Citation Nr: 21011842 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 19-01 383 DATE: March 2, 2021 ORDER For the period on appeal prior to November 26, 2018, an evaluation in excess of 10 percent for the left knee condition is denied. For the period beginning November 26, 2018, to February 8, 2020, an increased rating from 10 percent to 30 percent for a left knee condition, based on limitation of extension, is granted. For the period on appeal beginning February 8, 2020, an evaluation in excess of 30 percent for a left knee condition is denied. FINDING OF FACT For the period prior to November 26, 2018, the left knee did not manifest with extension limited to 20 degrees or flexion limited to 45 degrees. Earlier private examination results, from November 26, 2018, rather than those from the February 8, 2020, VA examination are the first to report left knee limitation of extension results between 20 and 29 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating for a left knee condition in excess of 10 percent prior to November 26, 2018, have not been met. 38 C.F.R. §§ 1155, 5103, 5103A, 5107, 7104 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 2. The criteria for entitlement to an increased rating of 30 percent for a left knee condition for the period beginning November 26, 2018 have been met. 38 C.F.R. §§ 1155, 5103, 5103A, 5107, 7104 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 3. The criteria for entitlement to an increased rating for a left knee condition in excess of 30 percent for the period beginning November 26, 2018 have not been met. 38 C.F.R. §§ 1155, 5103, 5103A, 5107, 7104 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Navy from August 1963 to October 1967. As a preliminary matter, the issue of right knee condition as secondary to the left knee has been raised by the record and the Veteran’s representative in his October 2020 Informal Hearing Presentation (IHP) but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). This appeal to the Board of Veterans’ Appeals (Board) arose from a June 2016 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) denied a rating greater than 10 percent for the left knee disability. In July 2017, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in November 2018. The Veteran filed a substantive appeal in January 2019. The Board remanded the issue for further development and a VA examination in September 2019, because the Veteran alleged his left knee disability had worsened. The Veteran attended a VA medical exam in February 2020, and the AOJ in a July 2020 Supplemental Statement of the Case (SSOC) increased the Veteran’s left knee disability from 10 to 30 percent effective February 18, 2020, the date of the VA examination that determined limitation of extension of 20 to 29 degrees. This issue is now returned to the Board. Also, this appeal has been advanced on the Board’s docket, pursuant to 38 U.S.C. § 7107(a)(2) and 38 C.F.R. § 20.900(c). In September 2019, the Board remanded the claim to the AOJ to obtain a VA medical examination. After review of the record, the Board finds there has been substantial compliance with the September 2019 remand orders and the claim is properly before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to an increased rating for a left knee condition evaluated as 10 percent disabling from April 7, 2016 to February 8, 2020 and 30 percent thereafter The Veteran contends three things through his representative in his October 2020 IHP; First, that an earlier 30 percent rating is justified based on a November 2018 private exam that had similar limitation of extension findings to the February 2020 VA examination. Second, the Veteran contends that he is entitled to a separate rating based on instability of his left knee, and finally that the record raises the issue of right knee condition as secondary to the left. Taking the three contentions in reverse order: Since the Board does not have jurisdiction over the right knee disability, which it agrees is reasonably raised by the February 2020 VA examiner’s findings, it is referred to the AOJ for consideration and handling in the first instance. 38 C.F.R. § 19.9(b) (2017). The second contention raised by the Veteran through his service representative, is that of instability of the left knee qualifying the Veteran for a separate compensable disability rating under Diagnostic Code (DC) 5257. In his October 2020 IHP, the representative argues, “Since the private exam indicated he had instability, he should be rated for that and should be granted a separate rating for the limitation of motion in accordance with GC Opinion 23-97.” VA’s Office of General Counsel has determined that a Veteran may receive separate disability ratings for limitation of motion, under Code 5260, and for instability of the knee, under Code 5257, since these Codes pertain to different symptoms. See VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63, 604 (1997); and VAOPGCPREC 9-98 (August 14, 1998), 63 Fed. Reg. 56, 704 (1998). VA’s Office of General Counsel has also held that the Veteran may receive separate ratings for limitation of flexion and extension for the same joint. VAOPGCPREC 9-2004 (September 17, 2004), 69 Fed. Reg. 59, 990 (2004). DC 5257 governs other impairment of the knee, providing respective ratings of 10, 20, and 30 percent for slight, moderate, or severe recurrent subluxation or lateral instability of the knee. See 38 C.F.R. § 4.71a. Because the terms "slight," "moderate," and "severe" are not defined in the Rating Schedule, instead of applying a mechanical formula, the Board must evaluate all the evidence of record to ensure that its adjudication of an increased rating claim is equitable and just. See 38 C.F.R. § 4.6. The Board notes that these provisions were amended effective February 7, 2021, as of this date a 30 percent rating is assigned for recurrent subluxation or instability: Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation, a 20 percent rating is assigned for recurrent subluxation or instability with 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 (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation, a 10 percent rating is assigned for recurrent subluxation or instability with sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For patellar instability, 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, 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, and a 10 percent is assigned 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. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). In the November 2018 private exam, the examiner mentions “instability” twice: “His symptoms include weakness, swelling, instability, difficulty walking for an extended distance, climbing stairs, and sleep deprivation.” Elsewhere he says, “examination of the left knee shows moderate effusion, skin is intact, he has 20° loss of extension secondary to pain, flexion to 95°, very painful for him, varus or valgus instability at 30°.” When tested for left knee instability by the VA examiner in February 2020, the examiner found no history of subluxation or lateral instability in the left or right knee, and when he performed the joint stability testing, again found no instability. The VA examiner tested anterior, posterior, medial as well as lateral instability for both knees, and all results were normal. The examiner had the option to check none, slight, moderate, or severe for all findings, and checked none for all, to include varus and valgus testing in extension and 30 degrees of flexion. These tests were also previously performed during the October 2018 VA medical exam with the same negative results across the board for subluxation and lateral instability. The Board reviewed the 2002 to 2020 CAPRI records for instability findings. Those reflect that the Veteran’s local VA Medical Center (VAMC) in Dublin, Georgia performed lateral instability testing and reported negative results for varus and valgus instability. The record also contains a May 2015 VA contract knee examination that included instability testing. Medial and lateral instability testing were performed then as well with normal test results. This contract examination also tested and reported no lateral instability. A September 2008 VA examination also found the left knee to be stable. In cases such as this, where there are conflicting statements or opinions from medical professionals, it is within the Board’s province to weigh the probative value of those opinions. In Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the U.S. Court of Appeals for Veterans Claims (Court) stated: The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . .. As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . . So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Greater weight may be placed on one examiner’s opinion over another depending on factors such as reasoning employed by the examiners and whether, and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, the thoroughness and detail of a medical opinion are among the factors for assessing the probative value of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Even though the November 2018 private examiner uses the term “instability” twice in his report, it is unclear what stability testing was performed, no list of possible outcomes (mild, moderate or severe), nor factors considered. The private examiner uses the term as a descriptor alongside other descriptive terms in the same sentence. The Board finds all the medical reporters on subluxation and lateral stability competent. The VA examinations are more oriented towards gathering and assessing the information needed to make adjudicative decisions in line with VA regulations, and are greater in number and agree on there being no subluxation or instability historically or at the time of the examinations. Furthermore, aside from this one record, the record does not reflect the Veteran subjectively reported instability to treating providers throughout the course of the appeal. Considering all the medical opinions and lay reports of symptoms of record, the preponderance of the evidence is against the Veteran’s request for a separate lateral instability finding under the old or revised regulations. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's request for additional rating consideration. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Now moving on to the Veteran’s last remaining contention, the Board looks at the issue of an earlier increased rating date based on an earlier finding of limitation of extension that supports a 30 percent left knee disability rating. The Board agrees with the Veteran’s representative in this contention. The Veteran’s service-connected left knee disability has been assigned a 10 percent evaluation under DC 5010-5261 for degenerative arthritis for part of the appeal period and 30 percent for the rest. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. See 38 U.S.C. § 1115; 38 C.F.R. §§ 3.321(a), 4.1, 4.21. Disability evaluations are based upon the ability of the body, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. § 4.27. VA has a duty to acknowledge and to consider all regulations that are potentially applicable to issues raised in the record and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). 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, 4.21. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of the Veteran's disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 4.3 Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In determining the severity of a disability, the Board is required to consider the potential application of various other VA regulations, regardless of whether they were raised by the Veteran, as well as the entire history of the Veteran's disability. See 38 C.F.R. §§ 4.1, 4.2; see also Schafrath, 1 Vet. App. at 595. Separate evaluations may be assigned for separate periods of time, or staged, where factual findings show distinct time periods during which the Veteran's disability exhibits symptoms that warrant the application of different ratings. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). However, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. See 38 C.F.R. § 4.40. It is essential that the examination on which disability ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. See id. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the Veteran undertaking the motion. See id. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. See id. The evaluation of joint disabilities must involve the following factors: less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); weakened movement (due to muscle injury, disease, or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination and impaired ability to execute skilled movements smoothly; and pain on movement, swelling, deformity, or atrophy of disuse. See 38 C.F.R. § 4.45. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing must also be considered. See id. A rating based on painful motion of a joint may be appropriate regardless of whether the painful motion stemmed from joint or periarticular pathology. See Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011). Functional loss caused by pain must be rated as though it were caused by another factor, such as deformity, atrophy, adhesions, or any of the other factors cited above. See Schafrath, 1 Vet. App. at 592. In rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See id. Painful motion is an important factor of disability, and facial expressions such as wincing exhibited in the presence of pressure on or manipulation of the affected joints should be carefully noted and related to the affected joints. See 38 C.F.R. § 4.59. Painful, unstable, or malaligned joints due to healed injury are at the very least entitled to the minimum compensable rating for the affected joint. See id. Crepitation within the joint structures or the soft tissues, such as the tendons or ligaments, should be noted carefully as points of contact which are diseased, and flexion elicits such manifestations. See id. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. See id. When adjudicating disabilities evaluated based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 pertaining to functional impairment must be applied, and examinations must assess whether the disability at issue manifested weakened movement, excess fatigability, or incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). Such inquiry should not be limited to muscles or nerves, and, if feasible, these determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. See id. In order to constitute functional loss, pain must affect some aspect of the normal working movements of the body, such as excursion, strength, speed, coordination and endurance. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). Although pain may cause functional loss, pain itself does not constitute functional loss and is merely one factor to be considered when evaluating functional impairment. See id. However, 38 C.F.R. § 4.40 does not require a separate rating for pain, but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997). Once the evidence has been assembled in the record, it is the Board's responsibility to evaluate the evidence. See 38 U.S.C. § 7104(a). The Board shall consider all competent lay and medical evidence of record, analyze the credibility and probative value of the evidence, and provide reasons for rejecting any favorable material evidence. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In addressing lay evidence and determining its probative value, the Board must assess both its competency, a legal concept determining whether testimony may be heard and considered, and its credibility, a factual determination regarding its probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Diagnostic Codes (DC) 5256 through 5263 set forth the relevant provisions for disabilities of the knee. See 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27. DC 5260 governs the limitation of leg flexion and provides a zero percent rating for flexion limited to 60 degrees, 10 percent for flexion limited to 45 degrees, 20 percent for flexion limited to 30 degrees, and a maximum 30 percent rating for flexion limited to 15 degrees. See id. DC 5261 governs the limitation of leg extension and provides a zero percent rating for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and a maximum 50 percent rating for extension limited to 45 degrees. See id. DC 5010 provides that traumatic arthritis established by X-ray findings is rated as degenerative arthritis. DC 5003 provides that degenerative arthritis established by X-ray findings is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a 10 percent rating may be assigned for each such major joint or group of minor joints so affected. See 38 C.F.R. § 4.71a; DC 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, X-ray evidence of arthritis involving two or more major or minor joint groups will warrant a 10 percent rating, and two or more major or minor joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The 10 percent and 20 percent ratings based on X-ray findings may not be combined with ratings based on limitation of motion. See 38 C.F.R. § 4.71a, DC 5003, Note 1. The Board notes that the provisions concerning musculoskeletal diagnostic codes were amended effective February 7, 2021. These revisions did not alter Diagnostic codes 5256, 5258, 5259, 5260, or 5261. The assignment of a DC depends upon the facts of each case, and the Board is authorized to choose an appropriate DC that is supported by both the evidence of record and a sufficiently articulated rationale. See Butts v. Brown, 5 Vet. App. 532, 538-39 (1993). Moreover, service connection for a disability is not severed when the DC assigned to that disability is revised in order to more accurately reflect the Veteran's relevant medical history, diagnoses, and demonstrated symptomatology. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). The latest VA examination of February 2020 has the following findings: The Veteran states that he has constant bilateral knee pain, sharp, aching, severe, 7 to 8- 10 /10 where 10 is the worst pain. He states that he does not have flare ups of his left knee, his left knee pain is bad all the time. The Veteran states that due to his bilateral knee condition he has not been able to climb the stairs to the upstairs of his home in 5 years. Range of Motion (ROM) - The Service-connected left knee has abnormal range of motion: Flexion 22 to 85 and extension 85 to 22. Range of motion itself contributes to functional loss. The Veteran states that he is unable to climb up to 2 steps due to his knee conditions. There is objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions. There was additional loss of range of motion after three repetitions. For the left knee after three repetitions, flexion was 25 to 73 and extension was73 to 25. The Veteran does not have flare-ups. He has decreased range of motion of both knees. The Veteran states that he can climb up to 2 steps, unable to kneel, stand for up to 20 minutes, able to drive for up to 2 hours, unable to climb ladders and unable to ride a bike. Muscle strength of the right knee for flexion is 5/5; for Extension it is 4/5. The diagnosed conditions are not entirely responsible for the reduction in muscle strength. His back as well as his knees affect the strength of the Veteran's muscles when his knees are flexed and extended. His left knee strength is 4/5 for both flexion and extension. The Veteran does not have muscle atrophy nor ankylosis, nor a history of recurrent subluxation, or lateral instability. But he does have a history of recurrent effusion. The Veteran says he has swelling of both knees constantly. Joint stability testing was performed for both knees. Joint medial, posterior, anterior, and lateral stability were all normal. The Veteran does not have and has never had recurrent patellar dislocation, stress fractures, or chronic exertional compartment syndrome or any other tibial and or fibular impairment. The Veteran has not now, nor has he ever had a meniscus condition. The Veteran has no scars, surgical or otherwise, related to any conditions or to the treatment of any conditions listed in the diagnosis above. The Veteran uses assistive devices as a normal mode of locomotion; although, occasional locomotion by other methods may be possible. He uses both braces and a cane regularly. He uses the cane for his knee and back conditions and a brace for his left knee daily. Functioning is not so diminished that amputation with prosthesis would equally serve the Veteran. The functional impact of the Veteran's knee condition on employability is that he is unable to stand up for more than ten minutes. The Veteran states he works 4 hours per week as a minister. The Veteran states that he does not have flare ups of his knees, because his bilateral knee pain is bad all the time. Correia testing - 1. Is there evidence that the Veteran has joint pain when the joint is passively moved? “Yes. The Veteran states that he has pain in both knees when his knees are passively moved.” - 2. Is there evidence that the Veteran has joint pain when his joint is in a non-weight bearing status? “Yes. The Veteran states that he has pain in both knees when his knees are in a non-weight bearing status.” The VA examiner reports, “It is at least as likely as not that the Veteran's right knee is damaged as the Veteran has pain in both knees, and the patient has decreased range of motion of both knees. The Veteran has pain in both knees. The Veteran states that his left knee pain is worse than his right knee pain.” Looking at all the findings from the February 2020 VA exam, the compensable rating is for limitation of extension of the Veteran’s left knee. The Veteran is entitled to a 30 percent disability rating because his service-connected left knee extension is limited to 85 to 22 normally and was 73 to 25 after repetitive use. Because the Veteran’s service-connected left knee limitation of extension is 20 to 25 degree, it equates to a 30 percent disability rating. A higher rating is not warranted as extension is not limited to 30 degrees. A separate evaluation for flexion is not warranted as the Veteran had flexion to 85 degrees. Even after repetitive testing, flexion was noted to be to 73 degrees. This exceeds flexion limited to 45 degrees needed to warrant a separate compensable evaluation. The Veteran contends that he is entitled to an earlier date for his 30 percent limitation of extension rating, because the November 26, 2018 private examination record has similar qualifying results and predates the February 18, 2020 VA examination. The Board agrees. The private medical examination reported the Veteran already had 20 degrees loss of extension secondary to pain on November 26, 2018. Therefore, based on DC 5261, the Board finds the Veteran is entitled to an earlier 30 percent left knee disability rating based on limitation of extension from November 26, 2018. A separate evaluation for flexion is not warranted as the November 2018 private examination also reflected flexion of 95 degrees, exceeding the 45 degrees needed to assign a separate compensable evaluation. Other VA and private treatment records prior to November 26, 2018 do not reflect extension limited to 20 degrees or flexion limited to 45 degrees. In fact, records during this time do not demonstrate extension limited to 15 degrees. As such, the Board finds that the November 26, 2018 date is the earliest date for the grant of 30 percent for extension. The Board has also considered whether a separate or increased rating may be assigned under other diagnostic codes but finds that there is no competent medical evidence to assign evaluations in excess of the rating already assigned for the period of appeal. Specifically, in the VA examination and treatment records, there is no evidence of ankylosis, involvement of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum that would support a separate or increased evaluation under the criteria set forth in Diagnostic Codes 5256 (ankylosis), 5258 (dislocated semilunar cartilage), 5259 (removal of semilunar cartilage), 5262 (malunion or nonunion of the tibia and fibula), and 5263 (genu recurvatum). As such, further separate evaluations are not warranted at this time. . H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Black, 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.