Citation Nr: 21005765 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 12-10 426 DATE: February 2, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral syndrome with degenerative joint disease is denied. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral syndrome with degenerative joint disease is denied. FINDINGS OF FACT 1. The Veteran’s service-connected right knee patellofemoral syndrome with degenerative joint disease has manifested in flexion limited to, at worst, 120 degrees and full extension without further limitation after repetitive use testing due to pain, fatigue, weakness, lack of endurance or incoordination. 2. The Veteran’s service-connected left knee patellofemoral syndrome with degenerative joint disease has manifested in flexion limited to, at worst, 120 degrees and full extension without further limitation after repetitive use testing due to pain, fatigue, weakness, lack of endurance or incoordination. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for right knee patellofemoral syndrome with degenerative joint disease have not been met or approximated. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5014, 5256-5262. 2. The criteria for a disability rating in excess of 10 percent for left knee patellofemoral syndrome with degenerative joint disease have not been met or approximated. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5014, 5256-5262. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1987 to July 2009. The issues of entitlement to initial ratings in excess of 10 percent for bilateral knee patellofemoral syndrome with degenerative joint disease have been before the Board on previous occasions. In a July 2017 Board decision, the Veterans claims were remanded in order to afford the Veteran a new VA knee examination which complied with the holdings in Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016). Upon return of the Veteran’s claims to the Board, the claims were denied in a November 2018 decision. The Veteran filed a timely appeal of the November 2018 Board decision to Court of Appeals for Veterans Claims (Court). In a July 2019 Joint Motion for Remand (JMR), the November 2018 Board decision was vacated, because the Board relied on inadequate examinations conducted in September 2009, October 2011, July 2015 and August 2017. These examinations were deemed inadequate, because they did not adequately address the functional loss caused by the Veteran’s bilateral knee disabilities as required by DeLuca v. Brown, 8 Vet. App. 202 (1995), Sharp v. Shulkin, 29 Vet. App. 26, 35 (2017), and Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Furthermore, the July 2015 and August 2017 VA examiner failed to provide clear conclusions with supporting data, as well as a rationale connecting the two, when discussing the Veteran’s complaints of flare-ups. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). Therefore, the Court vacated the November 2018 decision of the Board which denied the Veteran’s claims of entitlement to initial ratings in excess of 10 percent for both left and right knee patellofemoral syndrome with degenerative joint disease and remanded these matters for further proceedings in accordance with the Court’s order and the JMR. In December 2019, the Board found that in light of the concerns raised in the JMR, a remand was necessary in order to afford the Veteran a medical examination to adequately address the Veteran’s claim and to reflect the evidence of record. Increased Rating 1. Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral syndrome with degenerative joint disease. 2. Entitlement to an initial rating in excess of 10 percent for left knee patellofemoral syndrome with degenerative joint disease. The Veteran contends that he is entitled to increased evaluations for his service-connected patellofemoral syndrome with degenerative joint disease of the left and right knees. Increased rating disability evaluations (ratings) are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). Where 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. See 38 C.F.R. § 4.7 (2016). Reasonable doubt regarding the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2016). Separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102 (2017). The General Rating Formula for Diseases and Injuries of the knee are governed under 38 C.F.R. § 4.71a. The Veteran is currently in receipt of bilateral initial disability ratings of 10 percent under Diagnostic Code 5010. Diagnostic Code (DC) 5010 states that traumatic arthritis is to be rated as degenerative arthritis under DC 5003, which in turn provides that the severity of degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is, for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, under DC 5003, X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups warrants a 10 percent rating. Involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations warrants a 20 percent rating. The 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, DC 5003. DC 5257 assigns ratings based on recurrent subluxation or lateral instability of the knee: slight impairment warrants a 10 percent disability rating; moderate impairment warrants a 20 percent disability rating; and severe impairment warrants a 30 percent disability rating. 