Citation Nr: 21010856 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 15-34 319 DATE: February 25, 2021 ORDER Entitlement to an increased rating, in excess of 10 percent, for patellofemoral syndrome with ligament laxity and small effusion of the left knee, prior to September 17, 2015, is denied. Entitlement to an increased rating, in excess of 10 percent, for patellofemoral syndrome with ligament laxity and small effusion of the right knee, prior to September 17, 2015, is denied. Entitlement to an increased rating of 30 percent, but not higher, for patellofemoral syndrome with ligament laxity and small effusion of the left knee from September 17, 2015 is granted. Entitlement to an increased rating of 30 percent, but not higher, for patellofemoral syndrome with ligament laxity and small effusion of the right knee from September 17, 2015 is granted. Entitlement to an increased rating, in excess of 10 percent, for limitation of flexion from arthritis of the left knee is denied. Entitlement to an increased rating, in excess of 10 percent, for minimal degenerative changes of the right knee is denied. FINDINGS OF FACT 1. Prior to September 17, 2015, the Veteran had recurrent instability of the left knee that was mild. 2. From September 17, 2015, the overall level of impairment of the left knee is best assessed as severe. 3. Prior to September 17, 2015, the Veteran had recurrent instability of the right knee that was mild. 4. From September 17, 2015, the overall level of impairment of the right knee is best assessed as severe. 5. During the entire period of the appeal, the left knee manifested with range of motion of 0 degrees extension, to not less than 90 degrees flexion and five degrees extension; with symptoms of pain and flare-ups; but, without muscle atrophy, ankylosis, instability, clinical indications of recurrent patellar dislocation, and/or impairment of the tibia or fibula. 6. During the entire period of the appeal, the right knee with minimal degenerative changes manifested with range of motion of not more than 5 degrees extension, to not less than 120 degrees flexion; with symptoms of pain and flare-ups; but, without muscle atrophy, ankylosis, instability, clinical indications of recurrent patellar dislocation, and/or impairment of the tibia or fibula. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent, for the right knee patellofemoral syndrome with laxity prior to September 17, 2015 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5757 (2019). 2. The criteria for entitlement to a rating of 30 percent, but not higher, for the right knee patellofemoral syndrome with laxity from September 17, 2015 have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5757 (2019). 3. The criteria for entitlement to a rating in excess of 10 percent, for the left knee patellofemoral syndrome with laxity prior to September 17, 2015 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5757 (2019). 4. The criteria for entitlement to a rating of 30 percent, but not higher, for the left knee patellofemoral syndrome with laxity from September 17, 2015 have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5757 (2019). 5. The criteria for an evaluation in excess of 10 percent for limitation of flexion, left knee arthritis have not been met. 8 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5003-5260 (2019). 6. The criteria for an evaluation in excess of 10 percent for minimal degenerative changes, right knee degenerative changes have not been met. 8 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5003-5260 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army as a finance specialist from April 1984 to March 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2017 and July 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the claims file. Increased Rating Disability ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. VA must consider whether the Veteran is entitled to "staged" ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. As discussed in more detail below, staged ratings are not appropriate in the instant case. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the Veteran undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. Bilateral Knees Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. As such, the Veteran's bilateral knee disabilities will be rated based on the Diagnostic Code concerning limitation of motion of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5003-5260. