Citation Nr: 21021387 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 10-43 076 DATE: April 12, 2021 ORDER Entitlement to service connection for costochondritis, claimed as chest pain, is granted. Entitlement to a disability rating in excess of 30 percent for a left knee total knee replacement from September 1, 2017 is denied. Entitlement to a separate 10 percent disability rating prior to July 18, 2016, based on instability of the left knee, is granted. Entitlement to a disability rating in excess of 10 percent prior to July 18, 2016 for chronic left knee strain with degenerative joint disease is denied. FINDINGS OF FACT 1. The Veteran has a current diagnosis of costochondritis which began during active duty service. 2. Effective September 1, 2017, the Veteran’s residuals of a total left knee replacement have included intermittent degrees of pain, weakness, or limitation of motion but not severe painful motion or weakness, extension limited to 30 degrees or more, ankylosis, or tibial or fibular impairment. 3. Prior to July 18, 2016, the Veteran’s left knee strain resulted in slight instability of the left knee . 4. Prior to July 18, 2016, the Veteran’s chronic left knee strain with degenerative joint disease was characterized by flexion limited to no less than 90 degrees and extension to 0 degrees, with pain reported on motion but without additional functional loss due to pain, weakness, fatigability, and incoordination during flare-ups. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for costochondritis, claimed as chest pain, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to a disability rating in excess of 30 percent for a left knee total knee replacement from September 1, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40-45, 4.71a, Diagnostic Codes 5055, 5256-63 (2020); 4.71a, Diagnostic Codes 5055, 5256-63 (2021). 3. The criteria for entitlement to a separate disability rating of 10 percent and no higher prior to July 18, 2016, based on instability of the left knee, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40-45, 4.71a, Diagnostic Code 5257 (2020). 4. The criteria for entitlement to a disability rating in excess of 10 percent prior to July 18, 2016 for chronic left knee strain with degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40-45, 4.71a, Diagnostic Codes 5256-63 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1981 to August 1981, May 1990 to February 1996, October 2004 to October 2006, November 2007 to May 2008, and August 2010 to November 2011. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2009 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). This case was previously before the Board in August 2017, January 2019, and August 2020. In August 2017, the Board denied the Veteran’s claims for a disability rating in excess of 10 percent prior to July 18, 2016, for his left knee osteoarthritis and denied service connection for the Veteran’s costochondritis. The Veteran timely filed an appeal with the Court of Appeals for Veterans Claims (Court). In June 2018, the Court granted a Joint Motion for Remand (JMR), vacating the Board’s August 2017 decision and remanding the case for further adjudication. In January 2019, the Board denied the Veteran’s claim for a disability rating in excess of 10 percent prior to July 18, 2016, for his left knee osteoarthritis; the Board did not also consider a disability rating in excess of 30 percent for his left total knee replacement residuals. The Board remanded the claim for service connection for costochondritis, seeking additional treatment records, a new VA examination, and, if appropriate, issuance of a Supplemental Statement of the Case (SSOC). The Veteran timely appealed the decision to the Court. In April 2020, the Veteran’s representative and a representative from VA’s Office of General Counsel (OGC) agreed to a Joint Motion for Partial Remand (JMPR), specifically finding that the issue of a 30 percent disability rating for a left total knee replacement from September 1, 2017, and thereafter, was before the Board at the time of the January 2019 decision; the Court also determined that the Board was to specifically consider whether the Veteran’s left knee warranted a separately compensable rating, due to instability, prior to July 18, 2016. These issues were subsequently remanded to the RO in August 2020. The case has been returned to the Board for appellate consideration. 1. Entitlement to service connection for costochondritis, claimed as chest pain The Veteran seeks service connection for costochondritis, claimed as chest pain. He asserts this disability began during active duty service, and service connection is therefore warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Considering first the service treatment records, these reflect the first complaints of chest pain dating to March 1995, when he was seen for a cough and headaches. He also reported chest pain with coughing. An upper respiratory infection was diagnosed. A June 2005 clinical record noted that the Veteran sought treatment for atypical chest pain. The VA examiner reported that the Veteran had been diagnosed with costochondritis for which he was prescribed NSAID medication. Also, in June 2005, a medical care provider noted that the Veteran had recurrent costochondritis. In August 2005, the Veteran again