38 C.F.R. § 4.71a, DC 5257. DC 5260 assigns ratings based on limitation of flexion and provides a noncompensable rating if flexion is limited to 60 degrees; a 10 percent rating where flexion is limited to 45 degrees; a 20 percent rating where flexion is limited to 30 degrees; and a 30 percent rating where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. DC 5261 assigns ratings based on limitation of extension of the leg and provides a noncompensable rating if extension is limited to 5 degrees; a 10 percent rating if extension is limited to 10 degrees; a 20 percent rating if extension is limited to 15 degrees; a 30 percent rating if extension is limited to 20 degrees; a 40 percent rating if extension is limited to 30 degrees; and a 50 percent rating if extension is limited to 45 degrees. DC 5262 assigns ratings based on impairment of the tibia and fibula and provides a 10 percent disability rating for malunion with slight knee or ankle disability; a 20 percent disability rating for malunion with moderate knee or ankle disability; a 30 percent disability rating for malunion with marked knee or ankle disability; and a 40 percent disability rating for nonunion of the tibia and fibula with loose motion requiring a brace. DC 5263 assigns a 10 percent rating for acquired and traumatic genu recurvatum with weakness and insecurity in weight-bearing that is 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. 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. 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.”). In Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the Veterans themselves, when a flare-up is not observable at the time of examination. The Board observes that the words “slight,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent from August 2009 for left and right knee patellofemoral syndrome with degenerative joint disease. In September 2009 the Veteran underwent a VA knee examination. The Veteran was diagnosed with patellofemoral syndrome dating back to 1998. He denied daily pain, but experienced flare-ups described as 8/10 usually lasting two hours after excessive running. The Veteran had occasional swelling and no left knee subluxation, dislocation or instability. He occasionally wore a brace but did not use an assistive device and it did not affect his gait or walk. With flares and repetitive use, he elevated his knee and used Motrin and ice. His daily limitations were to walk one mile, run one mile and decreased squatting. He had not been totally incapacitated in the past 12 months. He had a strain in January 2005. He had x-rays that were negative and had no operations. He was on a profile for running. He would wear a brace episodically but did not use a cane. No objective evidence of painful motion. The September 2009 VA examination imaging studies showed bilateral degenerative or traumatic arthritis of the knees. Examination of the right knee revealed a normal appearance with no effusion, and no redness. Minimal tenderness in the patella on the inferior area was observed. With regard to instability, Lachman’s testing, collateral ligament testing, and McMurray test were all negative, and there was no laxity or crepitus. Range of motion revealed flexion to 130 degrees and extension to 0 degrees with normal patella movement. Examination of the left knee revealed a normal appearance with no effusion or redness. There was minimal tenderness on the patellar compression test and no joint line tenderness. With regard to instability, Lachman’s testing, collateral ligament testing, and McMurray test were all negative, and there was no laxity or crepitus. Range of motion revealed flexion to 130 degrees and extension to 0 degrees with normal patella movement. The Veteran experienced flare-ups in his left knee if he ran or used the stairs. The discomfort was under the medial aspect of the kneecap and had occasional swelling with it. He denied any dislocation, subluxation or instability. He did not change his gait or walk. Flare-ups were described as 8/10 lasting about two hours. His daily limitations were to walk one mile, run one mile and decreased squatting. The Board acknowledges the September 2009 Veteran’s lay reports of no daily pain with his left knee but symptoms experienced during flare ups. The Veteran reported occasional difficulty with discomfort under the medial aspect of the kneecap and occasional swelling. However, even considering the Veteran’s lay reports of symptoms and functional loss due to flare ups, the degree of additional limitation reflected by occasional discomfort and swelling would not result in symptoms more nearly approximating limitation of flexion to at least 30 degrees to warrant the next higher schedular rating of 20 percent under DC 5260. The Veteran reported that he experienced flare-ups caused by running and climbing, but in the absence of ankylosis, a rating under DC 5256 is not warranted and in the absence of evidence of dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, a rating under DC 5258 is not warranted. Similarly, there is no genu recurvatum or impairment of the tibia and fibula with malunion which would warrant ratings under DCs 5263 and 5262. The Veteran underwent a second VA examination in October 2011. He was diagnosed with bilateral chondromalacia of the patella and bilateral degenerative joint disease of the knees. The examiner noted that the Veteran experienced pain with squatting and kneeling, as well as flare-ups with squatting and kneeling. Initial range of motion testing showed right knee flexion to 135 degrees with no objective evidence of painful motion and extension with zero or any degree of hyperextension and no objective evidence of painful motion. Left knee flexion measured to 135 degrees with no objective evidence of painful motion and extension with zero or any degree of hyperextension and no objective evidence of painful