Citation Nr: 21025280 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 12-01 706 DATE: April 27, 2021 ORDER A rating in excess of 10 percent for right hip strain is denied. A rating in excess of 10 percent for left hip strain is denied. The separate rating for right hip limitation of extension associated with right hip strain, evaluated as noncompensably disabling as of September 3, 2019, is proper; the appeal is denied. The separate rating for left hip limitation of extension associated with left hip strain, evaluated as 10 percent disabling as of September 3, 2019, is proper; the appeal is denied. The separate rating for right thigh impairment associated with right hip strain, evaluated as 20 percent disabling as of September 3, 2019, is proper; the appeal is denied. The separate rating for left thigh impairment associated with left hip strain, evaluated as 20 percent disabling as of September 3, 2019, is proper; the appeal is denied. A rating in excess of 10 percent for chondromalacia patella of right knee is denied. A rating in excess of 10 percent for chondromalacia patella of left knee is denied. The separate rating for right knee laxity, evaluated as 10 percent disabling for the entire appeal period, is proper; the appeal is denied. The separate rating for left knee laxity, evaluated as 10 percent disabling as of February 27, 2013, is proper; the appeal is denied. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s right hip strain resulted in flexion limited to, at most, 45 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. 2. For the entire appeal period, the Veteran’s left hip strain resulted in flexion limited to, at most, 45 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. 3. Prior to September 3, 2019, the Veteran’s right hip strain did not result in limitation of extension and, as of such date, resulted in extension limited to, at most, seven degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. 4. Prior to September 3, 2019, the Veteran’s left hip strain did not result in limitation of extension and, as of such date, she is in receipt of the maximum schedular rating for limitation of extension. 5. Prior to September 3, 2019, the Veteran’s right hip strain did not result in impairment of the thigh and, as of such date, she is in receipt of the maximum schedular rating for impairment of the right thigh. 6. Prior to September 3, 2019, the Veteran’s left hip strain did not result in impairment of the thigh and, as of such date, she is in receipt of the maximum schedular rating for impairment of the left thigh. 7. For the entire appeal period, the Veteran’s right and left hip strains did not result in ankylosis of the hip, flail joint of the hip, or impairment of the femur. 8. For the entire appeal period, the Veteran’s chondromalacia patella of right knee is manifested by flexion limited to, at most, 45 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 9. For the entire appeal period, the Veteran’s chondromalacia patella of left knee is manifested by flexion limited to, at most, 45 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 10. For the entire appeal period, the Veteran’s chondromalacia patella of right knee resulted in no more than slight lateral instability, without persistent or recurrent instability and the need for surgical repair or a prescribed assistive device. 11. Prior to February 27, 2013, the Veteran’s chondromalacia patella of left knee did not result in recurrent subluxation or lateral instability and, as of such date, resulted in no more than slight lateral instability, without persistent or recurrent instability and the need for surgical repair or a prescribed assistive device. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right hip strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 2. The criteria for a rating in excess of 10 percent for left hip strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5252. 3. The separate rating for right hip limitation of extension associated with right hip strain, evaluated as noncompensably disabling as of September 3, 2019, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 4. The separate rating for left hip limitation of extension associated with left hip strain, evaluated as 10 percent disabling as of September 3, 2019, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 5. The separate rating for right thigh impairment associated with right hip strain, evaluated as 20 percent disabling as of September 3, 2019, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253. 6. The separate rating for left thigh impairment associated with left hip strain, evaluated as 20 percent disabling as of September 3, 2019, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5253. 7. The criteria for a rating in excess of 10 percent for chondromalacia patella of right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5014-5261. 8. The criteria for a rating in excess of 10 percent for chondromalacia patella of left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5014-5261. 