reported chest pain, and costochondritis (Tietze’s syndrome) was diagnosed. He was provided medication. On periodic examination in November 2005, a past medical history of costochondritis was noted. In September 2006, the Veteran was noted to have costochondritis (Tietze’s syndrome). On several occasions between November 2007 and May 2008, the Veteran complained of rib and chest pain. He was prescribed pain medication. Finally, according to a January 2012 periodic examination, costochondritis (Tietze’s syndrome) was again noted as an ongoing problem. The Veteran first filed a service connection claim for costochondritis in June 2008. The Board recognizes that the Court has held that the presence of a chronic disability at any time during or immediately preceding the claims process can justify a grant of service connection, even where the most recent diagnosis is negative. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (holding the current disability requirement may be satisfied by evidence of the disability shortly before the claim is filed). In the present case, while VA examinations in December 2008, May 2017, and December 2020 found no current evidence sufficient to establish diagnoses of costochondritis and/or Tietze’s syndrome, the January 2012 periodic examination shortly after the Veteran’s final separation from active duty service in November 2011 noted costochondritis as an ongoing problem. Additionally, the Veteran has reported intermittent episodes of chest pain. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As a layperson, he is competent to report such symptomatology. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Thus, after consideration of the entire record and affording the Veteran the full benefit of the doubt, the Board concludes service connection for costochondritis is warranted. Increased Rating Disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In adjudicating increased rating claims, the level of disability in all periods since the effective date of the grant of service connection must be taken into account, to include the possibility that a staged rating may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, the Board will consider whether staged ratings are appropriate to the pending appeals. In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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. 38 C.F.R. § 4.7. With any form of arthritis or other orthopedic disorders, painful motion is an important factor of disability. Joints that are actually painful, unstable, or misaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59; see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). While pain alone does not constitute functional loss, the Court has clearly indicated that the Board must consider the effects of pain, particularly as to any adverse impact on the normal working movements of the body. Mitchell, 25 Vet. App at 44 (noting that although “pain itself does not rise to the level of functional loss,” pain which “affects some aspect of ‘the normal working movements of the body’ such as ‘excursion, strength, speed, coordination, and endurance,’“ may constitute functional loss). Additionally, the Board must consider pain on both active and passive motion of the affected joint, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158 (2016). 2. Entitlement to a disability rating in excess of 30 percent for a left knee total knee replacement from September 1, 2017 The Veteran seeks a disability rating in excess of 30 percent for his residuals of a total knee replacement. He asserts this disability has increased in service, and an increased initial rating is therefore warranted. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, total knee replacement was rated under Diagnostic Code (DC) 5055. Pursuant to this Code, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent, and 60 percent is the maximum schedular rating for this code. 38 C.F.R. § 4.71a, DC 5055 (2019). In the present case, the Veteran was awarded a 100 percent rating from July 18, 2016, to September 1, 2017, a period of more than one year. Thereafter, he was awarded a 30 percent rating under DC 5055. As of February 7, 2021, under the amended criteria, the minimum convalescence period is reduced to four months. As the Veteran has already been granted the prior convalescence period of one year, the prior criteria, which are more favorable to the Veteran, have already been applied. Upon the end of the convalescence period, the amended criteria specify a minimum evaluation of 30 percent, provided a total knee replacement was afforded; if the knee joint was merely resurfaced, no minimum evaluation applies. The remainder of the criteria are unchanged. 38 C.F.R. § 4.71a , DC 5055 (2021). Regarding the rating criteria for evaluation of the knee, knee disabilities were previously rated, in most cases, based on limitation of motion of the knee joint. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the knee is evaluated under DC 5260 and 5261. Under DC 5260, a noncompensable rating is assigned for limitation of flexion to 60 degrees, a 10 percent rating is assigned for flexion limited to 45 degrees, a 20 percent rating is assigned for flexion limited to 30 degrees, and a 30 percent rating is assigned for flexion limited to 15 degrees. Pursuant to DC 5261, a noncompensable rating is assigned for limitation of extension to 5 degrees, a 10 percent rating will be assigned for extension of the knee limited to 10 degrees, a 20 percent rating is assigned for extension limited to 15 degrees, a 30 percent rating for limitation to 20 degrees, and a 40 percent rating for limitation to 30 degrees. 