Citation Nr: 21010747 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 18-34 555 DATE: February 25, 2021 ORDER Entitlement to a compensable disability rating for bilateral hearing loss is denied. Entitlement to a disability rating in excess of 10 percent for lumbar spine strain is denied. Entitlement to a disability rating in excess of 10 percent for left knee patellofemoral pain syndrome is denied. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral pain syndrome is denied. Entitlement to an initial disability rating of 10 percent, but no greater, for left knee limitation of extension is granted. Entitlement to an initial disability rating of 10 percent, but no greater, for right knee limitation of extension is granted. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran had no worse than Level II hearing acuity in the right ear, and no worse than Level I hearing acuity the left ear. 2. The Veteran’s impairment of the thoracolumbar spine is manifested by forward flexion of the thoracolumbar spine greater than 60 degrees, and without muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. 3. The Veteran’s service-connected left knee patellofemoral pain syndrome disability is manifested by flexion limited to 30 degrees or greater. Ankylosis, recurrent subluxation or lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum are not present. 4. The Veteran’s service-connected right knee patellofemoral pain syndrome disability is manifested by flexion limited to 30 degrees or greater. Ankylosis, recurrent subluxation or lateral instability, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum are not present. 5. The Veteran’s service-connected left knee limitation of extension is manifested by limitation of extension of 10 degrees or less. 6. The Veteran’s service-connected right knee limitation of extension is manifested by limitation of extension of 10 degrees or less. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 2. The criteria for a rating in excess of 10 percent for degenerative arthritis of the thoracolumbar spine are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5237. 3. The criteria for entitlement to a rating in excess of 10 percent for left knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5260-5019. 4. The criteria for entitlement to a rating in excess of 10 percent for right knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5260-5019. 5. The criteria for entitlement to a rating of 10 percent, but no greater, for left knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 6. The criteria for entitlement to a rating of 10 percent, but no greater, for right knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from March 1986 to August 2006. In September 2020, the Board remanded these matters to the Agency of Original Jurisdiction (AOJ) to obtain relevant private treatment records and updated VA examinations. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Substantial compliance has long been held as the standard applied to the VA when carrying out remand directives to comply with Stegall authority. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The updated VA examinations were provided in November 2020. In September 2020, the VA provided with the Veteran a copy of VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs. Without such a signed release, the VA is unable to obtain treatment records from private healthcare providers. The record does not reflect any response from the Veteran. As the AOJ has provided the Veteran with new VA examinations and the appropriate release forms, there has been substantial compliance with the remand directives and these matters are again before the Board. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her 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. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, as is the case here, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 1. Entitlement to a compensable disability rating for bilateral hearing loss The Veteran’s service-connected bilateral hearing loss is rated as noncompensable (zero percent disabling) under Diagnostic Code 6100. In October 2016, the Veteran filed a claim for an increased rating. The Veteran contends that the severity of his bilateral hearing loss warrants a compensable rating. The Rating Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on puretone thresholds and controlled speech discrimination (Maryland CNC) testing. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85. The “puretone threshold average” as used in Table VI is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIa. 38 C.F.R. § 4.85(d). Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, the rating may be based solely on puretone threshold testing. An exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies 1000, 2000, 3000, and 4000 Hertz are 55 decibels or greater, or when the puretone threshold at 1000 Hertz is 30 decibels or less and the threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86(a), (b). During the February 2017 VA audiology examination, the Veteran reported that he has difficulty communicating and functioning at work due to his hearing loss. On the authorized audiological evaluation in February 2017, puretone thresholds in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 30 30 45 80 LEFT 25 30 30 60 75 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 in the left ear. The examiner noted that the puretone test results are valid for rating purposes, and that use of word recognition score is appropriate for this Veteran. The puretone threshold average in the right ear was 46.25, and the puretone threshold average in the left ear was 48.75. According to table VI, a numeric designation of I is obtained for the right ear, and a number designation of I is obtained for the left ear. The designations of Level I for the right ear and Level I for the left ear correspond with a noncompensable rating under Table VII. During the March 2018 VA audiology examination, the Veteran reported that his hearing loss interferes with hearing and communication abilities at work, in his social life, and while at school. On the authorized audiological evaluation in March 2018, puretone thresholds in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 20 45 70 LEFT 20 25 25 65 80 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 96 in the left ear. The examiner noted that the puretone test results are valid for rating purposes, and that use of word recognition score is appropriate for this Veteran. The puretone threshold average in the right ear was 38.75, and the puretone threshold average in the left ear was 48.75. According to table VI, a numeric designation of I is obtained for the right ear, and a number designation of I is obtained for the left ear. The designations of Level I for the right ear and Level I for the left ear correspond with a noncompensable rating under Table VII. During the November 2020 VA audiology examination, the Veteran reported trouble hearing his wife in conversation, especially when in background noise. He also reported that he was working as an Educational Aide for children with special needs, and he had trouble hearing the children and the beepers they used. On the authorized audiological evaluation in November 2020, puretone thresholds in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 25 50 70 LEFT 20 25 30 60 75 Speech audiometry revealed speech recognition ability of 90 percent in the right ear and of 94 in the left ear. The examiner noted that the puretone test results are valid for rating purposes, and that use of word recognition score is appropriate for this Veteran. The puretone threshold average in the right ear was 41.25, and the puretone threshold average in the left ear was 47.5. According to table VI, a numeric designation of II is obtained for the right ear, and a number designation of I is obtained for the left ear. The designations of Level II for the right ear and Level I for the left ear correspond with a noncompensable rating under Table VII. The Board has considered the Veteran’s statements regarding the severity of his hearing loss. The Board finds that the Veteran is both competent and credible in his report of his hearing loss symptomatology. However, the rating criteria for hearing impairment is designed to consider the Veteran’s diminished hearing acuity, and as outlined above, the assignment of a disability evaluation on a schedular basis is a purely mechanical process based on audiometric test results. As such, based on the Veteran’s audiological examination, the Veteran’s hearing loss does not meet the criteria for a rating higher than that already assigned. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for an initial compensable rating for hearing loss must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a disability rating in excess of 10 percent for lumbar spine strain The Veteran’s lumbar spine strain is evaluated as 10 percent disabling under Diagnostic Code 5237. 38 C.F.R. § 4.71a. In October 2016, VA received the Veteran’s claim for an increased rating for his lumbar spine strain. The Veteran contends that the severity of his service-connected lumbar spine strain warrants a rating in excess of 10 percent. Diagnostic Code 5237 indicates that lumbosacral strain should be evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). The Board notes that the regulations pertaining to rating the musculoskeletal system were amended, effective February 7, 2021, per Final Rule AP88. Claims, such as this, pending prior to the effective date will be considered under both the old and new rating criteria from that date, and whatever criteria is more favorable to the Veteran will be applied from that date. However, the General Rating Formula has not changed during the period on appeal. Moreover, as there is no relevant evidence pertaining to the lumbar spine dated since February 7, 2021, the amended regulations do not apply in this case. Under the General Rating Formula, a 10 percent disability evaluation is assigned when there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; when the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 135 degrees; when there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, when there is vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a. A 20 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; when the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, when there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent evaluation is warranted when there is forward flexion of the thoracolumbar spine 30 degrees or less, or when there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Id. Note (1) directs the rater to evaluate any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Id. Note (2) provides that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Prior to February 7, 2021, under Diagnostic Code 5242, degenerative arthritis of the spine was rated under Diagnostic Code 5003. After February 7, 2021, degenerative arthritis of the spine is rated under either Diagnostic Code 5003 or 5010. Diagnostic Code 5010 pertains to rating arthritis due to trauma, substantiated by X-ray findings, and provides that this disorder is to be rated as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, arthritis is rated on the basis of the limitation of motion of the affected joint. When the limitation of motion of the affected joint is noncompensable under the appropriate diagnostic code, a rating of 10 percent is applied to each affected major joint. See 38 C.F.R. § 4.71(a), Diagnostic Code 5003. For the purpose of rating a disability from arthritis, the lumbar vertebrae are considered a group of minor joints, ratable on parity with major joints. 38 C.F.R. § 4.45 (f). After February 7, 2021, Diagnostic Code 5010, post-traumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under the affected joint. Disability of the spine may be evaluated under either the General Rating Formula or under the formula for rating intervertebral disc syndrome (IVDS) based on incapacitating episodes (Diagnostic Code 5243), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Diagnostic Code 5243 provides evaluations for intervertebral disc syndrome (IVDS) based on the frequency of incapacitating episodes. A 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is available for IVDS with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is available with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is available with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a. Since February 7, 2021, Diagnostic Code 5243 only applies when there is disc herniation with compression and/or irritation of the adjacent nerve root. March 2017 VA Examination In March 2017, the Veteran was provided with a VA back condition examination. The examiner diagnosed the Veteran with lumbar spine strain. The Veteran reported primarily low back pain, sometimes severe, with occasional radiating pain on the right. The Veteran reports rest helps the condition. He also reports physical therapy and taking NSAIDs. The Veteran reported flare-ups causing episodes of more severe pain and stiffness sometimes lasting a day or two. A physical examination of the spine showed forward flexion to 75 degrees, extension to 25 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 25 degrees. The Veteran’s combined range of motion of the thoracolumbar spine was greater than 120 degrees but not greater than 235 degrees, consistent with a 10 percent rating. The examiner noted that poor forward flexion would limit lifting ability, and reduced lateral flexion and rotation would limit dexterity for general physical work. There was no pain on examination, and no evidence of pain with weight bearing. Repetitive use testing did not cause additional loss of function or range of motion. The examiner did note that pain would limit functional ability with repeated use over time, but the examiner was not able to describe this in terms of range of motion. The examiner found no evidence of guarding or muscle spasm of the thoracolumbar spine. Muscle strength was normal except for bilateral knee extension. Deep tendon reflexes and sensory examination were normal. Straight leg raising was negative and there were no signs of radiculopathy. There were no other neurologic abnormalities or findings related to the Veteran’s back condition such as bowel or bladder problems/pathologic reflexes. There was no ankylosis. The examiner did not find that the Veteran had intervertebral disc syndrome (IVDS) or episodes requiring rest. Regarding the neurological findings, the examiner found that, although the Veteran reported symptoms of radiculopathy including constant right lower extremity pain, there was insufficient objective evidence found to diagnose a neurological condition. The examiner found that the Veteran’s reduction in knee muscle strengths was due to Bilateral Patellofemoral Pain Syndrome. April 2018 VA Examination In April 2018, the Veteran was provided with a VA back condition examination. The examiner diagnosed the Veteran with lumbar spine strain. The Veteran reported daily low back pain at a level of three to four out of 10. Increased daily activity can aggravate his back pain to five to six out of 10. The Veteran stated just bending down can aggravate his back pain from the three to four out of 10 to the five to six out of 10. There were no other reports of flare-ups. A physical examination of the spine showed forward flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. The Veteran’s combined range of motion of the thoracolumbar spine was 240 degrees. No pain was noted on the examination, and there was no evidence of pain with weight bearing. Repetitive use testing did not cause additional