motion. The Veteran was able to perform repetitive use testing, but such repetitive use testing did not result in additional functional loss or range of motion in either knee. There was no pain or tenderness to palpation for joint line or soft tissues of either knee. In October 2011, muscle strength testing showed bilateral normal strength on flexion and extension. Joint stability testing also showed bilateral normal anterior, posterior and medial lateral stability. There was no evidence or history of recurrent patellar subluxation/ dislocation. The examiner also noted that the Veteran had patellofemoral grinding/ crepitation. The Board acknowledges the October 2011 reports of pain with squatting and kneeling, as well as flare-ups with squatting and kneeling. However, even considering the Veteran’s lay reports of symptoms due to flare ups, the degree of additional limitation reflected by occasional painful motion discomfort would not result in symptoms more nearly approximating limitation of flexion to at least 30 degrees to warrant the next higher schedular rating of 20 percent under DC 5260. The Veteran reported that he experienced flare-ups caused by squatting and kneeling, but in the absence of ankylosis, a rating under DC 5256 is not warranted and in the absence of evidence of dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, a rating under DC 5258 is not warranted. Similarly, there is no genu recurvatum or impairment of the tibia and fibula with malunion which would warrant ratings under DCs 5263 and 5262. An October 2014 a VA treatment record noted that the Veteran was being evaluated for bilateral knee pain. The pattern of joint symptoms had been episodic flare-ups with symptom free periods in between. Associated symptoms included swelling with recent increased pain. He was positive for arthralgias, joint stiffness and limb pain in both knees. The Veteran also had pain with range of motion in his knees, but a normal gait. There was also bilateral crepitus of the knees. Although the physician in October 2014 noted pain with range of motion in his knees, no range of motion test results were noted. The Board acknowledges the Veteran’s October 2014 lay reports of episodic flare-ups with symptom free periods in between, swelling with recent increased pain, joint stiffness, limb pain in both knees and positive for arthralgias (aching pain in the joints), pain with range of motion in his knees, but a normal gait. However, even considering the Veteran’s lay reports of symptoms and functional loss due to flare ups, the degree of additional limitation reflected by episodic flare-ups with symptom free periods in between, swelling, pain, joint stiffness, pain with range of motion in his knees, but a normal gait would not result in symptoms more nearly approximating limitation of flexion to at least 30 degrees to warrant the next higher schedular rating of 20 percent under DC 5260. The Veteran reported that he experienced flare-ups and otherwise had a normal gait. In the absence of ankylosis, a rating under DC 5256 is not warranted and in the absence of evidence of dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, a rating under DC 5258 is not warranted. Similarly, there is no genu recurvatum or impairment of the tibia and fibula with malunion which would warrant ratings under DCs 5263 and 5262. In February 2015 the Veteran testified at a Board video conference hearing. During the Board hearing the Veteran testified that he experienced swelling in his knees which he treated with ibuprofen and ice. He also described experiencing pain with knee bending and constant knee pain. The Veteran testified that his left knee symptoms were worse than his right. In July 2015 the Veteran underwent a VA knee examination. The Veteran was diagnosed with bilateral patellofemoral pain syndrome and degenerative arthritis. He reported flare-ups of the knee and/or lower leg. The Veteran limited standing to one hour and walking to two blocks with flare-ups. He had pain and weakness/fatigability during flare or following repeated use over time with each knee. Pain was the more limiting factor. No additional loss of motion or discoordination with flares or following repeated use over time. Repeated use over time caused knee flare-ups leading to functional restrictions. The Veteran reported functional loss or functional impairment of the joint. There were no sedentary restrictions, he could stand two hours, walk one mile and he avoids climbing and squatting due to knees. The range of motion itself did not contribute to functional loss. Pain was noted on flexion and extension. In July 2015 there was also pain on weight bearing and objective evidence of localized tenderness on palpation of the joint. The pain was described as mild tenderness anterior knee directly related to his knee conditions. The Veteran was able to perform repetitive use testing with at least three repetitions but did not result in any additional functional loss or range of motion for his bilateral knees. The Veteran’s functional ability was significantly limited by pain, fatigue, weakness and lack of endurance with repeated use over a period of time. The functional limitation of the right knee was described in terms of range of motion as flexion from 0 to 125 degrees and extension from 125 to 0 degrees. The functional limitation of the left knee was described in terms of range of motion as flexion from 0 to 120 degrees and extension from 120 to 0 degrees. Identical symptoms and range of motion measurements were found for the bilateral knees during flare-ups. Muscle