9. The separate rating for right knee laxity associated with chondromalacia patella of right knee, evaluated as 10 percent disabling for the entire appeal period, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 10. The separate rating for left knee laxity associated with chondromalacia patella of left knee, evaluated as 10 percent disabling as of February 27, 2013, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Air Force Reserve, to include a period of initial active duty for training from August 1998 to November 1998. She also served in the U.S. Navy Reserve, to include a period of full-time duty for training and administration of the reserves from May 2000 to June 2002. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in September 2010 and November 2011 by a Department of Veterans Affairs (VA) Regional Office. In August 2014, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In March 2015 and August 2017, the Board remanded the case, to include the issues of the propriety of the reductions from 10 percent to zero percent, effective February 1, 2012, for right and left hip strain, for additional development. In an August 2018 rating decision, the Agency of Original Jurisdiction (AOJ) restored the Veteran’s ratings for right and left hip strains to 10 percent, effective February 1, 2012. Therefore, such aspect of the Veteran’s claims for increased ratings for her bilateral hip disabilities is no longer on appeal. Additionally, while the separate 10 percent rating for right knee laxity had previously been assigned as of September 14, 2015, the August 2018 rating decision awarded such as of July 1, 2002, the date service connection for chondromalacia of the right knee had been established. As such award predates the appeal period stemming from the Veteran’s June 2010 claim for an increased rating, the issue has been recharacterized as shown on the title page of this decision. In November 2018, the Board remanded the case for additional development. While on remand, the AOJ issued a rating decision in April 2020 that awarded separate ratings for impairment of the thigh of the bilateral hips, each evaluated as 20 percent disabling, and limitation of extension of the thigh of the bilateral hips, each evaluated as noncompensably disabling, as of September 3, 2019. As such matters are part and parcel of the Veteran’s claims for increased ratings for her bilateral hip strain, the Board assumed jurisdiction over the propriety of the assigned ratings and effective dates in a May 2020 decision and remanded the case for additional development. It now returns for further appellate review. Increased Ratings Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The appeal period for the Veteran’s bilateral hip disabilities stems from her claim for a total disability rating based on individual unemployability, which was received on January 5, 2011, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The appeal period for her bilateral knee disabilities stems from her informal claim received on June 10, 2010, plus the one-year look-back period. Id. 1. Entitlement to a rating in excess of 10 percent for right hip strain. 2. Entitlement to a rating in excess of 10 percent for left hip strain. 3. Propriety of the assignment of a separate rating for limitation of extension of the thigh of the right hip, evaluated as noncompensably disabling as of September 3, 2019. 4. Propriety of the assignment of a separate rating for limitation of extension of the thigh of the left hip, evaluated as 10 percent disabling as of September 3, 2019. 5. Propriety of the assignment of a separate rating for impairment of the thigh of the right hip, evaluated as 20 percent disabling as of September 3, 2019. 6. Propriety of the assignment of a separate rating for impairment of the thigh of the left hip, evaluated as 20 percent disabling as of September 3, 2019. For the entire appeal period, the Veteran’s right and left hip strain are each evaluated as 10 percent disabling pursuant to Diagnostic Code 5252, which pertains to limitation of flexion, based on painful limitation of motion. 38 C.F.R. §§ 4.59, 4.71a. As of September 3, 2019, the Veteran is also in receipt of a separate noncompensable rating for right hip limitation of extension, a 10 percent rating for left hip limitation of extension, and 20 percent ratings for right and left thigh impairment pursuant to Diagnostic Codes 5251 and 5253, respectively. 