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5260 provides for the assignment of a noncompensable rating when flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A 10 percent rating is warranted when flexion of the leg is limited to 45 degrees. Id. A rating of 20 percent is appropriate when leg flexion is limited to 30 degrees, and a rating of 30 percent is warranted when flexion is limited to 15 degrees. Id. Under DC 5261, limitation of extension of the leg warrants a noncompensable rating if extension is limited to five degrees, a 10 percent rating if limited to 10 degrees, a 20 percent rating if limited to 15 degrees, a 30 percent rating if limited to 20 degrees, a 40 percent rating if limited to 30 degrees, and a 50 percent rating if limited to 45 degrees. See 38 C.F.R. § 4.71a, DC 5261. Under Diagnostic Code 5257, the criteria for impairment of the knee other than ankylosis, 10, 20, and 30 percent evaluations are assigned for slight, moderate, and severe recurrent subluxation or instability, respectively. C.F.R. § 4.71a, Diagnostic Code 5257. The terms "slight," "moderate," "severe," and "marked" are not defined in the regulations. The Board will look to the overall level of functional impairment in assigning the appropriate rating. Dislocation of the semilunar cartilage of the knee with frequent episodes of "locking," pain and effusion into the joint warrants a 20 percent evaluation. See 38 C.F.R. § 4.71a, DC 5258. Evidence In a February 2012 VA treatment record, a clinician indicated that the Veteran had chronic knee pain since service and that the Veteran was informed that weight loss and exercise would help. See June 2012 Capri, p.4. In June 2012, the Veteran was afforded a knee and lower leg conditions examination. The examiner diagnosed bilateral osteoarthritis and arthralgia. The Veteran indicated that she believed time and wear and tear made her left knee condition worse when standing after seating for a prolonged period. She also stated that she experienced burning pain in her left knee and that it occasionally would pop backwards. The Veteran reported flareups of the knee/ lower leg. The Veteran indicated that her knee would flare-up when she climbed stairs. The initial range of motion for the right and left knee was 120 degrees flexion and zero degrees extension. The examiner indicated that the Veteran’s body mass index (BMI) was a limiting factor in the Veteran’s bilateral knee ROM. The Veteran was able to perform repetitive use testing with three repetitions and range of motion stayed the same. The Veteran had functional loss and/ or functional impairment of the knee. The contributing factors were pain on movement; disturbance of locomotion and interference with sitting, standing and weight bearing. There was no tenderness or pain on palpation. Muscle strength testing was a 5/5; there was no joint instability or patellar subluxation/ dislocation. There were no meniscal conditions. The Veteran used a brace as an assistive device. The Veteran’s condition impacted her ability to work. The examiner noted that there was insufficient evidence to suggest the Veteran had an increase in her disabilities. The stated the Veteran’s increasing BMI was the reason for her increase in knee pain, not her time in-service. In August 2012, the Veteran was seen by a private clinician for knee pain. The clinician gave the Veteran a diagnosis of bilateral knee pain. The Veteran reported chronic bilateral knee pain with progressive worsening of symptoms in those past 10 years. The Veteran indicated that she sustained the injuries 25 years prior while in the military. The Veteran denied numbness/ tingling, and pain at night but indicated that pain was aggravated by sitting, driving, walking, cough/sneeze, extending, bending and lifting. Range of motion was 111 degrees flexion for the right knee and 115 degrees flexion for the left knee. See October 2020 Medical Treatment Record-Non-Government Facility, p.3. In November 2013, the Veteran was afforded another knee and lower leg conditions VA examination. The examiner indicated that the Veteran’s claims file was not reviewed; only her VA treatment records were reviewed. The examiner noted the Veteran had bilateral knee joint osteoarthritis and patellofemoral pain syndrome. The Veteran reported that she had the same type of pain that she had during her last examination; but the pain had worsened. She stated the pain was most noticeable when she got up from a sitting position or going up stairs; due to “crunching and grinding” in her knees. The Veteran did not report flare-ups. The initial range of motion was 125 degrees flexion for the right and left knee and zero degrees extension bilaterally. The Veteran was able to perform repetitive use testing with three repetitions; but range of motion stayed the same. The Veteran had functional loss and/or impairment, the contributing factors were less movement than normal; pain on movement; swelling and interference with sitting; standing and weight-bearing. The Veteran had bilateral tenderness or pain to palpation and muscle strength testing was normal. There was no joint instability; recurrent patellar subluxation/ dislocation; or shin splints. The examiner indicated that meniscal conditions and meniscal surgery were not applicable. The Veteran used braces as an assistive device regularly. The examiner noted that imaging studies of the knee had been performed and degenerative or traumatic arthritis was documented. However, there were no other significant diagnostic test findings. The examiner indicated that the condition impacted the Veteran’s ability to work; because she would be unlikely to perform a job that required ambulation or stair climbing. The Veteran worked a part time job until the prior month before the examination; but stopped working due to other medical issues. The examiner stated that she was unable to reconcile the Veteran’s report of worsening