loss of function or range of motion. The examiner was unable to say without mere speculation whether pain, weakness, fatigability or incoordination would significantly limit functional ability with repeated use over a period of time or during flare-ups. The examiner found no evidence of guarding or muscle spasm of the thoracolumbar spine. Muscle strength was normal. Deep tendon reflexes and sensory examination were normal. Straight leg raising was negative and there were no signs of radiculopathy. There were no other neurologic abnormalities or findings related to the Veteran’s back condition. There was no ankylosis. The examiner did not find that the Veteran had intervertebral disc syndrome (IVDS) or episodes requiring rest. Regarding functional impact, the examiner found that the Veteran’s back pain would lead to poor tolerance for general physical work, especially heavy physical work involving lifting or twisting motions. The examiner noted that poor tolerance for extended standing, walking, or driving limits options for many jobs. November 2020 VA Examination In November 2020, the Veteran was provided with a VA back condition examination. The examiner diagnosed the Veteran with lumbosacral strain. The Veteran reported low back discomfort in the middle and which did not go into the sides or down the legs. At the day of the examination, the Veteran reported that today is a good day with minimal pain rate, at one to two out of 10, which is less than usual. The Veteran reported that he treats his condition with Diclofenac cream and Aleve or Tylenol arthritis pain tablets as necessary. The Veteran reported flare-ups twice per month, that will put him in bed for half a day. These flare-ups were caused by working on a car or truck, or something as simple as being in a boat. The Veteran reported that he cannot bend or twist, and he avoids all activity during flare-ups until it is better. A physical examination of the spine showed forward flexion to 85 degrees, extension to 20 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 25 degrees. The Veteran’s combined range of motion of the thoracolumbar spine was 230 degrees. No pain was noted on the examination, and there was no evidence of pain with weight bearing. Repetitive use testing did not cause additional loss of function or range of motion. The examiner did find that pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time. The examiner described this functional loss in terms of range of motion: forward flexion to 75 degrees, extension to 15 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 20 degrees. Considering this additional functional loss, the Veteran’s combined range of motion of the thoracolumbar spine was greater than 120 degrees but not greater than 235 degrees, still consistent with a 10 percent rating. There was no additional limitation with flare-ups. The examiner found no evidence of guarding or muscle spasm of the thoracolumbar spine. Muscle strength was normal. Deep tendon reflexes and sensory examination were normal. Straight leg raising was negative and there were no signs of radiculopathy. There were no other neurologic abnormalities or findings related to the Veteran’s back condition. There was no ankylosis. The examiner did not find that the Veteran had intervertebral disc syndrome (IVDS) or episodes requiring rest. Regarding functional impact, the examiner found that the Veteran’s lumbar spine strain restricts movement including functional play with students, limited bending, moving, walking, standing, hiking. Analysis The Veteran’s 10 percent rating takes into account all attendant functional loss. None of the other medical evidence shows forward flexion of the thoracolumbar spine to less than 60 degrees; combined range of motion of the thoracolumbar spine to less than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, to include following repetitive testing. A rating in excess of 10 percent is not warranted by Diagnostic Code 5243 during the entire period on appeal, as the evidence has not shown incapacitating episodes having a total duration of at least two weeks during the past 12 months, or bed rest prescribed by a physician. Diagnostic Codes 5003 and Diagnostic Code 5010 are not for application as there has been no documented arthritis of the spine. The Board has considered the implications of the decision in Correia v. McDonald, 28 Vet. App. 158, 170 (2016), in which the Court held that 38 C.F.R. § 4.59 creates range of motion testing requirements with which VA must comply. 28 Vet. App. 158 (2016). However, the November 2020 VA examiner specifically addressed Correia considerations in rendering findings that there was no pain in weight bearing and non-weight bearing testing, and the examiner explained why passive range of motion testing was contraindicated. The Board has also considered additional limitation of function due to pain on range of motion and during flare ups. Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Sharp v. Shulkin, 29 Vet. App. 26 (2017); DeLuca, 8 Vet. App. at 206-07. In this regard, the record is clear that the Veteran experiences back pain. However, as explained above, pain itself does not constitute functional loss. Rather, the pain must produce functional loss which results in disability which more nearly approximates the next higher rating, which has not been shown. The November 2020 VA examiner’s description of the Veteran’s functional loss in terms of range of motion are still consistent with a 10 percent rating. After reviewing the record, the Board concludes that the objective evidence does not reflect the functional equivalent of symptoms, supported by adequate pathology, required for the assignment of ratings in excess of that assigned herein based on functional loss due to pain. Finally, separately ratable neurological manifestations related to the Veteran’s thoracolumbar disability are not shown during the period in question. There is no evidence of any bowel or bladder impairment or radiculopathy associated with the Veteran’s service-connected thoracolumbar disability. The March 2017 VA examiner attributed any lower extremity weakness to the Veteran’s service-connected knee patellofemoral pain syndrome, which is addressed below. The Veteran is competent to attest to things he experiences through his senses, such as back pain and spontaneous weakness of his back that resulted in symptoms that caused some limitations on prolonged standing and walking. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the lay statements do not indicate that the Veteran has ankylosis of the spine or that the Veteran’s spinal impairment would otherwise meet the criteria for an increased rating. For all the above reasons, higher disability ratings for service-connected disability of the thoracolumbar spine are not warranted. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to a disability rating in excess of 10 percent for left knee patellofemoral pain syndrome 4. Entitlement to a disability rating in excess of 10 percent for right knee patellofemoral pain syndrome 5. Entitlement to an initial compensable disability rating for left knee limitation of extension 6. Entitlement to an initial compensable disability rating for right knee limitation of extension The Veteran’s service-connected left knee and right knee patellofemoral pain syndrome were each rated as 10 percent disabling under Diagnostic Code 5260-5019 for limitation of flexion. In October 2016, the Veteran filed claims for increased rating for his knees. In a March 2017 rating decision, the Veteran was award separate noncompensable (zero percent) ratings for limitation of extension of the left and right knees under Diagnostic Code 5261, and the 10 percent ratings for limitation of flexion were continued. The Veteran contends that the severity of his service-connected left and right knee disabilities warrants ratings in excess of those assigned. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5260 refers to limitation of flexion. Under Diagnostic Code 5019, bursitis is rated as degenerative arthritis, based on limitation of motion of affected parts. Diagnostic Criteria for the Knee VA’s Schedule for Rating Disabilities includes several Diagnostic Codes applicable to evaluating knee and leg disabilities. See 38 C.F.R. § 4.71a. As discussed above, the regulations pertaining to rating the musculoskeletal system effective February 7, 2021, per Final Rule AP88. Claims, such as this, pending prior to the effective date will be considered under both the old and new rating criteria from that date, and whatever criteria is more favorable to the Veteran will be applied from that date. However, as there is no relevant evidence pertaining to the knees dated since February 7, 2021, the amended regulations do not apply in this case. Diagnostic Code 5003 provides that degenerative arthritis that is 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 there is some limitation of motion of the specific joint or joints involved that is non-compensable (zero percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent 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. Since February 7, 2021, Diagnostic Code 5003 applies to degenerative arthritis other than post-traumatic arthritis, and Diagnostic Code 5010 applies to post-traumatic arthritis. Under Diagnostic Code 5019, bursitis is evaluated as degenerative arthritis, on the basis of limitation of motion of the affected part. Diagnostic Codes 5260 and 5261 are used to rate limitation of flexion and of extension of the knee. Under Diagnostic Code 5260, limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating, and limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, limitation of extension of the knee to 5 degrees warrants a zero or non-compensable rating. Limitation of extension of the knee to 10 degrees warrants a 10 percent rating. Limitation of extension of the knee to 15 degrees warrants a 20 percent rating. Limitation of extension of the knee to 20 degrees warrants a 30 percent rating. Limitation of extension of the knee to 30 degrees warrants a 40 percent rating, and limitation of extension of the knee to 45 degrees warrants a 50 percent rating. Normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Prior to February 7, 2021, under Diagnostic Code 5257, a 10 percent rating is warranted for slight knee impairment, that is, recurrent subluxation or lateral instability. A 20 percent rating is assigned for a moderate degree of impairment, and a maximum rating of 