38 C.F.R. §§ 4.31, 4.71a. Normal range of hip motion is 125 degrees of flexion, 140 degrees of extension, and 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5251 provides that limitation of extension of the thigh to 5 degrees warrants a 10 percent rating. Diagnostic Code 5252 provides that limitation of flexion of the thigh to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 20 degrees warrants a 30 percent rating and flexion limited to 10 degrees warrants a 40 percent rating. Diagnostic Code 5253 provides that impairment of the thigh resulting in limitation of rotation of the affected leg such that the veteran cannot toe-out more than 15 degrees warrants a 10 percent rating. Impairment of the thigh resulting in limitation of adduction and an inability to cross legs warrants a 10 percent rating. Impairment of the thigh resulting in limitation of abduction and motion lost beyond 10 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a. In addition to the foregoing Diagnostic Codes, Diagnostic Code 5250 provides ratings for ankylosis of the hip, Diagnostic Code 5254 provides an 80 percent rating for flail joint of the hip, and Diagnostic Code 5255 provides ratings for impairment of the femur. Id. With regard to the Veteran’s reported bilateral hip symptoms, she indicated that she had chronic pain and stiffness associated with walking and prolonged standing at a November 2011 VA examination. In February 2013, she reported intermittent, variable pain that was worse in the morning, but no swelling, stiffness, or instability. At the August 2014 Board hearing, the Veteran testified that her hips stuck and popped when standing and sitting for a long time. On VA examination in September 2015, the Veteran described stiffness and achiness when her hips were in the same position for a period of time and occasional clicking or catching when sitting on hard chairs. At a February 2016 VA examination, she reported a sensation of stiffness and achiness with prolonged sitting or driving, intermittent clicking or locking with prolonged sitting, and hip pain/achiness present about 98 percent of the time. She stated such would limit her from walking for prolonged periods of time and she could not perform winter sports due to her hip pain. On VA examination in September 2017, the Veteran described soreness, stiffness, locking, weakness, and inability to stand/walk for long periods of time and distance, and, in September 2019, she reported an inability to run, sit for 60 minutes, or stand for 30 minutes before the onset of hip pain. At the October 2020 VA examination, the Veteran stated she experienced stiffness, locking, and pain that prevented her from standing for long periods and impacted walking, running, and sitting. However, even taking into consideration such reports of hip symptomatology, the Board finds that, as will be discussed below, such does not result in functional loss that more nearly approximates higher or separate ratings under any relevant Diagnostic Code. See DeLuca, supra; Mitchell, supra. As noted above, the Veteran is currently in receipt of 10 percent ratings for the entire appeal period pursuant to Diagnostic Code 5252, which pertains to limitation of flexion, based on painful limitation of motion. In order to receive higher ratings under such Diagnostic Code, the evidence must demonstrate flexion limited to at least 30 degrees. On VA examination in November 2011, the Veteran had full flexion of both hips, with no additional limitation following three repetitions, while the February 2013 VA examination report reflects right hip flexion limited to 110 degrees and left hip flexion to 115 degrees, even after repetitive testing, and the Veteran’s denial of flare-ups. In September 2015, flexion of the right hip was limited to 115 degrees and flexion of the left hip was limited to 120 degrees, with no additional loss following repetitive-use testing, and range of motion testing in February 2016 and September 2017 demonstrated full flexion in both hips. The September 2019 VA examination report shows both right hip and left hip flexion limited to, at most, 45 degrees, whereas flexion in both hips was limited to 110 degrees even after three repetitions on VA examination in October 2020. Additionally, the October 2020 VA examiner noted that, although the Veteran reported functional impact and/or loss with repeated use and flare-ups, current examination and medical record findings were not consistent with a functional loss; therefore, the Veteran would have increased pain during flare-ups and repeated use, but no further loss of range of motion. Further, the VA examiner reviewed the aforementioned examination reports and provided an addendum in December 2020, finding it would not be possible to offer an opinion without resorting to mere speculation as to the range of motion findings rendered during such examinations for pain on both active and passive motion and on weight-bearing and nonweight-bearing as she was not the examining provider for all the examinations. The VA examiner explained that there were too many varying factors, such as how much effort the claimant gave, symptoms that wax and wane, subjectively reported symptoms, and the examining provider’s interpretation of the objective findings. Jones v. Shinseki, 23 Vet. App. 382 (2010). Based on the foregoing, the Board finds that the Veteran’s right and left hip strain did not result in limitation of flexion to 30 degrees or less and, thus, ratings in excess of 10 percent are not warranted under Diagnostic Code 5252. Additionally, as noted previously, the Veteran has been assigned separate ratings for limitation of extension and thigh impairment associated with her bilateral hip strains as of September 3, 2019. Prior to such date, the medical