pain with her report in improvement in pain following weight loss. In September 2015, the Veteran was afforded another knee and lower leg conditions VA examination. The examiner noted the Veteran had bilateral knee joint osteoarthritis and patellofemoral pain syndrome. The Veteran reported that since her September 2011 VA examination her bilateral knee condition continued to worsen. She stated her knees were stiff and she experienced clicking and some “give way”, requiring her to use a cane and braces for stability. The Veteran reported that she had to change her lifestyle due to her knee conditions. She had to live on a single floor housing, get a higher toilet, disabled parking, had an inability to sit, stand, walk or kneel. The Veteran reported flareups and functional loss of the knees. The Veteran experienced flareups with walking, sitting and standing. The Veteran described the functional loss as having to sit after walking for only 15 minutes and not being able to drive or sit for long periods of time. The initial range of motion for the right and left knee was 0 to 120 degrees. The range of motion did not contribute to functional loss, but pain was exhibited on flexion and extension. There was pain on weight bearing; objective evidence of localized tenderness or pain on palpation; and objective evidence of crepitus. 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 after three repetitions. The examiner indicated that there was pain, weakness, fatigability or incoordination significantly limited repeated use over a period of time or flareups. Factors describing included were pain and lack of endurance. Additional contributing factors included disturbance of locomotion; interference with standing; limited stair climbing and walking. Muscle strength testing was a 5/5; there was no reduction in muscle strength, no muscle atrophy and no ankylosis. There was no history of recurrent subluxation, or recurrent effusion. There was a history of bilateral moderate lateral instability. There was joint instability with +1 medial instability and 2+ lateral instability. The Veteran never had recurrent patellar dislocation; shin splints; stress fractures; chronic exertional compartment syndrome or any other tibial or fibular impairment. The Veteran never had a meniscus (semilunar cartilage) condition. The Veteran used a brace regularly and cane constantly as assistive devices. The examiner noted that imaging studies of the knee had been performed and that degenerative or traumatic arthritis was documented. However, the examiner indicated that there were no other significant diagnostic test findings. The examiner indicated the Veteran’s condition impacted her ability to work; because the she was unable to stand for longer than 15 minutes; unable to sit longer than 30 minutes; unable to walk for longer than 20-30 minutes. She was also unable to repeatedly bend, kneel, stoop, squat, use ladders or stairs. In February 2017, the Veteran was afforded a knee and lower leg conditions examination. The examiner noted the Veteran had bilateral knee joint osteoarthritis and patellofemoral pain syndrome. The Veteran reported flareups and functional loss of the knees. The initial range of motion for the right and left knee was 0 to 120 degrees. The range of motion did not contribute to functional loss, but pain was exhibited on flexion. There was pain on weight bearing; objective evidence of localized tenderness or pain on palpation; and objective evidence of crepitus. 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 after three repetitions. The examiner was unable to say without mere speculation that pain, weakness, fatigability or incoordination significantly limited repeated use over a period of time or flareups. Additional contributing factors included disturbance of locomotion; interference with standing; limited stair climbing and walking. Muscle strength testing was a 5/5; there was no reduction in muscle strength, muscle atrophy and no ankylosis. There was no history of recurrent subluxation, lateral instability, but there was recurrent effusion. There was no joint instability. The Veteran never had recurrent patellar dislocation; shin splints; stress fractures; chronic exertional compartment syndrome or any other tibial or fibular impairment. Imaging studies of the knee had been performed and degenerative or traumatic arthritis was documented. The Veteran never had a meniscus condition. The Veteran used a brace and cane regularly as assistive devices. The examiner indicated the Veteran’s condition impacted her ability to work; because the Veteran would be less likely capable of performing any job requiring standing, walking and climbing. The examiner also noted that pain with non-weight bearing (at rest) was not noted on exam; there was pain with range of motion but no functional loss at rest; and there was pain with weight bearing that caused functional loss. In March 2017, the Veteran submitted a statement. The Veteran stated that her degenerative knee condition had gotten worse over time and with age. She reported that it was painful completing her normal daily activities. She stated that it was a struggle to sit, stand, climb stairs, get