Citation Nr: 21021493 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 15-11 072 DATE: April 13, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for right knee instability is denied. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s right knee instability is not shown to be productive of manifestations meeting or approximating moderate impairment. 2. The Veteran does not have a sprain or a ligament tear, either incomplete or complete, in the right knee, and has not required surgical repair of a patellofemoral complex. 3. The Veteran is separately rated for limitation of right knee motion. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent for right knee instability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from June 1975 to June 1978, and from March 1979 to August 1984. This case originally came before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which decreased the disability rating for right knee instability to noncompensable, effective July 31, 2014. In August 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) by videoconference. A transcript has been associated with the claims file. The claim was last before the Board in February 2019, at which time the Board, in part, restored the 10 percent rating, effective July 31, 2014, and remanded the increased rating claim for right knee instability. The Board notes that total disability due to individual unemployability due to service-connected disabilities (TDIU) has been granted, effective February 17, 2010, which is beyond the extent of the appeal period at issue here. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion (ROM) testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, supra. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a disability rating in excess of 10 percent for right knee instability The Veteran contends that a higher rating is warranted for his right knee instability. See April 2015 VA Form 9. In this case, the Veteran’s right knee instability is evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, DC 5257. The Board notes that he is also service-connected for right knee degenerative joint disease (DJD) with limitation of motion with a 10 percent rating under DC 5260-5010. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including DC 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021, the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, DC 5257 addresses recurrent subluxation or lateral instability of the knee. Under that code, a 30 percent rating is warranted where subluxation or lateral instability is severe. A 20 percent rating is warranted where subluxation or lateral instability is moderate. A 10 percent rating is warranted where subluxation or lateral instability is slight. The Board observes that the terms “unstable” and “instability” are general and can have many meanings depending on context, including instability in the normal plane of motion of the joint (weakness, giving way). Ratings based on limitation of motion, including weakness, incoordination, fatigue, etc., reasonably contemplate this type of instability. “Lateral” instability is a specific type of instability that is demonstrated by clinical testing, such as varus and valgus stress, Lachman, Drawer, and McMurray, and which under VA law is not contemplated in a rating based on limited motion. Additionally, the Board notes that words such as “slight,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. As of February 7, 2021, DC 5257 contains two sections for rating other impairment of the knee. The first is for recurrent subluxation or instability and the second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. “Persistent” is defined as “continuing or inclined to persist in a course” with “continuing” defined as “constant” and “persist” defined as “to continue to exist.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). Under the current criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes 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 with either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for 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 or bracing for ambulation. Lastly, regarding patellar instability, 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 warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. 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 warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). 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). Id., Note (2). Separate disability ratings are possible for limitation of knee motion and instability of a knee under DC 5257. See VAOPGCPREC 23-97 (July 1, 1997). When x-ray findings of arthritis are present and a veteran’s knee disability is rated under DC 5257, the veteran would be entitled to a separate compensable rating under DC 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98 (August 14, 1980; see also Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Prior to February 7, 2021, DC 5010 for arthritis due to trauma substantiated by x-ray findings instructs to rate the disability as degenerative arthritis. DC 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when there is some limitation of motion of the specific joint or joints involved that is noncompensable under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. A 20 percent rating is authorized if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. Any limitation of motion must be confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. For these purposes, VA regulations consider the knees to be major joints. 