evidence does not reflect such limitation of motion. Specifically, VA examinations in November 2011, February 2013, September 2015, February 2016, and September 2017 revealed full extension and no limitation of abduction, adduction, or rotation bilaterally, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Conversely, on September 3, 2019, the VA examiner determined right hip extension would be limited to seven degrees and left hip extension would be limited to five degrees after repeated use over time and during flare-ups. Based on these findings, a noncompensable rating is warranted for right hip limitation of extension and the maximum 10 percent rating is provided for left hip limitation of extension pursuant to Diagnostic Code 5251. Additionally, the VA examiner found right hip abduction would be limited to seven degrees and left hip abduction would be limited to 10 degrees with repeated use over time and during flare-ups. Based on these estimations, the AOJ assigned separate 20 percent ratings under Diagnostic Code 5253, which is the maximum schedular rating available. As of September 3, 2019, the evidence does not reflect right hip extension limited to five degrees or less. Rather, the October 2020 VA examination report shows the Veteran had full extension, with no estimated additional loss of range of motion following repetitive-use testing or during flare-ups. Thus, the Board finds the assignment of the separate ratings for right hip limitation of extension associated with right hip strain, evaluated as noncompensably disabling, left hip limitation of extension associated with left hip strain, evaluated as 10 percent disabling, right thigh impairment associated with right hip strain, evaluated as 20 percent disabling, and left thigh impairment associated with left hip strain, evaluated as 20 percent disabling, as of September 3, 2019, was proper and, consequently, higher and/or additional separate ratings are not warranted under Diagnostic Codes 5251 or 5253. The Board has also considered whether higher and/or separate ratings are warranted under any other applicable Diagnostic Code. However, as the medical evidence does not reflect ankylosis of the hip, flail joint of the hip, or impairment of the femur, higher and/or separate ratings are not warranted under Diagnostic Codes 5250, 5254, or 5255. 7. Entitlement to a rating in excess of 10 percent for chondromalacia patella of right knee. 8. Entitlement to a rating in excess of 10 percent for chondromalacia patella of left knee. 9. Propriety of the assignment of a separate rating for right knee laxity, evaluated as 10 percent disabling for the entire appeal period. 10. Propriety of the assignment of a separate rating for left knee laxity, evaluated as 10 percent disabling as of February 27, 2013. For the entire appeal period, the Veteran’s chondromalacia patella of the right and left knees are each evaluated as 10 percent disabling pursuant to Diagnostic Code 5014-5261 based on painful limitation of motion. 38 C.F.R. §§ 4.59, 4.71a. She is also in receipt of a separate 10 percent rating for right knee laxity for the entire appeal period and a 10 percent rating for left knee laxity as of February 27, 2013, pursuant to Diagnostic Code 5257. Id. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. For a 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. VA’s General Counsel has also stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). During the pendency of the appeal, the rating criteria for evaluating musculo-skeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 83 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). 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. 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, applying the criteria that is more favorable to the Veteran. Prior to February 7, 2021, Diagnostic Code 5257 provides for the assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. As of February 7, 2021, Diagnostic Code 5257 provides ratings for patellar instability and recurrent subluxation or lateral instability. For the former, a 10 percent rating 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. A 20 percent rating is provided 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. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. With regard to recurrent subluxation or lateral instability under the amended Diagnostic Code 5257, 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 assistance device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is assigned 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. 