in and out of a car and off/on a toilet. The Veteran also noted that bending, squatting, lifting, standing and sitting for extended periods affected her ability to work. See March 2017 VA 21-4138 Statement In Support of Claim. In March 2017, a VA clinician submitted a letter. The physician stated she had been seeing the Veteran since 1998 and over that 20-year period the Veteran’s knee pain had worsened. The Veteran required a cane to ambulate and tried physical therapy and medications but her bilateral knee pain worsened despite the treatments. See March 2017 Medical Treatment Record-Government Facility, p.1. In an April 2017 VA treatment record, a VA clinician that the Veteran regularly saw for years indicated that the Veteran’s knee pain had worsened and that the Veteran had moderate knee impairment. The clinician also indicated that the Veteran required a cane to ambulate. See May 2017 Capri, p.19. In October 2018, the Veteran attended a Board hearing. The Veteran testified that she had constant knee pain, that was a 6/10 the day of the hearing. She stated that she had to get up at 7:00am in order to get to the hearing at 1pm due to the constant pain. See October 2018 Hearing Transcript, p.6. The Veteran described while sitting she had a burning sensation in both of her knees. The Veteran stated that when she stood up or sat down her knees would make a grinding sound. The Veteran testified that she had issues getting in and out of the shower and putting on clothes. The Veteran and her representative testified that due to the pain in her knees getting worse; there were things she just could not do anymore except going to the grocery store. The Veteran stated that she could not cook due to having to stand for long periods since it hurts her knees. The Veteran testified that she wanted to get a job and make more money but felt as though if they saw a lady with a cane, they would not hire her. She also testified she moved out of her apartment because she had to go up and down 10 flights of stairs. The Veteran’s representative testified that the Veteran’s VA doctor submitted a letter in April 2017 noting that the Veteran’s knees had gotten a lot worse. The Veteran further described her knees had begun making “snap” “crackle” and “pop” sounds. The Veteran also testified that she was told that there was no cartilage in her right knee. See Hearing Transcript, p.17. The Veteran stated that she was never a candidate for a total knee replacement. During the hearing the Veteran stated that she was able to drive a car and had drove to her hearing. The Veteran stated that she worked as a journalist in the past and had a bachelor’s degree in public relations and a master’s degree in communications. The Veteran stated that she was unable to work due to a combination of all her disabilities but running to chase leads on stories would have affected her knees. See October 2018 Hearing Transcript. In December 2018, the March 2017 clinician submitted an additional letter. The clinician indicated that the Veteran’s knees were getting worse and medication did not help. The clinician stated that the Veteran needed braces for ambulation. See November 2019 Medical Treatment Record-Government Facility, p.1. In January 2019, the Veteran submitted a statement. The Veteran contended that her disability should have been raised from the current 20 percent rating. The Veteran stated it was her belief that the rating was moderate, but her condition was not. She indicated her condition was moderate prior to her having to use braces, bathroom appliances and a cane. The Veteran reported symptoms of constant clicking, grinding, weakness and pain of her knee. She also noted it was her belief that her condition was moderate before having to find a new home, since she could not get around the home, she was previously in. See November 2019 Correspondence. In January 2020, the Veteran was afforded another knee and lower leg conditions examination. The examiner noted that the Veteran had a diagnosis of degenerative arthritis and bilateral patellofemoral syndrome with ligament laxity. The Veteran reported the conditions had worsened over time, without improvement. The Veteran stated that she had to start wearing a brace and using a cane for ambulation. The Veteran reported symptoms of constant tingling and burning in both knees. The Veteran reported flareups. She stated when she performed prolonged activity of any kind it would trigger worsening of knee pain and a feeling of instability. The Veteran stated that she had to have frequent rest periods and had to be cautious with movement. She noted the flareups occurred several times per day, and the severity was moderate to severe; lastly for several minutes. The Veteran also reported functional loss or impairment; because she could not easily walkup/ down more than two steps; had to be cautious when ambulating and could not tolerate prolonged physical activity. Initial range of motion for the right knee was 5 to 100 degrees. Pain was noted on examination and it caused functional loss. There was objective evidence of localized tenderness or pain on palpation. There was evidence of pain on weight bearing and objective evidence of