Citation Nr: 21021770 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-27 761 DATE: April 14, 2021 ORDER Entitlement to a rating in excess of 10 percent for left knee strain prior to September 27, 2012, is denied. A 10 percent, but not higher, evaluation, for left knee strain for the period from September 27, 2012, to March 22, 2015, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 10 percent for left knee strain beginning March 23, 2015, is denied. Entitlement to a rating in excess of 10 percent for right knee strain is denied. A separate rating of 10 percent for right knee limitation of extension beginning July 19, 2018, is granted, subject to the law and regulations governing the payment of monetary benefits. A separate rating of 10 percent for left knee limitation of extension from July 19, 2018, to August 31, 2020, is granted, subject to the law and regulations governing the payment of monetary benefits. A separate rating of 10 percent for mild right knee instability beginning September 6, 2019, is granted, subject to the law and regulations governing the payment of monetary benefits. A separate rating of 10 percent for mild left knee instability beginning September 6, 2019, is granted, subject to the law and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. The Veteran’s left knee strain was characterized by arthritis-related painful motion and x-ray evidence of arthritis for the entire period on appeal. 2. The Veteran’s right knee strain was characterized by arthritis-related painful motion and x-ray evidence of arthritis for the entire period on appeal. 3. The preponderance of the evidence is against a finding that the Veteran’s left knee strain with limitation of motion and arthritis resulted in ankylosis, compensable limitation of flexion, impairment of the tibia or fibula, or genu recurvatum at any time during the appeal period. 4. The preponderance of the evidence is against a finding that the Veteran’s right knee strain with limitation of motion and arthritis resulted in ankylosis, compensable limitation of flexion, impairment of the tibia or fibula, or genu recurvatum at any time during the appeal period. 5. Beginning July 19, 2018, the Veteran’s right knee disability resulted in extension limited to 10 degrees. 6. From July 19, 2018, to August 31, 2020, the Veteran’s left knee disability resulted in extension limited to 10 degrees. 7. While there were no clinical findings of instability, the Veteran will be given the benefit of the doubt, and the Board will find that his complaints of instability and the use of a brace beginning September 6, 2019, constitutes mild right knee instability. 8. While there were no clinical findings of instability, the Veteran will be given the benefit of the doubt, and the Board will find that his complaints of instability and the use of a brace beginning September 6, 2019, constitutes mild left knee instability. CONCLUSIONS OF LAW 1. The criteria for an evaluation greater than 10 percent for service-connected left knee strain with painful motion and arthritis prior to September 27, 2012, have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2019). 2. The criteria for a 10 percent evaluation, but not higher, for service-connected left knee strain with painful motion and arthritis from September 27, 2012, to March 22, 2015, have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2019). 3. The criteria for an evaluation greater than 10 percent for service-connected left knee strain with painful motion and arthritis from March 23, 2015, have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2019). 4. The criteria for an evaluation greater than 10 percent for service-connected right knee strain with painful motion and arthritis have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260 (2019). 5. The criteria for a separate 10 percent evaluation for right knee limitation of extension beginning July 19, 2018, have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5261 (2019). 6. The criteria for a separate 10 percent rating for left knee limitation of extension from July 19, 2018, to August 31, 2020, have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5261 (2019). 7. The criteria for a separate 10 percent evaluation for mild right knee instability beginning September 6, 2019, have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2019). 8. The criteria for a separate 10 percent evaluation for mild left knee instability beginning September 6, 2019, have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1976 to August 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. Jurisdiction currently resides with the RO in Salt Lake City, Utah In September 2019, the Veteran testified at a videoconference hearing conducted with the undersigned Veterans Law Judge. A transcript of the hearing is of record. This claim was previously before the Board in December 2020, at which time it was remanded for further development. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified by the schedule are considered adequate to compensate veterans for considerable loss of working time from exacerbation or the illness proportionate to the severity of the several grades of disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left and Right Knee Strain In October 2011, the RO granted service connection for left knee strain and service connection for right knee strain at an initial noncompensable rating under Diagnostic Code 5260 beginning July 20, 2010, the date of the Veteran’s claim. In April 2015, the RO increased the Veteran’s evaluation for his right knee strain and left knee strain to 10 percent, effective March 23, 2015. In March 2016, the RO granted a 10 percent evaluation for right and left knee strain with degenerative changes, finding that a compensable evaluation was warranted for degenerative arthritis in two major joints, effective July 20, 2010. The evaluation was closed out on September 27, 2012. The RO also found that a 10 percent evaluation was warranted for the Veteran’s right knee strain with degenerative arthritis, effective September 27, 2012, under Diagnostic Code 5003-5260. Because the claim is an initial claim, the Board will consider evidence of symptomatology from July 20, 2010. 38 C.F.R. § 3.400 (o). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2019). Diagnostic Code 5003 provides that if arthritis is established in the joints involved, when “the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion.” Diagnostic Code 5260 pertains to limitation of flexion of the leg. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not considered to be contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (Court) clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, and less or more movement than is considered normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Court has held that the provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Significantly, regulations pertaining to musculoskeletal disabilities were recently amended and new criteria for rating musculoskeletal disabilities became effective on February 7, 2021. When 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. VAOPGCPREC 3- 2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The recently revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021. Hence, for the period beginning February 7, 2021, the version more favorable to the veteran will apply. Prior to February 7, 2021 Traumatic arthritis was rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When, however, the limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic code, a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted if there is X- ray evidence of involvement of two or more major joints or two or more minor joint groups and 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, Diagnostic Codes 5003, 5010. Full range of motion of the knee is from 0 degree of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2017). Under Diagnostic Code 5256, ankylosis at a favorable angle in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent rating; ankylosis with flexion between 10 degrees and 20 degrees warrants a 40 rating; ankylosis with flexion between 20 degrees and 45 degrees warrants a 50 rating; and extremely unfavorable ankylosis (flexion at an angle of 45 degrees or more) warrants a 60 percent rating. Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling and severe recurrent subluxation or lateral instability warrants a 30 percent rating. The terms “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 (2016). The use of terminology such as “slight” or “moderate” by VA examiners and others, 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 regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2017). Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. Under Diagnostic Code 5259, removal of the semilunar cartilage when symptomatic warrants a 10 percent rating. Under Diagnostic Code 5260, if flexion of the leg is limited to 60 degrees, a 0 percent rating is warranted. If flexion of the leg is limited to 45 degrees, a 10 percent rating is in order. If flexion of the leg is limited to 30 degrees, a 20 percent rating is in order. If flexion of the leg is limited to 15 degrees, a 30 percent rating is warranted. Under Diagnostic Code 5261, if extension of the leg is limited to 5 degrees, a 0 percent rating is warranted. If extension of the leg is limited to 10 degrees, a 10 percent rating is warranted. If extension of the leg is limited to 15 degrees, a 20 percent rating is warranted. If extension of the leg is limited to 20 degrees, a 30 percent rating is warranted. If extension of the leg is limited to 30 degrees, a 40 percent rating is warranted. If extension of the leg is limited to 45 degrees, a 50 percent rating is warranted. Under Diagnostic Code 5262, impairment of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating; with moderate knee or ankle disability, a 20 percent rating is warranted; with marked knee or ankle disability, a 30 percent rating is warranted; and with nonunion (loose motion requiring brace), a 40 percent rating is warranted. Under Diagnostic Code 5263, genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. VA’s General Counsel has