strength testing revealed bilateral normal strength on forward flexion and extension. There was no muscle atrophy present. Furthermore, in July 2015 there was no ankylosis, history of recurrent subluxation or history of lateral instability in the bilateral knees. There was history of recurrent effusion. Joint instability testing did not show any joint instability bilaterally. The Veteran did not have, or ever had, recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The examiner also noted that both knees appeared normal with slight prominence tibia tubercle in both knee. There was no swelling or laxity in the knees. Crepitus was found in both patella with range of motion in the knees. There was no additional weakness, fatigue, discoordination or additional loss of motion with repetition three times in both knees. No patella laxity was found in either knee. The only assistive device noted was regular use of a compression sleeve. Prior x-rays were reviewed and revealed degenerative joint disease. The examiner in July 2015 also noted that the examination, and the Veteran’s history, failed to reveal any evidence of lateral instability or subluxation in either knee. The Board acknowledges the February 2015 testimony and July 2015 Veteran’s lay reports of pain and weakness during flare ups, and reports that repeated use over time caused knee flare-ups, leading to functional restrictions of the joint. The Veteran reported that he had no sedentary restrictions, he could stand two hours, walk one mile and he avoided climbing and squatting due to his knee conditions. During examination, there was no evidence of lateral instability or subluxation in either knee. Even considering the Veteran’s lay reports of symptoms and functional loss due to flare ups, the degree of additional limitation reflected by pain and weakness during flare ups or following repeated use over time with each knee would not result in symptoms more nearly approximating limitation of flexion to at least 30 degrees to warrant the next higher schedular rating of 20 percent under DC 5260. The Veteran reported that he experienced flare-ups caused by repeated use and was able to stand two hours and walk one mile. In the absence of ankylosis, a rating under DC 5256 is not warranted and in the absence of evidence of dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, a rating under DC 5258 is not warranted. Similarly, there is no genu recurvatum or impairment of the tibia and fibula with malunion which would warrant ratings under DCs 5263 and 5262. The Veteran underwent a VA knee examination in August 2017. He was diagnosed with bilateral patellofemoral pain syndrome and degenerative arthritis. The Veteran described continued pain with walking one and a half miles or repetitive squatting. Current symptoms included aching and problems using stairs which he treated with over the counter Motrin. The Veteran denied flare-ups of the knee and/or lower leg and also denied any functional loss or functional impairment of the joint. The August 2017 initial range of motion testing showed right knee flexion of 0 to 130 degrees and extension from 130 to 0 degrees. The range of motion itself did not contribute to functional loss. Pain was noted on flexion. There was no pain on weight bearing, but there was evidence of localized tenderness or pain on palpation over the patella which was described as mild and consistent with patellofemoral pain syndrome. The examiner also found evidence of crepitus in the right knee. Initial range of motion testing also showed left knee flexion of 0 to 130 degrees and extension from 130 to 0 degrees. There was evidence of pain on flexion. However, there was no evidence of pain on weight bearing or crepitus. The examiner did note objective evidence of localized tenderness or pain on palpation of the anterior knee which was mild and was constituent with the condition. The Veteran was able to perform repetitive use testing with at least three repetitions but there was no additional functional loss or range of motion. In August 2017 the examination was not being conducted during a flare-up so the examiner could not describe functional loss during flare-ups in terms of range of motion without resorting to mere speculation. The examiner did not find any additional factors contributing to his disability. Muscle strength testing also revealed normal strength in flexion and extension of the bilateral knees. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability or recurrent effusion noted during joint stability tests. Joint stability testing found no anterior, posterior, medial or lateral instability of either knee. The August 2017 report indicated that the Veteran did not have, or ever had, recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. There was also no history of meniscal conditions, surgical procedures or assistive devices noted. Functional impact included avoiding walking over one and half miles and repetitive squatting or stairs. There was also no objective evidence of pain on non-weight bearing in either knee. Also, in August 2017, passive range of motion testing was the same as active range of motion for both knees and there was no objective evidence of pain on passive range of motion testing. The Board acknowledges the Veteran’s statements from August 2017. The Veteran described that he was able to walk one and a half miles. He experienced continued pain and aching with repetitive squatting and problems using stairs which he treated with over the counter Motrin. The Veteran denied flare-ups of the knee and/or lower leg