crepitus. The initial range of motion for the left knee was normal. There was no objective evidence of localized tenderness or pain on palpation. There was no evidence of pain with weight bearing but objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions; there was additional loss of function for the right knee but not the left knee. The right knee range of motion after three repetitions was 5 to 90 degrees. Pain, weakness, fatigability or incoordination significantly limited ability in both knees with repeated use over time and with flareups when range of motion was 5 to 90 degrees for the flexion of the right knee and 90 to 5 degrees at extension; and 5 to 120 degrees for the left knee flexion and 120 to 5 degrees for extension. Muscle strength testing was a 5/5 with no reduction in muscle strength. The Veteran had no muscle atrophy or ankylosis. There was no history of recurrent subluxation; lateral instability or joint instability. The Veteran never had recurrent patellar dislocation; shin splints; stress fractures; chronic exertional compartment syndrome or any other tibial or fibular impairment. The Veteran never had a meniscus condition. The Veteran used a brace and cane regularly as assistive devices. The examiner indicated the Veteran’s condition impacted her ability to work; because her last job as a reporter she missed 0-1 week of work within those past 12 months; and because she could not be rushed to do assignments due to her inability to move quickly. The examiner also noted that there was objective evidence of pain on passive range of motion testing for the right knee but not the left knee. And there was objective evidence of pain when the joint was used for non-weight bearing for the right knee but not the left knee. Limitation of Flexion Left Leg and Minimal Degenerative Changes, Right Knee The Veteran contends that the 10 percent disability ratings under Diagnostic Code 5003-5260 that are currently assigned to her right and left knee strains do not contemplate the severity of the Veteran's symptoms. Diagnostic Code 5010-5260 covers arthritis and limitation of flexion. The Board finds no objective evidence that would warrant a rating greater than 10 percent for the Veteran's knee disabilities under the diagnostic codes for limitation of motion due to arthritis, as discussed below. As an initial matter, the Board accepts that the Veteran experienced pain in her knees, as the Veteran is competent to report unpleasant physical sensation. To this extent, the Board finds her credible. See Layno, supra. However, the Board notes that the Veteran's initial award of a 10 percent disability rating for each knee was predicated upon her reports of painful motion, not upon loss of flexion or extension. See 38 C.F.R. § 4.59; Deluca v. Brown, 8 Vet. App. 202 (1995). A 10 percent is the highest award that can be given based solely upon painful motion. Therefore, the Board must determine whether the Veteran has the requisite limitation of flexion or extension that would allow for a grant of a disability rating of 20 percent or higher. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. As such, all relevant diagnostic codes that avoid pyramiding will be discussed below. No compensable ratings under Codes 5258 (dislocated semilunar cartilage) or 5259 (removal of semilunar cartilage, symptomatic), are for application. Even though the Veteran testified that someone told her of a meniscal abnormality, none were noted during multiple VA examinations. Turning to Diagnostic Code 5260, leg flexion limited to 30 degrees warrants a rating of 20 percent. In the January 2020 VA examination findings, the Veteran's right knee flexion was to 120 degrees, and her left knee flexion was to 120 degrees. The VA examination, and treatment records do not suggest that the Veteran's knee flexion was never limited to 30 degrees. The Board has also considered Diagnostic Code 5256, ankylosis of the knee. Ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259. As noted in the January 2020 VA examinations, the Veteran did not have ankylosis in either knee. As such, DC 5256 is not applicable. Diagnostic Code 5261 is however applicable because according to the January 2020 VA examination because extension was to 5 degrees. However, that only provides a noncompensable rating under diagnostic code 5261; limitation of 10 degrees is necessary for a 10 percent rating. Therefore, a noncompensable rating is granted for both the right and left knee extension under diagnostic code 5261. Finally, as there is no lay or medical evidence of impairment of the tibia and fibula, or genu recurvatum, Diagnostic Codes associated with these manifestations do not apply. 