38 C.F.R. § 4.71a , Diagnostic Codes 5260, 5261. These criteria were not changed. In adjudicating knee disabilities, the Board must also considered VA General Counsel Opinion (VAOPGCPREC) 23-97, which interprets that in certain cases where the Veteran has both limitation of motion due to arthritis, instability, and/or meniscal impairment of the affected knee joint, a separate compensable rating may be assigned without violating 38 C.F.R. § 4.14, the regulation against pyramiding. See VAOPGCPREC 9-98. The Board next notes that on September 17, 2004, the VA General Counsel issued VAOPGCPREC 9-2004, which interprets that a Veteran can receive separate ratings under DC 5260 (limitation of flexion), and DC 5261 (limitation of extension) for disability of the same joint if both extension and flexion of the knee are impaired to a compensable degree. VAOPGCPREC 9-2004 (2004). Instability of the knee is rated under DC 5257, for other impairment of the knee characterized by recurrent subluxation or lateral instability. This Code provides a 10 percent rating for slight impairment, 20 percent for moderate impairment, and a maximum schedular rating for severe impairment. 38 C.F.R. § 4.71a , DC 5257 (2019). According to MERRIAN WEBSTER’S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “slight” means small in amount. “Moderate” means limited in scope or effect. “Severe” means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under DC 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). DC 5257 was modified as part of the revised schedular criteria for orthopedic disabilities. The new version of DC 5257 provides for evaluation of the knee based on either recurrent subluxation or instability, or based on patellar instability. For recurrent subluxation or lateral instability, a 30 percent rating is warranted for 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 warranted 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 (e.g., cane(s), crutch(es), walker) for ambulation, or; (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. Finally, a 10 percent rating is warranted for a 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. 38 U.S.C. § 4.71a, DC 5257 (2021). For patellar instability, a 30 percent rating is warranted 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 disability rating is warranted 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. Finally, a 10 percent rating is warranted 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) provides that, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) provides that 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). 38 U.S.C. § 4.71a, DC 5257 (2021). The prior version of DC 5265, for impairment of the tibia and fibula, provides a 10 percent rating for slight knee or ankle disability due to malunion. Moderate impairment warrants a 20 percent rating, and a 30 percent rating is assigned for marked impairment. With nonunion, and associated loose motion requiring a brace, a 40 percent disability rating is warranted. 38 C.F.R. § 4.71a, DC 5262 (2019). The revised version of DC 5262 provides a noncompensable rating for treatment of less than 12 consecutive months involving one or both lower extremities. Impairment of the tibia and fibula resulting in medial tibial stress syndrome (MTSS) or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities, warrants a 10 percent rating. Treatment requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, involving one lower extremity, warrants a 20 percent rating. Impairment requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, involving both lower extremities, warrants a 30 percent rating. With nonunion, and associated loose motion requiring a brace, a 40 percent disability rating is warranted. The revised code also provides, however, that malunion may be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. 38 C.F.R. § 4.71a, DC 5262 (2021). As noted above, the Veteran has been granted a 30 percent rating effective September 1, 2017, following the expiration of his temporary total rating for convalescence. After considering the totality of the record for this period, the Board finds the preponderance of the evidence to be against a disability rating in excess of 30 percent for this period. Prior to this period but subsequent to the July 2016 total knee replacement, the Veteran was afforded a VA orthopedic examination. Current symptoms included continuing pain of the left knee, with an inability to ambulate for longer than 20-25 minutes. He was also unable to kneel or bend, by his report. On objective examination, range of motion testing indicated flexion to 115 degrees and extension to 0 degrees. Pain was reported with motion, but did not result in additional functional loss, and no additional pain was reported with weight-bearing or on passive range of motion. Localized tenderness on palpation and crepitus were also present. No additional limitation of motion was present with repetitive motion, or due to such factors as