and also denied any functional loss or functional impairment of the joint on both knees. The Veteran reported localized tenderness or mild pain on palpation over the patella and pain on flexion. There was no evidence that the Veteran experienced pain on weight bearing or crepitus in either knee. The examiner reported that the Veteran did not evidence pain on passive range of motion testing. The Veteran’s lay reports do not result in symptoms more nearly approximating limitation of flexion to at least 30 degrees to warrant the next higher schedular rating of 20 percent under DC 5260. The Veteran reported that he experienced pain and aching but also, he was able to walk one and a half miles and manage his pain with Motrin. In the absence of ankylosis, a rating under DC 5256 is not warranted and in the absence of evidence of dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, a rating under DC 5258 is not warranted. Similarly, there is no genu recurvatum or impairment of the tibia and fibula with malunion which would warrant ratings under DCs 5263 and 5262. The Veteran was afforded a VA examination January 2020. The Veteran’s diagnosis was patellofemoral pain syndrome and degenerative arthritis in both knees. The Veteran reported chronic bilateral knee pain over the last few years rated a 5 to 6 out of 10. He has flare ups related to his activities. During a flare, if he is able to then he gets off his feet for about thirty minutes. During flares he has pain and weakness in his knees rating pain 9 to 10 lasting 30 minutes following certain activities. He experiences stiffness in both knees. His right knee intermittently locks on an infrequent basis. Both knees intermittently swell approximately every two weeks which the Veteran describes as moderate and lasting up to a day. Flares are triggered by standing and walking activities. Knees do not give out. The Veteran has not had injections in his knees and takes Motrin to control pain. The Veteran does not report having any functional loss or functional impairment of the joint. The examiner notes pain upon examination but does not result in or cause functional loss. Flexion, extension and weight bearing cause evidence of pain. There is localized tenderness upon palpitation. The examiner reports that the range of motion is outside of normal but is normal for the Veteran. There is objective evidence of crepitus. The examination is medically consistent with the Veteran’s statements describing functional loss during flare ups. During flare ups, the Veteran is significantly limited in his functional ability due to pain, fatigue, weakness, and lack of endurance. Specifically, flexion during flare ups is described as zero degrees to 125 degrees and extension is described as 125 degrees to 0 degrees. The examiner describes that an additional contributing factor to the Veterans disability is a prominent tibial tubercle present in both knees. There is no ankylosis and no joint instability. The Veteran sometimes uses braces. With regard to the Veteran’s current employment status and the impact of the diagnosis on the Veteran’s ability to perform occupational tasks, the Veteran denies functional restrictions between flares. The Veteran reports that if at work, he works through the flares. During flares and after repeated use at home, he will stop his activities with easing of symptoms over 30 minutes. Pain historically is the most limiting factor. The Board acknowledges the Veteran’s statements from January 2020. The Veteran described that he was able to work as a loadmaster through his flare ups and although he experienced continued pain and aching with repeated use over time, he is able to treat with over the counter Motrin. The Veteran’s lay reports do not result in symptoms more nearly approximating limitation of flexion to at least 30 degrees to warrant the next higher schedular rating of 20 percent under DC 5260. In the absence of ankylosis, a rating under DC 5256 is not warranted. The Veteran’s right knee intermittently locks on an infrequent basis. In the absence of evidence of dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, a rating under DC 5258 is not warranted. Similarly, there is no genu recurvatum or impairment of the tibia and fibula with malunion which would warrant ratings under DCs 5263 and 5262. The Veteran was afforded a VA examination in April 2020 for arthritis. The Veteran’s diagnoses were right and left knee patellofemoral syndrome with degenerative joint disease. The Veteran indicated that his job duties as a loadmaster required jumping in and out of aircraft. The Veteran believes this work has caused wear and tear on his knees. He reports bilateral knee pain as chronic, worse with physical activity, and progressively worsening. The Veteran reports he experienced bilateral aching pain around both his kneecaps and he treated this with ibuprofen once a day as needed. The Veteran does not require continuous use of medication for the arthritis condition. During flare ups the Veteran reports he experienced impaired mobility that can cause limping. The Veteran does not experience any exacerbations that are incapacitating. He did not use any assistive devices and does not report the use of a brace. X-rays of the bilateral knees have been performed and the results were available to the examiner. The Veteran states that his diagnosis impacts his ability to perform his work as a civilian loadmaster because he finds it painful on his joints climbing in and out of aircraft. He believes he cannot perform his job duties as efficiently as his peers. The Veteran