38 C.F.R. § 4.71a, Diagnostic Codes 5262, 5263. As shown above, and as required by Schafrath, 1 Vet. App. at 594, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 10 percent for the Veteran's knee disabilities. Bilateral Patellofemoral Syndrome with Ligament Laxity and Small Effusion The RO has evaluated both right knee patellofemoral syndrome and left knee patellofemoral syndrome under 38 C.F.R. § 4.71a, Diagnostic Code 5257. The RO assigned a 20 percent disability rating from September 17, 2015, for both knees and then reduced the right knee rating to 10 percent from February 08, 2017. Under Diagnostic Code 5257, a 10 percent disability rating is warranted for slight recurrent subluxation or lateral instability of the knee; a 20 percent disability rating is warranted for medical evidence showing that the recurrent subluxation or lateral instability can be characterized as moderate; and a 30 percent disability rating is warranted for recurrent subluxation or lateral instability which medical evidence discloses can be characterized as severe. 38 C.F.R. § 4.71a, Diagnostic Code 5757. Prior to September 17, 2015 To receive a 20 percent rating, there would need to be a showing that the recurrent subluxation or lateral instability can be characterized as moderate. As the VA physician noted in the body of the November 2013 VA examination report, such findings associated with the 20 percent rating criteria were not disclosed. At worst, the service-connected right knee patellofemoral syndrome with laxity and manifested with pain warranting a 10 rating for a mild degree of impairment. Although the Veteran reported limitations in extended standing and sitting, there were no clinical indications of instability. The condition impacted the Veteran’s ability to work; because she would be unlikely to perform a job that required ambulation or stair climbing, but did not interfere with activities such as driving and leaving the home. 38 C.F.R. § 4.71a, Diagnostic Codes 5003. 5010, 5757-5262. Therefore, the Board finds that a 20 percent disability rating for the right and left knees for this period is not warranted. From September 17, 2015 to the present To receive a 30 percent rating, there would need to be a showing that the recurrent subluxation or lateral instability can be characterized as severe. The evaluation of patellofemoral syndrome with ligament laxity, right and left knee was increased to 20 percent disabling effective September 17, 2015, the date of a VA knee examination that sufficiently demonstrated evidence of moderate instability of both knees. This examination noted 1+ medial instability and 2+ lateral instability. The VA examination findings demonstrated evidence of moderate, but not severe instability, warranting at least a 20 percent rating strictly on the basis of the clinical assessment of knee instability. However, the overall level of impairment to included consideration of chronic pain, giving-way, and reported limitations in mobility and activity, the Board finds that a rating of 30 percent, but not higher, is warranted from September 17, 2015 for both knees because the limitations are best assessed as severe. The Board finds that the reduction in rating under this diagnostic code for the right knee assigned effective February 8, 2017 is in response to the clinical observations of lateral instability but there are no other compelling indications that the overall level of impairment improved. The Board places additional probative weight on some of the Veteran’s hearing testimony that is consistent with her reports of functional impairment reported to examiners. For example, the Veteran described while sitting she had a burning sensation in both of her knees. The Veteran testified that she had issues getting in and out of the shower and putting on clothes. The Veteran and her representative testified that due to the pain in her knees getting worse; there were things she just could not do anymore except going to the grocery store. The Veteran stated that she could not cook due to having to stand for long periods since it hurts her knees. She also testified she moved out of her apartment because she had to go up and down 10 flights of stairs. The Veteran’s representative testified that the Veteran’s VA doctor submitted a letter in April 2017 noting that the Veteran’s knees had gotten a lot worse. The Veteran testified that she was able to drive her vehicle but was unable to use stronger medication or be a candidate for knee replacements because of other medical conditions. Employability The Veteran reported on several occasions that she could no longer work or be hired because of her knees and the need for the use of a cane. The Board considered whether a total disability rating based on individual unemployability was warranted. The Veteran reported that she had education up to a master’s degree level in journalism and public relations and could no longer go into the field to track down stories. She also reported limitations in extended standing and sitting. On the other hand, she is able to drive an automobile and did not indicate difficulty with writing with the use of a keyboard or engage in conversations or meetings using telephone or computer videoconferencing tools. Even though mobility in the field is restricted, her education and skills remain suitable for telework, particularly in her field as a writer, editor, or simple administrative tasks such as scheduling and correspondence. The Board finds that the Veterans service connected disabilities do not preclude all forms of substantially gainful employment. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Long-Ellis, 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.