held that a Veteran who has arthritis and instability of the knee could receive separate ratings under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97 (1997); 62 Fed. Reg. 63,604 (1997). When a knee disorder is already rated under Diagnostic Code 5257, the Veteran must also have limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 in order to obtain a separate rating for arthritis. If the Veteran does not at least meet the criteria for a zero-percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98 (1998); 64 Fed. Reg. 52,376 (1999), the VA General Counsel further explained that, when a Veteran has a knee disability rated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. In the alternative, a compensable rating may be granted by virtue of 38 C.F.R. § 4.59. In VAOPGCPREC 9-2004 (2004), 69 Fed. Reg. 59,990 (2004), the VA General Counsel held that when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a Veteran may receive a rating for limitation in flexion only, limitation of extension only, or separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion), and Diagnostic Code 5261 (leg, limitation of extension). Where a Veteran has both a limitation of flexion and limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Beginning February 7, 2021 As of February 7, 2021, changes have been implemented to the musculoskeletal rating criteria. The Board notes the only change to Diagnostic Code 5003 is a change in the title to the code, indicating that the criteria apply to all types of degenerative arthritis other than post-traumatic. No change was made to Diagnostic Code 5260. There are, however, significant changes to Diagnostic Code 5257, effective February 7, 2021. The new rating criteria specify that the code governs recurrent subluxation or instability (due to a knee sprain or ligament tear) and patellar instability. For recurrent subluxation or instability, a 10 percent evaluation 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. A 20 percent rating is warranted for one of the following: 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 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 30 percent evaluation 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 For patellar instability, a 10 percent evaluation is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability, without a prescription for an assistive device or bracing for ambulation. A 20 percent rating is assigned for a patellar condition after surgical repair with a prescription for either a brace, cane, or walker, and a 30 percent rating is assigned for the same with a prescription for both a brace and a cane or walker. The Board will apply the new criteria for any of the applicable Diagnostic Codes for the period beginning February 7, 2021, if the new criteria are more beneficial to the Veteran than the prior version of the regulation. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (regulations may not have retroactive effect unless their language specifies so). 1. Entitlement to a rating in excess of 10 percent for left knee strain prior to September 27, 2012, a compensable rating from September 27, 2012, to March 22, 2015, and a rating in excess of 10 percent from March 23, 2015 2. Entitlement to a rating in excess of 10 percent for right knee strain The Veteran received a VA examination in August 2011 and reported daily pain that was worse in the mornings. He did not, however, report flare-ups. Right knee and left knee flexion were 140 degrees or greater and there was no objective evidence of painful motion on flexion. There was no limitation of extension for either knee or evidence of painful motion on extension, and these measurements did not change after repetitive use. There was no tenderness or pain to palpation in the right knee, while muscle strength testing revealed normal strength on right knee flexion and right knee extension. Joint stability was normal, and there was no evidence or history of recurrent patellar subluxation or dislocation. Imaging studies were also performed but did not document degenerative arthritis. The Veteran received a VA examination in April 2015 and reported flare-ups of the knees where the pain became an 8 out of 10. Right knee flexion was from 0 to 60 degrees and extension was from 60 to 0 degrees. Left knee flexion was from 0 to 70 degrees and extension was from 70 to 0 degrees. These measurements did not change after repetitive use. There were limitations with kneeling and crouching, and there was pain on flexion that caused functional loss in both knees. The knees were tender to palpation of the patella but there was no evidence of pain with weight bearing and no objective evidence of crepitus. Pain, weakness, fatigability, and incoordination did not limit functional ability in either knee. Muscle strength testing revealed active movement against some resistance in right and left knee forward flexion, but normal strength in right and left knee extension. There was no muscle atrophy and no ankylosis. Joint stability was normal, and there was no evidence or history of recurrent patellar subluxation, lateral