further estimates that he has lost zero to one week of work time in the last 12 months due to this condition. In April 2020 the Veteran described that he was able to continue his employment although he finds it painful on his joints. He was able to treat with over the counter Ibuprofen. The Veteran does not experience any exacerbations that are incapacitating. X-rays of the bilateral knees have been performed. The Veteran’s lay reports do not result in symptoms more nearly approximating limitation of flexion to at least 30 degrees to warrant the next higher schedular rating of 20 percent under DC 5260. In the absence of ankylosis, a rating under DC 5256 is not warranted. He did not use any assistive devices and does not report that he used any braces. In the absence of evidence of dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, a rating under DC 5258 is not warranted. Similarly, there is no genu recurvatum or impairment of the tibia and fibula with malunion which would warrant ratings under DCs 5263 and 5262. The Veteran’s VA treatment records throughout the appeal period associated with the file are consistent with the findings documented during the enumerated examinations. The Board finds that throughout the entire period on appeal that the Veteran’s bilateral knee patellofemoral syndrome with degenerative joint disease is most consistent with a 10 percent disability rating. The Veteran does not have and has not had ankylosis, instability, symptomatic removal of semilunar cartilage, frequent episodes of locking, an impairment of the tibia or fibula, or genu recurvatum of the left knee at any point, so a rating under DC 5256, 5257, 5258, 5259, 5262, or 5263 is not warranted. Although the July 2015 VA examination noted a history of recurrent effusion, this is the only mention of recurrent effusion and it is not supported by the record. The January 2020 exam contains a report that the Veteran’s right knee intermittently locks on an infrequent basis, but the April 2020 examination is silent for locking and also reflects that the Veteran is not using any braces. The Veteran currently has a 10 percent rating under DC 5010, arthritis due to trauma, but he argues that he should have a higher rating. Although the Veteran has arthritis confirmed by x-ray evidence of the bilateral knees, which is sufficient to warrant a 10 percent disability rating for each knee, the Veteran does not experience incapacitating episodes due to his bilateral knee arthritis. In the April 2020 examination it is specifically noted that the Veteran does not experience any exacerbations that are incapacitating. Therefore, the Veteran does not meet the criteria for a 20 percent disability rating under DC 5003 – 5010. None of the range of motion findings supports a rating higher than 10 percent under either DC 5260 or DC 5261. The 10 percent rating under DC 5260 was originally assigned based on painful motion (i.e. the DeLuca factors), because a 10 percent evaluation may be assigned for painful or limited motion of a major joint and may be also be applied once to multiple joints if there is no limited or painful motion. See March 2012 Rating Decision. The medical evidence during the appeal period documents flexion of at least 120 degrees in the right knee and 120 degrees in the left and extension to zero degrees from on all range of motion testing, including after repetitive use testing. Although all of the examination reports indicate there are flare-ups, there is no additional limitation of motion after repetitive use testing. Given the ranges of motion of at least 120 degrees of flexion in the right knee and 120 degrees of flexion in the left knee and extension to zero degrees in both knees, the Board finds that the symptoms of weakness, fatigue, and pain warrant, at most, a 10 percent rating under DC 5260 and 5261. The limitations, particularly given the range of motion testing (including repetitive testing) results at the VA examinations and elsewhere in the medical records, do not meet or more closely approximate the limitations that would be associated with a flexion limited to 30 degrees (the criteria for a 20 percent rating under DC 5260) or extension limited to 15 degrees (the criteria for a 20 percent rating under DC 5261). Rather, the currently assigned 10 percent rating under DC 5260 and 5261 adequately accounts for the limitations of motion, including after considering the DeLuca factors, documented in the medical records and VA examinations. The Board has considered whether staged ratings should be assigned but the Veteran’s bilateral knee disabilities do not more closely approximate the criteria for any rating in excess of 10 percent at any time during the period on appeal. For the foregoing reasons, entitlement to a compensable rating for bilateral knee patellofemoral syndrome with degenerative joint disease (other than the already assigned 10 percent rating under DC 5014) is denied. 38 C.F.R. §§ 4.7, 4.20, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5256-5263; Hart, 21 Vet. App. 505. In reaching its decision, the Board has considered the Veteran’s lay statements. The Veteran’s lay statements are outweighed by the examination reports of record that were based on an interview with the Veteran, examinations, and the medical expertise of the examiners. The VA examiners have specialized training to assess the severity of the Veteran’s knee disabilities. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claims. 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. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.