fatiguability, incoordination, or weakness. Muscle strength was 5/5 on both extension and flexion. No ankylosis or effusion was present. Joint stability testing was negative for lateral instability or recurrent subluxation. The Veteran did not use any assistance devices to aid mobility. Most recently, the Veteran was afforded a VA examination in December 2020. Reported symptoms included pain and weakness in the knee. On range of motion testing, extension was to 0 degrees and flexion was to 110 degrees. No pain was reported with motion, and crepitus was absent. Repetitive motion did not result in additional limitation of motion. No additional limitation of motion resulted from pain, fatigue, weakness, lack of endurance, or incoordination. With repeated use over time, however, the examiner determined flexion would be reduced to 105 degrees. The examiner further found that during a flare-up, flexion would be further limited to 90 degrees. Muscle strength was 4/5 on both flexion and extension, and no muscle atrophy was present. Joint stability testing was negative for lateral instability or recurrent subluxation. The Veteran did not use any assistance devices to aid mobility. After considering the totality of the record, the Board finds the preponderance of the evidence is against a disability rating in excess of 30 percent for the Veteran’s residuals of a total knee replacement of the left knee effective September 1, 2017. The pertinent evidence does not demonstrate chronic residuals consisting of severe painful motion or weakness in the affected extremity. While the Veteran has reported pain and weakness of the left knee joint, his muscle strength has been 4/5 or better in the left lower extremity, and he has been able to walk on his own without use of an assistance device, according to the most recent examination reports. In the absence of more severe chronic residuals, the next higher disability rating of 60 percent under DC 5055 is not warranted. For this period, the Veteran has consistently maintained normal extension to 0 degrees, which is significantly greater than the limitation to 30 degrees or more for a rating in excess of 30 percent under DC 5261. Flexion has also been greater than 60 degrees, and thus a higher rating would also not be warranted under DC 5260. Next, there is no evidence of ankylosis or tibial or fibular impairment in VA examinations or treatment records to warrant ratings under DC 5256 or 5262. The Veteran is competent to provide evidence of symptoms observed by his senses, such as pain and swelling. However, he is not competent to measure range of motion or instability as this requires specialized testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Finally, while VA examination reports confirm a scar on the Veteran’s left knee, a separate 10 percent rating has already been assigned for this scar, and entitlement to a higher evaluation for this scar is not before the Board. All possibly applicable diagnostic codes have been considered in compliance with Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991), but the Veteran could not receive a higher disability rating under other schedular criteria, either old or new, for his knee based on the evidence. See 38 C.F.R. § 4.71a. The knee symptoms were generally consistent during the period on appeal such that staged ratings are not appropriate. See Hart, 21 Vet. App. at 509-10. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent for total right knee replacement effective September 1, 2017. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 ; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a separate disability rating prior to July 18, 2016, based on instability of the left knee 4. Entitlement to a disability rating in excess of 10 percent prior to July 18, 2016 for a chronic left knee strain with degenerative joint disease The Veteran seeks a disability rating in excess of 10 percent prior to July 18, 2016, for his chronic left knee strain. He also seeks a separate rating based on instability of the knee for the same period. He asserts this disability resulted in a greater degree of impairment during this time period, and an increased rating is therefore warranted. The criteria for the evaluation of knee disabilities have already been noted above. The Board further notes, as discussed above, the criteria for the evaluation of orthopedic disabilities were changed effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). Because, however, these changes are effective subsequent to the dates at issue, the revised criteria do not apply to these pending issues. At present, the Veteran has been awarded, effective February 25, 2000, to July 18, 2016, a 10 percent rating pursuant to DC 5257-5010 for a chronic left knee strain with degenerative joint disease. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. He has also been awarded a separate 10 percent rating, effective June 1, 2008, to July 18, 2016, under DC 5259 for symptomatic residuals of the semilunar cartilage of the left knee. This award represents the maximum schedular rating under this DC. For the period prior to July 18, 2016, the Veteran was afforded both private and VA medical treatment. The records of this treatment have been obtained by VA and reviewed by the Board. In June 2008 the Veteran underwent an MRI scan of his left knee by a private clinician. The examiner provided diagnostic impressions of a medial meniscus tear with advancing chondromalacic changes and intact ligaments. A July 2008 clinical treatment record from U.C. Hospital reported that the Veteran sought treatment for left knee pain. The examiner considered the Veteran’s history of his condition and lay statements and provided a physical examination. The examiner noted the results of the MRI including the meniscal tear and observed left knee range of motion was to 110 degrees of flexion; the ligaments were intact; and the patella tracked well. The examiner reported that the Veteran was positive for McMurray’s test of the left knee and his neurovascular functioning was intact distally. As an assessment, the examiner stated that the Veteran had a meniscal tear of the left knee. Also, in light of the fact that the Veteran experienced no relief from a series of prior Hyalogen injection, arthritic debridement was recommended. A concurrent July 2008 diagnostic radiology report found advanced 3 compartment osteoarthritis with joint space narrowing, marginal osteophytes as well as chondrocalcinosis; no fractures; small joint effusion; and diffusely osteopenic bones. In an August 2008 operative report from U.C. Hospital, a private examiner reported that the Veteran underwent a debridement procedure of the left knee in the patellofemoral and tibiofemoral compartments. The examiner described the procedure in detail and that the Veteran appeared to do well. August 2008 clinical notes from U.C. Hospital opined as to the status of the Veteran post-left knee arthroscopy with severe tricompartmental arthritis which was performed in August 2008. On physical examination, the 3 port sites were clean, dry, and intact, with medial and lateral portals still with their Steri-Strips. Range of motion was to 115 degrees of flexion; the ligaments were stable; and the patella tracked well. The Veteran was neurovascularly intact distally. The examiner reported that he debrided large cartilage flaps from the patellofemoral as well as the tibiofemoral compartments. The examiner also noted that he informed the Veteran that this procedure was a temporizing measure and the Veteran wished to put off discussion of left knee replacement. In December 2008, the Veteran was afforded a VA examination. The examiner considered the Veteran’s history and lay statements concerning his left knee condition. The examiner noted that the Veteran reported a long history of left knee problems and had 4 surgeries. The examiner noted that the exact surgical details were not available other than the fact that there were all arthroscopic. The Veteran stated that each surgery provided relief for a period of time but did not relieve his discomfort altogether. He also stated that he had received steroid injections. The Veteran reported that his left knee affected and limited his daily activities, namely an inability to run or play basketball. The Veteran stated that he had lost many workdays due to left knee treatments, and, moreover, was unable to seek gainful employment while he was recovering from his left knee surgery. The examiner noted that the Veteran reported that he was able to walk 5 hours and sit and stand for 5 hours. Other limitations, according to the Veteran, included popping, cracking and his left knee giving out once or twice. Upon physical examination, the examiner noted that there were 4 scars from a well-healed non-tender recent surgery; the scars covered less than one percent total skin and zero percent exposed skin. The left knee joint was stable, without laxity or deformity. Both Lachman and McMurray’s tests were negative. There also was neither joint line tenderness nor effusion. Valgus and Varus stress testing caused the Veteran no discomfort. The popliteal fossa was unremarkable; the Veteran did not have crepitus present in left knee movement. The range of motion compared to the right side was completely normal, to 135 degrees-even after repetition. The examiner found the neurovascular examination results to be satisfactory. He also opined that the left knee was negative as to additional loss of function due to fatigue or incoordination. There were no areas of hyper- or hypoesthesia. Deep tendon reflexes were equal on both sides; there were no assistive devices required; and the Veteran experienced no pain on range of motion testing or on palpation. X-rays of the left knee revealed neither fracture nor dislocation. However, moderate to severe degenerative changes with mild to moderate narrowing of the joint space were present. There were moderate to severe degenerative changes of the patellofemoral articulation with joint space narrowing, and some evidence of chondrocalcinosis. There was no joint effusion. The x-ray report provided a diagnostic impression of moderate diffuse degenerative change. At the November 2009 Phoenix RO hearing, the Veteran’s representative asserted that there had never been a review as far as surgery goes for the Veteran’s right knee. He also stated that VA provisions provide for convalescence compensation because of surgery and the issue had not been addressed, noting that the convalescence compensation available was 100 percent. The Boards notes that 38 C.F.R. § 4.30 provides for 100 percent disability for convalescence only when “it is established by report at hospital discharge (regular discharge or release to non-bed care) or outpatient release” in 3 situations, none of which apply to the Veteran when considered in light of Dr. E.’s letter of July 2008. 