instability, or recurrent effusion. The Veteran wore a brace constantly on both knees and there were no meniscal conditions. The Veteran received a VA examination in April 2017 and reported pain in both knees that felt better when the knees were stretched out. The knees popped and cracked, and sometimes gave way. The Veteran had difficulty walking down stairs and could not cut the grass, play with his grandson like he would like, or play sports. Right and left knee flexion were from 0 to 130 degrees, and right and left knee extension were from 130 to 0 degrees. Pain was noted in flexion and extension but did not cause functional loss. There was no evidence of pain with weight bearing but there was objective evidence of localized tenderness or pain on palpation of both knee joints. There was also objective evidence of crepitus. The examiner was unable to opine without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time in either knee. Muscle strength testing revealed normal strength in flexion and extension in both knees. There was no muscle atrophy, no ankylosis and no meniscus condition. Joint stability was normal, and there was no evidence or history of recurrent patellar subluxation, lateral instability, or recurrent effusion. The Veteran wore a brace regularly on both knees and there were no meniscal conditions. Imaging studies were performed that revealed degenerative arthritis in both knees. A Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) was submitted by the Veteran’s private physician in April 2018 and the Veteran described decreased ambulation on flare-ups. Range of motion testing revealed flexion to 130 degrees and extension to 0 degrees in the right knee, and flexion to 120 degrees and extension to 0 degrees in the left knee. There was pain on active, passive, and repetitive use testing, and pain in weight-bearing and nonweight-bearing. There was also pain on palpation. The physician noted less movement than normal bilaterally, pain on movement bilateral, deformity in the left knee, and interference with sitting and standing bilaterally. There was no reduction in muscle strength and no muscle atrophy. There was, however, favorable ankylosis in full extension or in slight flexion between 0 and 10 degrees bilaterally. Joint stability was normal, and there was no evidence or history of recurrent patellar subluxation, lateral instability, or recurrent effusion. The physician noted that the Veteran had a meniscus condition but did not describe the severity and frequency of symptoms. The Veteran used a brace regularly and a cane occasionally. Imaging studies were performed, and degenerative arthritis was documented bilaterally. There was also evidence of crepitus bilaterally. The Veteran received a VA examination on July 19, 2018, and indicated that his knee conditions had worsened since his last examination. He had increased pain bilaterally that was constant and sharp; he described it as “9/10, where 10 is the worst pain.” Right knee flexion was 0 to 96 degrees and extension was 96 to 0 degrees. Left knee flexion was 0 to 92 degrees and extension was 92 to 0 degrees. Pain was noted in flexion and extension bilaterally and caused functional loss. There was also objective evidence of crepitus. The Veteran was able to perform the repetitive use testing, and pain, fatigue, weakness, lack of endurance, and incoordination caused additional functional loss bilaterally. Right knee flexion after repetitive use was from 10 to 85 degrees and extension was from 85 to 10 degrees. Left knee flexion after repetitive use was from 10 to 90 degrees and extension was from 90 to 10 degrees. Muscle strength testing was normal in flexion bilaterally but there was active movement against some resistance in extension bilaterally. There was no muscle atrophy, no ankylosis and no meniscus condition. Joint stability was normal, and there was no evidence or history of recurrent patellar subluxation, lateral instability, or recurrent effusion. He also used a brace regularly. Imaging studies were performed, and degenerative arthritis was documented bilaterally. At the September 6, 2019 Board hearing, the Veteran testified that he had instability in his knee and wore braces. The Veteran received a VA examination on August 31, 2020, and reported that he did not have flare-ups of the knees. However, he experienced functional loss with walking, standing, and sitting. Right knee flexion was from 10 to 90 degrees and extension was from 90 to 10 degrees. Left knee flexion was from 5 to 110 degrees and extension was from 110 degrees to 5 degrees. There was pain in flexion and extension bilaterally, and it caused trouble squatting and trouble using the stairs. There was objective evidence of localized tenderness or pain on palpation of the bilateral anterior knee that was rated 8/10. Repetitive use testing did not produce additional loss of function or range of motion in either knee. Muscle strength testing revealed active movement against some resistance in flexion and extension bilaterally. There was no muscle atrophy, no ankylosis and no meniscus condition. Joint stability