30 percent is assigned for severe impairment. The words slight, moderate, moderately severe, marked, 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 in reaching a decision that is “equitable and just.” 38 C.F.R. § 4.6. Since February 7, 2021, under Diagnostic Code 5257, recurrent subluxation or instability is rated at 10 percent disabling for sprain, incomplete ligament tear, or complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device. A 20 percent rating assigned for one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is assigned for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Since February 7, 2021, under Diagnostic Code 5257, patellar instability is rated as 10 percent disabling for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is assigned 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. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. March 2017 VA Examination In March 2017, the Veteran was provided with a VA knee and lower leg condition examination. The examiner noted a diagnosis of left and right patellofemoral pain syndrome. The Veteran reported continuing issues with both knees, with painful walking and significant difficulty with squatting or running. The Veteran reported gradual worsening since onset. The Veteran treated the condition with rest, physical therapy, and NSAIDs. No surgeries were reported. The Veteran reported flare-ups, which he described as episodes of more severe pain and stiffness, sometimes lasting up to a few days. The Veteran described his functional loss as poor tolerance for squatting, kneeling or running. For both the left and right knee, range of motion testing found flexion to 120 degrees and extension to 5 degrees. The examiner found that the Veteran’s limitation of range of motion slows walking pace and contributes to difficulty with stairs and squatting. Pain was noted on examination and causes functional loss on flexion. There was no objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue. There was no evidence of pain with weight bearing and no objective evidence of crepitus. For both knees, there was no additional loss of function or range of motion after three repetitions. The examiner found that pain would significantly limit functional ability with repeated use over a period of time. The examiner described this functional loss in terms of range of motion as flexion to 120 degrees and extension to 5 degrees. Pain was also found to significantly limit functional ability with flare ups, but the examiner was not able to describe this in terms of range of motion, as the Veteran was not being examined during a flare-up and was not able to replicate the associated range of motion loss. Muscle strength testing was four out of five for flexion and extension. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation or lateral instability. Joint stability testing was normal. There were no meniscal conditions. There were no other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran’s knee conditions. The examiner concluded that the Veteran’s knee conditions would cause poor tolerance for extended walking, especially on stairs, limits tolerance for jobs that require walking long distances over the course of the day. April 2018 VA Examination In April 2018, the Veteran was provided with a VA knee and lower leg condition examination. The examiner noted a diagnosis of left and right patellofemoral pain syndrome. The Veteran reported daily knee pain at a level of three to four out of 10. He reported that his pain can increase due to increased activity, which causes knee swelling. The Veteran treats his condition with Aleve but no surgery or physical therapy. The Veteran reported flare-ups four times per year, which causes moderate pain and lasts for a few days. The Veteran reported that he is unable to go hunting or kayaking due to ongoing knee pain. He has difficulty sitting on the ground with his students since he is a special education teacher. For the right knee, range of motion testing found flexion to 115 degrees and extension to 0 degrees. For the left knee, range of motion testing found flexion to 120 degrees and extension to 0 degrees. No pain was noted on examination. There was evidence of crepitus. No additional loss of function or range of motion was found after three repetitions. The examiner was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time or during a flare-up. Muscle strength testing was normal and there was no muscle atrophy. There was no ankylosis. There was no history of recurrent subluxation, lateral instability or recurrent effusion. Joint stability testing was normal. The examiner noted that the Veteran had medial tibial stress syndrome, or “shin splints,” during service, but this condition had resolved. There was no history of a meniscus condition. The examiner concluded that the Veteran’s knee pain functional impact would be poor tolerance for general physical work, especially heavy physical work involving lifting or twisting motions. Also, the knee pain would cause poor tolerance for extended walking or driving, limiting his options for many jobs. November 2020 VA Examination In November 2020, the Veteran was provided with a VA knee and lower leg condition examination. The examiner noted