38 C.F.R. § 4.30 is available when there is “(1) surgery [that] necessitates at least one month of convalescence; (2) surgery with severe post-operative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheel chair; and (3) immobilization by cast, without surgery, of one joint or more.” 38 C.F.R. § 4.30. As noted above. Dr. E. anticipated full recovery after the procedure and noted that the approximate length of care from surgery to full recovery would be 5 days. The Board notes that August 2008 clinical notes from U.C. Hospital reported that the Veteran had a range of motion to 115 degrees of flexion, stable ligaments, and a well-tracking patella, and was neurovascularly intact distally upon examination after the arthroscopic left knee procedure. This evidence of record makes it clear that the provisions set out in 38 C.F.R. § 4.30 do not apply at present. Another VA examination was afforded the Veteran in December 2015. The claims file was reviewed in conjunction with the examination. The examiner noted that the Veteran had multiple meniscectomies with residual scars and that there was a progression of a former diagnosis of left knee strain and degenerative joint disease. Upon physical examination, range of motion testing indicated flexion was to 105 degrees and extension was to 0 degrees, both results were indicated to be abnormal or outside of the normal range. The examiner opined that these range of motion findings did contribute to functional loss, noting that the Veteran experienced pain with both flexion and extension. In addition, the examiner reported objective evidence of localized tenderness and pain on palpation of the joint and its associated soft tissue, noting mild pain over the medial joint line. The examiner also reported that there was objective evidence of crepitus. The examiner further opined that pain, weakness, fatigability or incoordination significantly did not limit the Veteran’s functional ability over a period of time. No response was provided concerning flare-ups. Muscle strength testing showed results of 5/5 on forward flexion and 4/5 extension. There were neither signs of muscle atrophy nor ankylosis. Joint stability testing revealed that there was no history of recurrent subluxation and no history of lateral instability. The examiner reported that there was mild medial effusion. The Lachman test for anterior stability was normal; the posterior drawer test for posterior instability was normal; the medial instability test was normal; and the lateral instability test was normal. Pain and limited range of motion were noted as residuals of prior meniscectomy. The examiner noted that the Veteran did not have recurrent patellar dislocation, shin splints, stress fractures, or chronic exertional compartment syndrome of any other tibial and/or fibular impairment. The Veteran occasionally used a brace to assist in normal locomotion. Imaging studies revealed that there was mild to moderate medial compartmental narrowing. There were also moderate-sized tricompartmental osteophytes, but no joint effusion. Most recently, the Veteran was afforded a December 2020 VA examination of his left knee. While this examination was outside of the time period at issue, the examiner was requested by the Board in its August 2020 remand order to provide a retrospective opinion regarding the Veteran’s left knee disability and resulting impairment prior to July 18, 2016. After examination of the Veteran and review of the claims file, the VA examiner opined that the Veteran’s left knee disability prior to July 18, 2016 was similar to his current level of impairment for the left knee. The examiner found similar ranges of motion, with extension to 0 degrees and flexion greater than 90 degrees, and pain levels both then and now. The examiner further noted that the Veteran reported much less mobility and greater dependency on pain medication and outside help prior to his 2016 total knee replacement. In a February 2019 rating decision, as noted above, the Veteran was granted a separate disability rating of 10 percent for symptomatic residuals of impairment of the semilunar cartilage of the left knee. This award was made pursuant to DC 5259, and was effective from June 1, 2008, to July 18, 2016. A 10 percent rating is the maximum schedular rating under DC 5259. The Veteran and his representative seek a separate rating under DC 5257. As noted above, objective medical evidence is not required to establish lateral knee instability under DC 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Considering first entitlement to an increased rating based on limitation of motion of the left knee, the Board finds a disability rating in excess of 10 percent prior to July 18, 2016 is not warranted on that basis. Specifically, during the various VA examinations, the Veteran demonstrated normal extension to 0 degrees and flexion limited to no less than 85 degrees, which does not warrant an increased rating under DCs 5260 or 5261. The other medical evidence of record also does not contain any information or evidence regarding the severity of the Veteran’s knee range of motion which would