38 C.F.R. § 4.45(f). However, as of February 7, 2021, DC 5010 rates post-traumatic arthritis based on limitation of motion, dislocation, or other specified instability under the affected joint. If there are two or more joints affected, each rating is to be combined in accordance with 38 C.F.R. § 4.25. DC 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 15 degrees is rated 30 percent, flexion of the leg limited to 30 degrees is rated 20 percent, flexion of the leg limited to 45 degrees is rated 10 percent, and flexion of the leg limited to 60 degrees is rated as noncompensable. Under DC 5261 for limitation of extension of the knee, a 50 percent rating is warranted where extension is limited to 45 degrees, a 40 percent rating is warranted where extension is limited to 30 degrees, a 30 percent rating is warranted where extension is limited to 20 degrees, a 20 percent rating is warranted where extension is limited to 15 degrees, a 10 percent rating is warranted where extension is limited to 10 degrees, and a noncompensable rating is warranted where extension is limited to 5 degrees. Separate ratings under DC 5260 and DC 5261 may be assigned for limitation of flexion and limitation of extension of the same knee joint. See VAOPGCPREC 9-2004 (September 17, 2004). Normal ROMs of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. DC 5258 rates on the basis of dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. A 20 percent rating is the only rating available under that code. DC 5259 rates on the basis of symptomatic removal of the semilunar cartilage. A 10 percent rating is the only rating available under that code. Evidence Turning to the evidence, VA treatment records reflect that September 2000 magnetic resonance imaging (MRI) of the right knee revealed small joint effusion but was otherwise unremarkable with an articular cartilage that appeared intact. A November 2012 VA examination report reflects a diagnosis of mild bilateral DJD. The Veteran complained of pain, and wore a brace. He reported flare-ups described as worsening knee pain when it was cold or when he walked or stood for more than 10 to 15 minutes; he would need to stop and sit down to rest for about 15 minutes before continuing. ROM testing revealed flexion to 70 degrees and extension to 0 degrees with no objective evidence of painful motion in either direction. The Veteran did not have additional limitation in ROM following repetitive-use testing. He had no tenderness or pain to palpation, and had normal strength with both flexion and extension. Joint stability tests were all normal. There was no evidence or history of recurrent patellar subluxation or dislocation, tibial and/or fibular impairment, or a meniscal condition. He did not have any knee surgery or total knee replacement. He regularly used a brace and cane. A July 2013 VA physical therapy consultation reflects constant aching in the right knee that was sometimes sharp. The Veteran reported buckling of the knee and weakness of the lower extremity, but denied any falls and locking. He used a cane and wore a right knee brace. On examination, his right knee had no swelling, edema, redness, or effusion. Although ROM testing was done, his right knee was not tested. Valgus/varus stress test to assess for medial collateral ligament and lateral collateral ligament instability, anterior draw test to assess for anterior cruciate ligament instability, and posterior draw test to assess for posterior cruciate ligament instability were all negative bilaterally. He had an antalgic gait with a cane. He was assessed with bilateral chondromalacia patella and generalized osteoarthritis, as well as balance and gait impairment. At an August 2013 Decision Review Officer hearing, the Veteran testified that he saw a doctor around August 1, 2013, who recommended wearing a brace on both knees, as well as physical therapy. The Veteran stated that the right knee brace helped with his stability. Although the VA examiner found that the Veteran did not have any right knee instability, the Veteran contended that his instability was caused by the absence of cartilage in his knee such that it was difficult to walk comfortably or even sleep at night. July 2014 and August 2014 VA treatment records reflect active ROM testing with flexion to 95 degrees and extension to 0 degrees. A March 2015 VA examination report reflects review of the Veteran’s claims file and a diagnosis of right knee strain. The Veteran reported that in 2012 his knee was “bad” with pain, bending, walking, and some giving way. He was currently able to walk, but had to stop more frequently. He reported throbbing right knee pain that only improved with rest. He required a cane for balance. He stated that his right knee would likely give way with lifting. ROM testing revealed flexion to 100 degrees and extension to 0 degrees with pain causing functional loss with both flexion and extension. He had pain with weight-bearing and pain with any palpation of the knee/patella and joint line. He was unable to perform repetitive-use testing due to pain and guarding. The examiner stated that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare-ups. She was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or with flare-ups as it was not possible to predict within a reasonable degree of medical certainty a potential loss of ROM manifested as a consequence of a flare or exacerbation outside the clinical setting. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. All joint stability testing was normal, but the examiner noted instability of station and interference with standing. He had a reduction in muscle strength in the right knee, which was due to generalized weakness due to a lack of activity from all pain and less significantly from just the right knee. He constantly used a cane. He did not have ankylosis. He did not have nor did he ever have any meniscus condition. A March 2015 x-rays were unremarkable. Current x-rays were silent for osteoarthritis of the right knee. His current diagnosis was as likely as not right knee strain. March 2015 VA x-rays of the right knee revealed no radiographic evidence of acute fracture or dislocation. Joint spaces were preserved, there was no aggressive bone destruction, and soft tissues were unremarkable. April 2015 VA treatment records reflect the Veteran’s report of pain in the bilateral knees, described as anywhere from weakness in the knees to sharp and stabbing pants and balance problems due to pain sometimes. His knees got a “really hot feeling” and stiffened up. He had normal ROM with no deformity or swelling. April 2015 x-rays of the right knee were unremarkable. A July 2015 VA treatment record reflects that the Veteran had no joint effusions or swelling of the knees, and anterior and posterior drawer tests were negative. He had full ROM and no crepitus, but reported pain on the sides and all areas of the knees with no point tenderness. He was assessed with a history of arthritis pain and DJD of the knees. In September 2015, the Veteran reported burning, tingling, numbness, and cracking as he did not have any cartilage. A November 2015 VA treatment record noted bilateral knee buckling with sharp and achy pain. He was issued replacement hinged-knee braces, which he used for bilateral knee stability. November 2015 VA treatment records reflect that active ROM testing revealed flexion to 120 degrees, passive ROM testing with flexion to 45 degrees with significant pain, and normal knee extension. A September 2016 VA treatment record reflects the Veteran’s complaint of continued pain in his knees, right greater than the left, as well as difficulty ambulating, rising from sitting to standing position, decreased ROM, and constant pain that was exacerbated upon any movement. He had occasional tingling and numbness in the right knee. On examination, he had decreased ROM with tenderness to palpation over his knees and was wearing knee braces. The rheumatology fellow noted that past x-rays did not reveal significant degenerative changes, although the examination suggested possible osteoarthritis. An August 2017 VA examination report reflects a diagnosis of bilateral patellofemoral pain syndrome and the Veteran’s report of constant bilateral knee pain that was worse with prolonged standing, long distance ambulation, and bad weather. He could walk up to one-third miles and climb one flight of stairs with knee pain. He frequently wore bilateral knee braces, used a cane in his right hand, and took Tylenol three times a day as needed for his multiple pain syndromes including his knees and ankles. He reported flare-ups of his bilateral knee disabilities three to four times per year with pain lasting up to one day, at which time he avoided heavy manual labor. ROM testing demonstrated flexion to 100 degrees and normal extension with pain noted with flexion but which did not cause functional loss. The examiner stated that this ROM was normal for the Veteran for reasons other than the knee disability as it was due to pain and stiffness, which made it difficult to do certain activities, including long distance ambulation. His ROM was the same with active and passive ROM while sitting, standing, and supine. He did not have pain with weight-bearing, but had mostly anterior knee patella-femoral tenderness. There was no additional functional loss or ROM after three repetitions. The examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare-ups. He was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited his functional ability with repeated use over a period of time or with flare-ups as there was insufficient evidence or objective examination findings that provided a reliable prediction of decreased functional ability during flare-ups or after repeated use over a period of time. Based on the available evidence and examination findings, it was not possible, without resorting to speculation, to predict within a reasonable degree of medical certainty a potential loss of ROM manifested as a result of a flare or exacerbation outside the clinical setting. He had normal muscle strength and no ankylosis. He did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability tests were all normal. He did not now have nor did he ever have a tibial and/or fibular impairment or meniscus condition. He frequently wore bilateral knee braces and used a cane in his right hand. The examiner noted that the Veteran’s bilateral knee disability seemed to be stable. In an addendum, the examiner clarified that patella-femoral syndrome was a clinical diagnosis, and patella-femoral arthritis was a radiographic diagnosis. The Veteran had bilateral knee x-rays in April 2015, which were normal without mention of degenerative arthritis. However, he had bilateral knee x-ray reports from 2008 that mentioned evidence of minimal bilateral knee degenerative arthritis. He may indeed have mild subclinical degenerative arthritis of his knees, which may be seen on certain x-ray views, a CAT scan, an MRI, or during arthroscopy. Regardless, his bilateral knee disability seemed to be stable. At his August 2018 video hearing, the Veteran reported that he depended on daily pain medication, walked with a cane daily, and had difficulty with mobility, walking, and had difficulty with mobility “at all sense” including walking and going up and down stairs. He did not exercise much due to pain and elevated his legs whenever he sat. He complained of constant pain and throbbing, and stated that his symptoms had gotten worse since 2015 such that physical therapy did not help anymore. He walked with a cane specifically because of his knee. Pursuant to the February 2019 Board remand, the Veteran was scheduled for two VA knee examinations. Unfortunately, he went to the incorrect location for the first examination, and failed to report to the second VA examination with no explanation. As there is no evidence of good cause for the Veteran’s failure to report to the required VA examination, his increased rating claim shall be decided based on the evidence of record. See C.F.R. § 3.655(a), (b). Analysis The evidence reflects that the Veteran’s