was normal, and there was no evidence or history of recurrent patellar subluxation or lateral instability. There was evidence of bilateral knee effusion when walking over 200 yards or standing more than 30 minutes. The Veteran also wore knee sleeves constantly on both knees. Pursuant to the December 2020 Board remand, an addendum medical opinion was submitted in January 2021 to address whether the Veteran’s range of motion results from the August 2011 and April 2015 VA examinations would have been reduced if the knees had been tested in both active and passive motion, as well in weight-bearing and nonweight-bearing. The physician found that the results from both examinations would most likely have been the same whether in active motion, passive motion, weight-bearing or nonweight-bearing due to most veteran’s judgment to guard against exceeding a level of pain or injury of a joint because their instinct would be to guard against worsening their condition during examination. The physician continued that a lot of veterans would inform him how far they could go with passive range of motion or weight-bearing before they would stop him, and that range was usually no different from active range of motion or nonweight-bearing. The Board notes that the Veteran was assigned a disability rating of 10 percent under Diagnostic Code 5010-5260 based on functional loss due to painful motion and x-ray evidence of arthritis. The Board finds that the Veteran is not entitled to an increased rating under DeLuca. There is no additional non-compensated motion that can form the basis of an increased rating and no limitation of motion for which the Veteran is not already receiving compensation. To compensate the Veteran for the same painful motion under 38 C.F.R. § 4.59 and DeLuca would constitute the prohibited practice of pyramiding. See 38 C.F.R. § 4.14. In regard to Diagnostic Codes 5260, there is no compensable limitation of motion that can form the basis for the assignment of a separate disability rating. Therefore, the Board finds that a separate rating under this Diagnostic Code is not warranted. The evidence indicates that, beginning July 19, 2018, the Veteran’s left and right knee extension was limited to 10 degrees in repetitive testing. By August 31, 2020, the right knee extension continued to be limited to 10 degrees, but the left knee extension was limited to 5 degrees. As such, a separate 10 percent evaluation for right knee extension is warranted from July 19, 2018, and a separate 10 percent evaluation is warranted for left knee extension from July 19, 2018, to August 31, 2020. The Veteran is not entitled to a separate compensable evaluation for ankylosis because the record does not show any probative evidence of ankylosis. The Board notes that the April 2018 private DBQ found favorable ankylosis in full extension or in slight flexion between 0 and 10 degrees bilaterally. These findings, however, were never noted in any of the VA treatment records or other VA examinations, to include the July 2018 VA examination three months later. The private DBQ therefore has inconsistent findings and, while the private physician may recognize some sort of partial ankylosis, the Board is unable to assign a separate evaluation for such conditions. Therefore, separate compensable evaluations for ankylosis under Diagnostic Code 5256 is not warranted. On the other hand, the Board will take into consideration the Veteran’s statements with respect to his left and right knee disabilities and specifically his testimony at the September 6, 2019, Board hearing regarding complaints of instability and the use of knee braces. However, while the Veteran is considered to be competent to be able to report symptoms that he can personally observe because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of his left and right knee disabilities based on the appropriate Diagnostic Codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (lay testimony is considered competent as to symptoms of an injury or illness, which are within the realm of personal knowledge); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). To the extent the Board can consider his lay statements, the Board will give him the benefit of the doubt, and finds that these complaints together with his use of knee braces warrant separate ratings of 10 percent for right knee instability and left knee instability beginning September 6, 2019. Absent objective clinical findings, however, the Board finds that the evidence is against any higher rating for this symptom. There is also no evidence of cartilage, semilunar, dislocated or symptomatic residuals of removal of a semilunar cartilage. Thus, a separate rating under Diagnostic Code 5258 or 5259 is not warranted. As to Diagnostic Codes 5262 and 5263, there is also no probative evidence of any impairments of the Veteran’s tibia or fibula nor has the Veteran been shown to have genu recurvatum. Thus, an increased rating under these Diagnostic Codes is not warranted. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Daniels, 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.