for limitation of flexion associated with residuals of a right knee disability is denied. From July 1, 2010, entitlement to a disability rating greater than 10 percent for slight recurrent subluxation is denied. From July 1, 2010, entitlement to a disability rating greater than 10 percent for a limitation of flexion associated with residuals of a right knee disability is denied. Effective November 12, 2019, entitlement to a separate 20 percent disability rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion in the right knee is granted. FINDINGS OF FACT 1. From February 16, 2010, to May 4, 2010, the Veteran’s service-connected right knee disability was manifested by severe recurrent subluxation or lateral instability. 2. Prior to May 4, 2010, the Veteran’s service-connected right knee disability was manifested by painful limitation of motion with x-ray confirmed degenerative disease (DJD) without ankylosis. 3. From May 5, 2010 to June 30, 2010, the Veteran was granted a temporary total disability rating for surgical convalescence following arthroscopic anterior cruciate ligament (ACL) reconstruction. 4. From July 1, 2010, the Veteran’s service-connected right knee disability has been manifested by painful limitation of motion with x-ray confirmed DJD; slight recurrent subluxation or lateral instability without ankylosis; and a range of motion no worse than 0 degrees extension to 80 degrees flexion even taking into account functional impairment during flare-ups or due to repeated use. 5. From November 12, 2019, the Veteran’s service-connected right knee disability has been manifested by dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion. CONCLUSIONS OF LAW 1. From February 16, 2010, to May 4, 2010, the criteria for entitlement to a disability rating of 30 percent for severe subluxation have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.59, 4.71a, Diagnostic Codes (DC) 5257. 2. Prior to May 4, 2010, the criteria for entitlement to a disability rating in excess of 10 percent for limitation of flexion associated with residuals of a right knee disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.59, 4.71a, DCs 5003-5260. 3. From July 1, 2010, the criteria for entitlement to a disability rating in excess of 10 percent for slight recurrent subluxation have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.59, 4.71a, DC 5257. 4. From July 1, 2010, the criteria for entitlement to a disability rating in excess of 10 percent for limitation of flexion associated with residuals of a right knee disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.59, 4.71a, DCs 5003-5260. 5. The criteria for entitlement to a separate 20 percent disability rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion in the right knee is granted effective November 12, 2019. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.59, 4.71a, DC 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1993 to May 1994. This matter returns to the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision issued by the Department of Veterans’ Affairs (VA) Regional Office (RO) in Boston, Massachusetts, which denied a rating in excess of 10 percent for the right knee under Diagnostic Code 5257 (for knee impairments manifested by recurrent subluxation or lateral instability). By way of background, the Board previously remanded this claim for additional development in March 2020 and April 2018. As will be discussed in more detail below, substantial compliance with the March 2020 remand directives has been met. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding when a remand is issued, the Veteran is entitled, as a matter of law, the right to compliance with the remanded order). While in remand, the RO, in a January 2020 rating decision, awarded the Veteran a separate 10 percent rating for the right knee for limitation of flexion with degenerative changes, effective February 16, 2010, as well as a temporary total (100 percent) evaluation, effective May 5, 2010, to June 30, 2010, for surgical convalescence (following the Veteran’s right knee surgical procedure), with the 10 percent rating following thereafter, effective July 1, 2010. See January 2020 Rating Decision, awarded under Diagnostic Codes 5003-5260 (for arthritis with limitation of flexion of the knee). This separate rating was placed in addition to the 10 percent under Diagnostic Code 5257. Aside from the time period where a temporary total rating was put in place (May 5, 2010, through June 30, 2010), which will not be disturbed here, the separate rating 10 percent rating award only constitutes a partial grant of the benefits sought on appeal; therefore, the issue remains on appeal and is for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). The issues, then, have been appropriately recharacterized above to reflect the time periods and ratings for consideration before the Board. As an aside, the Board notes the Veteran stated that he has been “depressed and feeling helplessness” due to his knee disability but has not filed a service connection claim for any psychiatric conditions to date. As such, this contention is not properly before the Board. Should the Veteran wish to file for disability benefits for any additional conditions including as secondary to his right knee disability, he is directed to do so in accordance with 38 C.F.R. § 3.155. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating The Veteran contends his right knee disability and symptoms related thereto entitle him to an increased rating. Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Veteran’s entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. 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). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The United States Court of Appeals for Veterans Claims (CAVC or “the Court”) held in Correia v. McDonald, 28 Vet. App. 158 (2016) that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Further, in evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. at 592. Additionally, the Court has stated that flare-ups must be factored into an examiner’s assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). The Veteran’s right knee disability up to this point has been rated under DC 5257 for recurrent subluxation or lateral instability. DC 5257 provides a 10 percent disability rating for slight recurrent subluxation or lateral instability, a 20 percent disability rating for moderate recurrent subluxation or lateral instability, and a 30 percent disability rating for severe recurrent subluxation or lateral instability. The Veteran’s right knee disability is separately rated under DC 5003-5260 as well. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating, with the first code representing the underlying condition and the second code representing the residuals. 38 C.F.R. § 4.27. Degenerative arthritis as shown by x-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DC 5003. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. Id. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. Id. Under DC 5260, flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. Also relevant to any discussion of knee disabilities are the remaining criteria under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Under DC 5256, favorable ankylosis of the knee, in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent disability rating; ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent disability rating; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent disability rating. Under DC 5258, a claimant is entitled to a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5261, extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Under DC 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. Under DC 5263, a 10 percent rating is warranted for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. The Board notes that the terms “slight,” “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just.  38 C.F.R. § 4.6. According to Merriam Webster’s Collegiate Dictionary 999 (11th Ed. 2007), “slight” means small in amount. “Moderate” means limited in scope or effect. “Severe” means very painful or harmful or of a great degree. Although a medical examiner’s use of descriptive terminology such as “mild” is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. At the outset, the Board notes the Veteran was granted service connection for his right knee disability in a March 1995 rating decision wherein it was rated at 10 percent disabling. Within the year following the decision, the Veteran did not appeal or submit additional evidence. Thus, the decision became final. The Veteran filed an increased rating claim on December 21, 2009. As such, the Board will consider the period on appeal as early as one year prior to his increased rating claim or December 21, 2008. 38 C.F.R. § 3.400(o)(2). Turning to the relevant evidence of record, in February 2010, the Veteran sought medical evaluation and treatment for a right knee injury. See February 2010 non-government treatment records. He reported having an ACL tear with symptoms of intermittent swelling, aches, pains, occasional instability, popping, and grinding. Id. Upon examination, the provider noted that the Veteran had continued pain, swelling, occasional giving way especially with strenuous activity, no locking, continued popping, and limited functional ability. Id. The Veteran had difficulty climbing stairs, running, squatting with deep knee bends, sitting for a long time with the knee bent, and performing sports. Id. Range of motion (ROM) testing revealed extension of 0 degrees and flexion of 130 degrees. Id. Instability testing was positive. Id. Imaging revealed mild bilateral tricompartmental degenerative changes slightly worse on the right with small right intra-articular loose bodies. Id. The Veteran was noted to have severe cruciate ligament laxity with DJD and cruciate ligament surgery was recommended to decrease impairments. Id. In April 2010, the Veteran stated that his knee required continued treatment. See April 2010 Statement in Support of Claim. A provider stated that he had been scheduled to undergo a right knee arthroscopic ACL reconstruction in May 2010. See April 2010 