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. Note (1) provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states 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). In regard to the Veteran’s reported knee symptoms, she described constant pain in both knees all around the knee joint mediolateral and below the patella in July 2010. She also reported stiffness and swelling at times and complained of buckling once or twice a day, with her knees feeling unstable. At the April 2012 VA examination, she described symptoms consisting of pain, stiffness, swelling, buckling, and instability, and, in August 2012, she reported catching, increased pain, giving way, and an inability to perform certain activities of daily living. On VA examination in February 2013, the Veteran reported stiffness in the morning with discomfort decreasing with movement and no swelling. At the August 2014 Board hearing, the Veteran described difficulties with standing and sitting for long periods, sitting on high chairs, riding bikes, and walking stairs. She reported that her physical activity was really limited due to symptoms of constant pain. According to an October 2015 VA examination report, the Veteran complained of stiffness and pain, with slight catching while walking and occasional right knee swelling. She also reported that her knees would give out and cause her to fall. In February 2016, the Veteran stated that knee pain was present approximately 98 percent of the time, but, when she was relaxing or sitting, her knees were not a problem. If she did spend a lot of time in any single position, however, her knee pain and stiffness increased. The Veteran also reported wearing braces about two to three times per week and having the sensation that her knees would give out on her, although they had not actually done so recently. A September 2017 VA examination report reflects the Veteran’s complaints of soreness, stiffness, locking, weakness, and an inability to stand/walk for long periods of time and distance. According to the September 2019 VA examination report, the Veteran could walk for 100 yards and stand for 30 minutes before pain would force her to stop and rest. In October 2020, the Veteran reported knee pain, weakness, cramping, popping, and difficulty with stairs, standing, walking, and running. Even taking into consideration such reports of knee symptomatology, the Board nevertheless finds that, as will be discussed in greater detail below, such does not result in functional loss that more nearly approximates higher or separate ratings under any relevant Diagnostic Code. See DeLuca, supra; Mitchell, supra. On VA examination in July 2010, range of motion of the Veteran’s bilateral knees was zero to 130 degrees, with left knee pain at 130 degrees and right knee pain at 125 degrees. There was no change in active or passive range of motion during repeat testing and no additional losses of range of motion, swelling, tenderness, abnormal alignment, or instability observed. The April 2012 VA examination revealed flexion limited to, at most, 125 degrees and full extension bilaterally. In February 2013, the VA examiner observed right knee flexion limited to 135 degrees, with full left knee flexion and bilateral extension. There was no additional loss or limitation following repetitive-use testing. At the October 2015 VA examination, the Veteran’s right knee flexion was limited to 135 degrees, with no additional loss following three repetitions. She also had full left knee flexion and bilateral extension, and the VA examiner found that, although excessive, repetitive weight-bearing would cause increased pain and weakness, such would not affect range of motion. In February 2016, the Veteran had normal range of motion bilaterally, with no additional loss after repetition or projected with repeated use over a period of time. The September 2017 VA examination report shows the VA examiner’s estimation that flexion would be limited to, at most, 135 degrees bilaterally after repeated use over time, and the Veteran had full extension bilaterally. Following examination in September 2019, the VA examiner determined flexion would be limited to 45 degrees bilaterally, with no loss of extension following repeated use over time or during flare-ups. According to an October 2020 VA examination report, right knee flexion was limited to 120 degrees, while left knee flexion and bilateral extension were full. The VA examiner opined that, although the Veteran may report functional impact and/or loss with repeated use and flare-ups, current examination and medical record findings were not consistent with a functional loss; therefore, the Veteran would have increased pain during flare-ups and repeated use but no further loss of range of motion. Based on these findings, the Veteran’s right knee flexion and left knee flexion were limited to, at most, 45 degrees during the appeal period, respectively, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Thus, the Board finds ratings in excess of 10 percent are not warranted under Diagnostic Code 5260. 