a diagnosis of left and right patellofemoral pain syndrome and limitation of extension of the knee. The Veteran reported that his knees have gotten slightly worse over time. The Veteran reported going to physical therapy a couple years ago, and physical therapy notes show that his tight hamstrings improved and all physical therapy goals were met at discharge. The Veteran currently finds it difficult to bend and squat down, as it causes pain in both knees and experiences pain when working on cars or truck engines. On the date of the examination, the Veteran reported mild discomfort, dull ache, and pain rated at two out 10 in both knees. Increased activity causes flare-ups, with severe pain rated at eight to nine out of 10 and lasting for a couple of days. The Veteran treats the condition with Voltaren cream as needed, and Aleve or Tylenol arthritis tablets daily. The Veteran reported that his knee disability limits his activity, and that he cannot hike as long, limits walking, doing home repairs, exercise, squatting, or running. For the right knee, range of motion testing found extension to 10 degrees and flexion to 110 degrees. For the left knee, range of motion testing found extension to 10 degrees and flexion to 115 degrees. Mild pain was noted in the patella and parapatella, which increased with gentle palpation. No additional loss of function or range of motion was found after three repetitions. Pain and lack of endurance were found to significantly limit functional ability with repeated use over a period of time or flare-ups. This functional limitation was described in terms of range of motion as flexion to 100 degrees and extension to 10 degrees for the right knee and flexion to 110 degrees and extension to 10 degrees for the left knee. Muscle strength testing was normal and there was no muscle atrophy. There was no ankylosis. There was no history of recurrent subluxation, lateral instability or recurrent effusion. Joint stability testing was normal. There was no current or prior meniscus condition. The examiner concluded that the Veteran’s service-connected knee disabilities would cause limitations in squatting, bending, walking long distances, slower walking, and standing for a long time, and the Veteran cannot run. The Veteran is very limited in hiking, fishing, yard work, gardening, and home repairs. Analysis After review of the record, the Board finds that 10 percent ratings are appropriate for the Veteran’s left and right knee limitation of flexion. The record does not demonstrate limitation of flexion to 30 degrees or less to support 20 percent ratings. Therefore, the appeal for a higher rating for left and right knee limitation of flexion is denied. The Board further finds that 10 percent ratings, but no higher, are appropriate for the Veteran’s left and right knee limitation of extension. The record shows extension limited to 10 degrees, but not to 15 degrees or greater. Therefore, increased ratings of 10 percent, but no greater, are granted for limitation of extension of the left and right knee. The VA examinations show that an evaluation of the right and left knee under Diagnostic Code 5257 is not warranted as there is no evidence of recurrent subluxation, lateral instability, or patellar instability of the left or right knee. The record also does not contain evidence of dislocation of the semilunar cartilage to warrant a separate rating under Diagnostic Code 5258, or evidence of limitation of extension of the left knee to 10 degrees or more. See 38 C.F.R. § 4.71a, Diagnostic Code 5258, 5261. Likewise, as there is no evidence of ankylosis, removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum noted in any of the lay or medical evidence of record, evaluation of the left or right knee under Diagnostic Code 5256, 5259, 5262, or 5263, respectively, is not warranted. The Board has considered whether higher ratings should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria but determines that higher ratings are not warranted for the Veteran’s disability picture. The Veteran did report pain on repeated use. However, even after considering the effects of pain and functional loss, the evidence does not show that the Veteran’s left or right knee disability amounted to limitation of flexion to 30 degrees or less, or limitation of extension to more than 10 degrees. Thus, higher ratings under these provisions are not approximated in the Veteran’s disability picture. As discussed above, the preponderance of the evidence is against the claims for higher ratings for left and right knee limitation of flexion, and therefore, the doctrine of reasonable doubt is not for application for those claims. However, reasonable doubt has been considered in awarding 10 percent ratings, but no higher, for right and left knee limitation of extension. Accordingly, the claims of entitlement to evaluations in excess of 10 percent for the Veteran’s right and left knee limitation of flexion are denied, and 10 percent ratings, but no higher, for right and left knee limitation of extension are granted. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.71a, DC 5260; Gilbert, 1 Vet. App. at 54-56. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Casey 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.