right knee instability is best described as slight, at most. The November 2012, March 2015, and August 2017 VA examination reports reflect that all joint stability tests were consistently normal, and there was no evidence or a history of recurrent patellar subluxation or dislocation or lateral instability. However, the lay evidence includes the Veteran’s report of “weakness,” although he denied any falls; and his report that his right knee likely would give way with lifting. See 7/22/13 VA treatment record; March 2015 VA examination report. The March 2015 VA examiner also noted instability of station, although objective joint stability tests were normal. Additionally, the Veteran contended that his right knee brace helped with stability as absence of cartilage in his knee caused instability. See August 2013 DRO hearing testimony. The Board notes that the evidence does not reflect any absence of cartilage in his knee and, in fact, a September 2000 MRI of the right knee revealed that the articular cartilage was intact. Regarding the version of DC 5257 in effect prior to February 7, 2021, a disability rating in excess of 10 percent is not warranted as the evidence is against a finding of the presence of moderate lateral instability or recurrent subluxation. Rather, the evidence demonstrates that the Veteran’s right knee instability was described as weakness that did not result in any falls or “giving way,” except possibly with lifting. Regarding the version of DC 5257 in effect since February 7, 2021, a disability rating in excess of 10 percent for recurrent subluxation or instability is not warranted because the evidence does not reflect that the Veteran had a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability; or an unrepaired or failed repair of a complete ligament tear causing persistent instability. Rather, the evidence does not reflect a sprain, ligament tear of any severity, or any attempt to repair a complete ligament tear. A disability rating in excess of 10 percent based on patellar instability is also not warranted as the evidence does not reflect surgical repair involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon). Based on all evidence of record, the Board finds that the preponderance of the evidence is against finding that the right knee instability warrants a rating higher than 10 percent under DC 5257. Other Considerations The Board considered the applicability of other diagnostic codes pertaining to knee disabilities but finds that there are none which would provide higher or separate ratings for which the appropriate symptomatology is shown. In other words, there is no evidence of record of ankylosis (DC 5256), dislocated or removal of the semilunar cartilage (DCs 5258 and 5259), impairment of the tibia and fibula (DC 5262), or genu recurvatum (DC 5263). The Veteran is already service-connected for right knee DJD with limitation of motion and assigned a 10 percent rating, effective December 6, 1994. As such, the Board considers the application of DC 5010, which contemplates post-traumatic arthritis. Under the DC 5010 version in effect prior to February 7, 2021, the evidence does not reflect x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. DC 5010 since February 7, 2021, reflects that post-traumatic arthritis be rated as limitation of motion, dislocation, or other specified instability under the affected joint. The evidence reflects that the evidence reflects flexion of the right knee ranging from 70 degrees to 120 degrees with pain causing functional loss at times and extension to 0 degrees. The Board acknowledges that a November 2015 VA treatment record reflects passive ROM with flexion to 45 degrees with significant pain, but the evidence both before and after this treatment record reflect flexion above 60 degrees. As such, the November 2015 VA treatment record appears to be an anomaly. Additionally, it is inadequate as it does not meet all the requirements pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016). The Board considered whether there is functional loss caused by pain, weakness, and other factors, in evaluating the Veteran’s right knee disabilities. 38 C.F.R. §§ 4.40, 4.45; see DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The VA examination reports are inadequate as the examiners merely stated that they were unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or with flare-ups as it was not possible, without resorting to speculation, to predict within a reasonable degree of medical certainty a potential loss of ROM manifested as a result of a flare or exacerbation outside the clinical setting. However, the Veteran is competent and credible to report such, and reported pain with mobility and bad weather. However, the evidence does not reflect that flexion is limited to at least 30 degrees to warrant an increased rating, or that extension is limited to 10 degrees to warrant a separate rating under DC 5261. Again, the Board provided the Veteran with an opportunity to present to a new examination to address the inadequacies of prior VA examinations and to evaluate the current severity of his right knee disabilities. Unfortunately, however, he failed to report to two VA examinations. The Board notes that “the duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where she may or should have information that is essential in obtaining the evidence.” See Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). As such, the Board is limited by the evidence currently before it in order to adjudicate the Veteran’s claim. In summary, based on the evidence, the Board finds that a disability rating in excess of 10 percent is not warranted for right knee instability. Additionally, separate ratings or increased ratings for other right knee disabilities are not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Lee, 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.