non-government treatment record. In May 2010, the Veteran underwent a right knee ACL replacement. See May 2020 non-government treatment records. The surgeon noted that the Veteran had been experiencing continued symptoms of instability. Id. In the days following the procedure, the Veteran was found to be “doing well” with “good stability and motion.” Id. In July 2010, the Veteran’s right knee was found to be “doing well following ACL reconstruction.” See July 2010 non-government treatment records. Pain was indicated but noted to be improving with no complaints of tenderness and negative stability tests. Id. The Veteran had a ROM of 0 degrees extension and 135 degrees flexion. Id. In February 2011, the Veteran’s right knee was found to be functionally stable and “improved” with intermittent swelling after excess activities. See February 2011 non-government treatment records. Occasional pain with twisting was indicated with no instability or giving way. Id. The Veteran stated that he continues to experience difficulty moving and doing activities with his knee. See September 2014 VA Form 9. He noted that his knee prevents him from playing sports. Id. During the period on appeal, the Veteran was afforded multiple VA examinations to determine the current severity of his right knee disability, the first of which occurred in November 2019. Upon examination, the Veteran was noted to have right knee meniscal tear, right knee ACL tear, and right knee degenerative arthritis. See November 2019 VA examination. He reported experiencing stabbing pain that worsens with repeated use including standing for long periods, walking longer distances, and going up the stairs. Id. The Veteran noted that he no longer jogs due to the pain. Id. He is on his feet all day for work. Id. Flare-ups were reported a few times a month lasting 1-3 days manifested by increased pain and swelling and more limited function due to the increased pain. Id. ROM testing revealed flexion to 90 degrees and extension to 90 degrees with pain noted that does not result in or cause functional loss. Id. Repetitive use testing was completed without additional functional loss or range of motion. Id. Pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time including during flare-ups. Id. There was evidence of pain with weight bearing. Id. Objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue was found with crepitus. Id. Additional factors contributing to the Veteran’s right knee disability included swelling, disturbance of locomotion, interference with standing, and difficulty kneeling to pick up items. Id. Muscle atrophy and ankylosis were not found. Id. The Veteran had a noted history of recurrent effusion. Id. A history of recurrent subluxation or lateral instability was not found. Id. Joint stability testing was performed with normal results. Id. The Veteran does not have recurrent patellar dislocation, “shin splints,” stress fractures, chronic compartment syndrome or any other tibial and/or fibular impairment. Id. The examiner found the Veteran has a right knee meniscus condition of meniscal tear manifesting in frequent episodes of joint “locking,” pain, and effusion. Id. Residuals from his 2010 ACL repair include ROM pain including with weight bearing. Id. The Veteran relies upon the “constant” use of a brace for his right knee. Id. Another VA examination occurred most recently in September 2020 wherein the examiner found that the Veteran had a right knee meniscal tear with an ACL tear, instability, and degenerative arthritis. See September 2020 VA examination. During the examination, the Veteran reported daily pain with flare-ups occurring once per month and lasting for a day. Id. He also described mild swelling. Id. Functional loss due to right knee pain was noted to include limitations on activities that require prolonged (greater than 30 minutes) standing, sitting, walking, any running, kneeling, crawling, squatting, and high impact activities. Id. ROM testing revealed 0 to 100 degrees flexion and 100 to 0 degrees extension with pain but did not result in or cause functional loss. Id. There was no objective evidence of pain on passive ROM testing or when the joint is used in non-weight bearing. Id. There was no objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue. Id. Pain with weight bearing was not found. Id. There was no objective evidence of crepitus, atrophy, or ankylosis. Id. Repetitive motion testing revealed no additional loss of function or range of motion after three repetitions. Id. Pain, however, significantly limits functional ability with repeated use over a period of time that the examiner described in terms of ROM as 0 to 80 degrees flexion and 80 to 0 degrees extension. Id. The same limitation in ROM was noted due to pain during flare-ups. Id. The examiner noted a lack of history of recurrent subluxation and lateral instability. Id. Recurrent effusion was noted during flare-ups productive of mild to moderate swelling for approximately a day. Id. Joint stability testing was performed with a finding of anterior and posterior instability. Id. The Veteran does not have recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. Id. The Veteran has a meniscus (semilunar cartilage) condition with frequent episodes of joint pain and effusion. Id. His meniscal tear and instability of the right knee causes the Veteran to be limited in prolonged (greater than 30 minutes) standing, walking, any running, kneeling, crawling, squatting, and high impact activities. Id. The Board finds the November 2019 and September 2020 VA examinations are sufficient to determine the extent and severity of the Veteran’s right knee disability when taken together and considered with the entire evidence of record. The requirements of DeLuca, Correia, and Sharp were all addressed by the examiners as well as the Veteran’s own descriptions of his limitations which were taken into account in determining functional impact and additional loss in terms of ROM with repetitive use over time. Flare-ups were noted with symptoms of increased pain depending on use and additional functional loss including in terms of ROM. While the matter was remanded for additional development following the November 2019 VA examination, the information gathered from said examination still carries probative value regarding the Veteran’s symptoms and severity thereof. The Board finds the September 2020 VA examination substantially complied with the specific remand directives issued by the Board in March 2020. 1. From February 16, 2010, to May 4, 2010, entitlement to a disability rating of 30 percent for severe subluxation is granted. The Board finds, upon review of the medical and lay evidence of record between February 16, 2010, and May 4, 2010, a 30 percent disability rating is warranted for the Veteran’s right knee due to severe subluxation. During this time period, the Veteran’s recurrent subluxation more closely approximates a 30 percent disability rating under DC 5257. The Veteran competently and credibly stated that he experienced instability, pain, and swelling. The February 2010 provider found that the Veteran experiences giving way especially with strenuous activity and noted pain. The Veteran’s subluxation symptoms were further corroborated and confirmed through stability testing during his February 2010 right knee evaluation. Following the evaluation, the provider found that the Veteran had “severe” cruciate ligament laxity in the right knee. The Board determines this evidence is highly probative and corroborated by the Veteran’s reports of symptoms. Indeed, it was around this time that surgery was recommended and scheduled for May 5, 2010. The Board notes consideration has been given to the period on appeal prior to February 16, 2010, but finds that an increase in severity is not factually ascertainable prior to this date. While the Veteran noted on his December 2009 increased rating claim that he generally “needed surgery,” the medical and lay evidence of record prior to February 16, 2010, merely indicate continued reports of pain and swelling. There was no specific contentions or findings related to laxity, instability, or subluxation. The preponderance of the evidence is against finding that the Veteran’s symptoms more nearly approximated moderate or severe recurrent subluxation during the period on appeal prior to February 16, 2010. Thus, a 30 percent disability rating under DC 5257 is warranted for severe recurrent subluxation beginning February 16, 2010, to May 4, 2010. 2. Prior to May 4, 2010, entitlement to a disability rating greater than 10 percent for limitation of flexion associated with residuals of a right knee disability is denied. The Board finds a rating in excess of 10 percent for limitation of flexion prior to May 4, 2010, is not warranted. The Veteran is currently rated at 10 percent disabling under DCs 5003-5260. He receives a 10 percent rating under DC 5003 because he experiences limitation of motion that is noncompensable under DC 5260. In order to receive a higher rating under DC 5003, the Veteran would have to experience occasional incapacitating exacerbations of his right knee disability which is unsupported by the record. Prior to the Veteran’s total disability rating in association with his ACL reconstruction, the medical and lay evidence of record lacks any reference to incapacitation or incapacitating episodes. The Board recognizes the Veteran’s reports of experiencing pain and having limited range of motion due to his pain when completing physical activities such as walking or standing for too long. The Board finds, however, the Veteran’s reports of symptoms and those documented in the record do not amount to incapacitation under DC 5003. The Veteran’s pain and limited motion more nearly approximate the criteria addressed by the 10 percent disability rating for DC 5003-5260. Thus, the preponderance of the evidence is against an increased rating under DC 5003. The Board has also considered whether a higher rating could be awarded based upon the Veteran’s ROM testing under DC 5260. During the period on appeal prior to May 4, 2010, the record lacks flexion ROM testing. Thus, the Board is unable to determine based upon the evidence of record the Veteran’s flexion ROM prior to May 4, 2010. The Board notes, however, in later ROM testing as mentioned above, flexion continued to remain noncompensable under DC 5260. Additionally, the Veteran was awarded a 10 percent disability rating under DC 5003-5260 due to a noncompensable limitation of motion with noted pain. Thus, the Board relies upon the Veteran’s competent and credible continued reports of pain with movement to continue a 10 percent disability rating under DC 5003-5260 and finds the preponderance of the evidence is against a compensable rating under DC 5260 for limited flexion. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg during the period on appeal prior to May 4, 2010. 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, 6 Vet. App. at 261-62. Other potential diagnostic codes are inapplicable here because there is no medical evidence in support. The Veteran’s right knee is not ankylosed (i.e., frozen); therefore, DC 5256 is not for application. The right knee disability does not affect the tibia, fibula, or genu recurvatum; therefore, DCs 5262 and 5263 are not for application. DC 5259 is not applicable as the Veteran has not had semilunar cartilage removed in the right knee. Regarding DC 5261, a higher disability rating would not be achieved through limitation of extension as ROM testing revealed ROM that was not limited to 15 degrees extension. In fact, the most limited ROM extension was 130 degrees in February 2010, which is noncompensable under DC 5261. The Board notes this ROM, however, did not include repetitive use testing. Unfortunately, during this time period, a VA examination was not completed for reference. Considering the Veteran’s symptoms of pain and limited use during activities in conjunction with ROM testing during the period prior to May 4, 2010, the Board finds a rating under DC 5261 is not warranted. 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 limited flexion prior to May 4, 2010, to include consideration of the separate ratings discussed above. 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. 3. From July 1, 2010, entitlement to a disability rating greater than 10 percent for slight recurrent subluxation is denied. Beginning July 1, 2010, the Board finds the medical and lay evidence of record is against a rating in excess of 10 percent for recurrent subluxation. The Board finds the Veteran’s recurrent subluxation symptoms more nearly approximate slight impairment under DC 5257 as of July 1, 2010. As previously mentioned, the Veteran underwent ACL reconstruction in May 2010. Treatment records following the procedure indicate a successful reconstruction with “good stability and motion.” Post-operative records indicate in the months following ACL reconstruction, the Veteran’s right knee continued to be “doing well.” The Veteran continued to competently and credibly report experiencing pain and difficulty doing activities. A year following the ACL reconstruction, the Veteran continued to experience intermittent swelling after excess activities. The Board finds, the Veteran’s continued symptoms of recurrent subluxation are appropriately rated as slight with a 10 percent disability rating under DC 5257 beginning July 1, 2010. The Board has also determined that the Veteran’s recurrent subluxation symptoms do not amount to moderate or severe impairment after July 1, 2010. In doing so, the Board has carefully considered the Veteran’s reports of symptoms including continued pain and intermittent swelling with excess activities. Upon examination in July 2010, tenderness was not indicated, and stability testing was negative. In comparison, prior to the Veteran’s ACL reconstruction, instability testing was positive in February 2010. A year later in February 2011, the provider indicated the Veteran’s right knee was functionally stable and improved with only intermittent swelling after excess activities. Instability and “giving way” were not found. Of note, neither the November 2019 or September 2020 VA examiners found right knee recurrent subluxation or lateral instability. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018) (finding objective medical evidence is not required to establish lateral knee instability under DC 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code). Joint testing during the 2020 VA examination did reveal anterior instability and posterior instability in the right knee. Overall, the lay and medical evidence indicates that the recurrent subluxation/instability symptoms have varied in severity and frequency since July 1, 2010, and do not suggest the presence of symptoms more nearly approximating moderate severity. Consequently, the Board finds the preponderance of the evidence is against a finding of moderate or severe recurrent subluxation any time after July 1, 2010. Based on the aforementioned, the Board concludes the Veteran’s recurrent subluxation symptoms more nearly approximate a 10 percent disability rating under DC 5257 beginning July 1, 2010. 