warrant a higher rating. The Board acknowledges the Veteran’s lay reports of crepitus and flare-ups of pain that occur with activities, such as standing, walking, bending, squatting, prolonged sitting, and using stairs. Nevertheless, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran’s statements would not result in his flexion being limited to or more nearly approximating 30 degrees, to warrant the assignment of a rating higher than 10 percent under Diagnostic Code 5260, or his extension being limited to or more nearly approximating 10 degrees, to warrant the assignment of a separate 10 percent rating under Diagnostic Code 5261. Indeed, the Veteran has not otherwise described or reported that his flare-ups are of the severity or frequency to result in an additional loss of flexion to a compensable degree or an inability to completely straighten (extend) his knee during flare-ups and, in this regard, the Board finds probative that repetitive use testing did not result in any additional loss in motion to a compensable degree. Therefore, even when considering pain, weakened movement, excess fatigability, and incoordination, including during flare-ups, the Board finds the preponderance of the evidence is against the grant of a rating in excess of 10 percent prior to July 18, 2016, based upon limitation of flexion or the assignment of a separate, compensable rating based upon limitation of extension. Pain alone does not constitute functional loss, and the Veteran has already been granted a compensable rating based on his reported pain with motion. See Mitchell, 25 Vet. App. at 36, 44. Moreover, because his reported pain is already considered as part of the symptoms requirement of DC 5259, entitlement to a separate rating for painful motion under DCs 5260-61 is also not warranted. Considering next lateral instability and recurrent subluxation, the Veteran has reported his knee “giving out” on occasion. Specifically, he told a VA examiner in December 2008 that the left knee gave out “once or twice” but he was otherwise able to stand and walk on the knee for extended periods. On private examination in 2008, a McMurray’s test of the left knee was positive. On VA examination in December 2015, he reported using a brace on occasion as well. He also reported instability during this examination. Based on the Veteran’s lay statements and in light of 38 C.F.R. § 4.3, and 4.7, the Board finds a separate rating of 10 percent and no higher, based on slight lateral instability of the left knee, is warranted prior to July 18, 2016. The Board further finds a disability rating in excess of 10 percent under DC 5257 is not warranted for this period, as the preponderance of the evidence is against a finding of moderate impairment of the left knee due to lateral instability and recurrent subluxation. The Veteran’s lay testimony established only slight impairment during this period due to instability and subluxation, but otherwise suggested a high degree of functionality. Additionally, the objective medical evidence of record established that, prior to July 18, 2016, the Veteran’s left knee has been generally stable, without laxity or deformity, and with intact ligaments of the left knee. The left knee has more recently displayed negative Lachman and McMurray’s tests, along with valgus and varus stress testing within normal limits. The most recent VA examination in December 2015 indicated Lachman, posterior drawer, medial, and lateral instability tests were all normal. Overall, the preponderance of the evidence is against a finding of moderate impairment due to lateral instability and recurrent subluxation, and a 20 percent disability rating under DC 5257 is therefore not warranted. The Board has considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). There is no lay or medical evidence showing the Veteran’s knee disability has been manifested by ankylosis, impairment of the tibia or fibula, or genu recurvatum at any time during the appeal period. Therefore, DCs 5256, 5262, and 5263 are not applicable in this case. DC 5258 provides a 20 percent rating for dislocation of the semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the knee joint. As discussed above, the Veteran has reported pain, clicking, and grinding of the left knee, but no frequent locking episodes. As such, a higher evaluation under DC 5258 is also not warranted. Additionally, while the Veteran has scars of the knee resulting from his various meniscal repairs, he has already been granted a separate disability rating for that disability, and that issue is not currently on appeal before the Board. Thus, it will not be considered at this time. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a disability rating in excess of 10 percent for his chronic left knee strain with degenerative joint disease at any time during the pendency of the appeal prior to July 18, 2016. The evidence does, however, support a separate compensable rating of 10 percent and no higher prior to July 18, 2016, for lateral instability and recurrent subluxation resulting from this same disability. In denying disability ratings in excess of those already awarded, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. B. G. LeMoine Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Thomas D. Jones, 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.