38 C.F.R. § 4.71a. Likewise, as the medical evidence does not demonstrate limitation of extension at any time during the appeal period, higher and/or separate ratings are not warranted pursuant to Diagnostic Code 5261. Id. Similarly, as the evidence of record does not demonstrate ankylosis, dislocated or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum at any time during the pendency of the appeal, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not for application. In this regard, a July 2012 clinical evaluation reflects the impression of “chondral/degenerative tears, bilaterally, with patellar maltracking” and a reference to a tear of the medial meniscus on the left. However, in March 2016, a VA clinician reviewed the file, to include such findings, and found it determinative that a September 2012 magnetic resonance imaging scan was only positive for some gracilis tendonitis and negative for knee pathology. Additionally, although the record indicates the Veteran had a history of shin splints (medial tibial stress syndrome), the evidence shows such resolved during boot camp, prior to the appeal period, and the Veteran does not assert otherwise. As noted above, the Veteran is also in receipt of a separate 10 percent rating for right knee laxity for the entire appeal period and a separate 10 percent rating for left knee laxity as of February 27, 2013, under Diagnostic Code 5257. Notably, such Diagnostic Code does not require objective medical evidence of lateral instability for a rating to be assigned. English v. Wilkie, 30 Vet. App. 347 (2018). However, while the Veteran is competent to describe feelings of giving way, she is not competent as a lay person to diagnose lateral instability or recurrent subluxation as such requires the administration and interpretation of specialized testing of the ligaments and patella, respectively. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Upon review, the Board finds the criteria for higher ratings under either the old or amended Diagnostic Code 5257 have not been met at any time during the appeal period. VA examiners in July 2010 and April 2012 determined that, despite the Veteran’s subjective reports of buckling and instability, she did not have instability, subluxation, or dislocation on physical examination. However, VA examination on February 27, 2013, revealed slight medial-lateral instability of the left knee, but there was no evidence or history of recurrent patellar subluxation/dislocation. Likewise, VA examination in October 2015 demonstrated only slight lateral instability of the left knee, and the VA examiner noted there was no history of recurrent subluxation and only a history of slight lateral instability in the left knee. On VA examination in February 2016, joint stability testing revealed slight anterior instability, slight medial instability, and slight lateral instability of both knees. In this regard, however, the VA examiner found such was more likely congenital than due to trauma or overuse. In addition, while the lax ligaments in her knees may predispose the Veteran to some mild lateral instability and cause her to feel like her knees may give out, the VA examiner noted she did not have a longstanding history of her knees actually giving out on her to the point where she fell down. Further, the VA examiner recorded that the Veteran did not have a history of recurrent subluxation, and she only had a history of slight lateral instability. According to VA examination reports dated in September 2017, September 2019, and October 2020, however, the Veteran did not have any joint instability on testing. Here, the evidence does not reflect findings of moderate right knee instability at any time during the appeal period or findings of moderate left knee instability as of February 27, 2013, to warrant ratings in excess of 10 percent under Diagnostic Code 5257. Additionally, the record does not demonstrate findings of left knee laxity prior to February 27, 2013. Furthermore, the medical evidence fails to reflect a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair or persistent instability requiring a prescription by a medical provider for an assistive device. Thus, higher ratings are not warranted pursuant to the amended criteria under Diagnostic Code 5257 as of February 7, 2021. Other Considerations In reaching its conclusions in the instant case, the Board acknowledges the Veteran’s belief that her bilateral hip/thigh and knee disabilities are more severe than as reflected by the current assigned disability ratings. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe her symptomatology, she is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, supra. Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged her reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than her own reports regarding the severity of her disabilities. The Board has also considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran’s service-connected disabilities; however, the Board finds that her symptomatology has been stable throughout each period on appeal. Thus, assigning additional staged ratings for such disabilities is not warranted. Furthermore, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). In reaching such determinations, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claims for increased ratings for her bilateral hip/thigh and knee disabilities. Thus, the benefit of the doubt doctrine is not applicable and her increased rating claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Celli, 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.