4. From July 1, 2010, entitlement to a disability rating greater than 10 percent for a limitation of flexion associated with residuals of a right knee disability is denied. Again, the Veteran is currently rated at 10 percent disabling under DCs 5003-5260. He receives a 10 percent rating under DC 5003 because he experiences limitation of motion that is noncompensable under DC 5260. In order to receive a higher rating under DC 5003, the Veteran would have to experience occasional incapacitating exacerbations of his right knee disability which is unsupported by the record. The Board notes the Veteran received a total disability rating of 100 percent during the period surrounding his right knee surgery. Otherwise, the medical evidence and lay statements of record lack any reference to occasional incapacitating episodes. The Veteran reported experiencing pain and having limited range of motion due to his pain when completing physical activities such as walking or standing for too long. The Board finds, however, the Veteran’s reports of symptoms and those documented in the record do not amount to incapacitation under DC 5003. The Veteran’s pain and limited motion more nearly approximate the criteria addressed by the 10 percent disability rating for DC 5003-5260. Thus, the preponderance of the evidence is against an increased rating under DC 5003. The Board has also considered whether a higher rating could be awarded based upon the Veteran’s ROM testing under DC 5260. The Veteran’s flexion ROM, however, has consistently remained noncompensable under DC 5260. In 2019, ROM testing revealed 90 degrees flexion even with repetitive motion testing. In 2020, ROM testing revealed 100 degrees flexion but noted a decreased ROM of 80 degrees flexion with repeated use considerations. Flexion limited to 80 degrees is noncompensable under DC 5260. ROM testing completed in July 2010 revealed 135 flexion, but the Board recognizes this did not include any additional functional loss due to flare-ups or repetitive use. As such, the Board will consider the most limited ROM of 80 degrees flexion which remains noncompensable under DC 5260. While the Veteran competently complained of limited movement, the Board finds ROM testing remains noncompensable and the Veteran is properly rated under DC 5003-5260 for limited motion that is noncompensable. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg beginning July 1, 2010. Other potential diagnostic codes are inapplicable here because there is no medical evidence in support. The Veteran’s right knee is not ankylosed (i.e., frozen); therefore, DC 5256 is not for application. The right knee disability does not affect the tibia, fibula, or genu recurvatum; therefore, DCs 5262 and 5263 are not for application. DC 5259 is not applicable as the Veteran has not had semilunar cartilage removed in the right knee. Regarding DC 5261, a higher disability rating would not be achieved through limitation of extension as ROM testing revealed ROM that was not limited to 15 degrees extension. In fact, the most limited ROM extension was 80 degrees in 2020 which is noncompensable under DC 5261. 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 limited flexion beginning July 1, 2010, to include consideration of the separate ratings discussed above. 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. 5. Effective November 12, 2019, entitlement to a separate 20 percent disability rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion in the right knee is granted. In consideration of Lyles v. Shulkin, the Board finds an additional separate rating is warranted under DC 5258 for the Veteran’s right knee dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion beginning November 12, 2019. See Lyles, 29 Vet. App. 107. Specifically, the 2019 and 2020 VA examiners both found the Veteran has a meniscus (semilunar) condition with frequent episodes of pain and effusion. While the September 2020 VA examiner did not include frequent episodes of joint locking as a symptom of the Veteran’s meniscus condition, the November 2019 VA examiner did. Thus, finding the evidence to be at least in equipoise, the Board resolves all doubt in favor of the Veteran and awards a separate disability rating of 20 percent under DC 5258 for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion, the highest rating available under DC 5258. See 38 C.F.R. § 3.102. Regarding the effective date upon which to award a rating under DC 5258, the Board finds the record lacks evidence of dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion until the November 2019 VA examination. While there is evidence of pain, the Veteran’s treatment records do not reference episodes of locking and effusion with the requisite frequency under DC 5258 prior to November 12, 2019. Thus, the effective date is based upon the date entitlement arose under 38 C.F.R. § 3.400(o)(1). Based on the aforementioned, the Veteran is awarded a separate 20 percent disability rating under DC 5258 for right knee dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion effective November 12, 2019. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.C. Allen, 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.