Citation Nr: 21031996 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 15-35 896 DATE: May 25, 2021 ORDER Entitlement to an initial disability rating in excess of 10 percent for right knee strain with degenerative joint disease (right knee DJD) is denied. Entitlement to a separate disability rating of 10 percent, and no higher, for right knee instability beginning August 1, 2002 is granted. Entitlement to a disability rating in excess of 10 percent for right knee instability beginning December 1, 2020, is denied. Entitlement to an initial disability rating in excess of 10 percent for left knee strain with degenerative joint disease (left knee DJD) is denied. Entitlement to a separate disability rating of 10 percent, and no higher, for left knee instability from August 1, 2002 to December 1, 2020 is granted. Entitlement to a disability rating in excess of 20 percent for left knee instability beginning December 1, 2020, is denied. FINDINGS OF FACT 1. The competent evidence of record shows that throughout the appeal period, the Veteran's right knee flexion was limited to, at worst, 65 degrees. 2. For the period on appeal prior to December 1, 2020, resolving reasonable doubt in favor of the Veteran, the competent evidence of record shows that the Veteran has slight right knee instability. 3. For the period on appeal beginning December 1, 2020, the competent evidence of record shows that the Veteran has slight right knee instability; moderate right knee instability and/or 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 has not been shown. 4. The competent evidence of record shows that throughout the appeal period, the Veteran's left knee flexion was limited to, at worst, 55 degrees. 5. For the period on appeal prior to December 1, 2020, resolving reasonable doubt in favor of the Veteran, the competent evidence of record shows that the Veteran has slight left knee instability. 6. For the period on appeal beginning December 1, 2020, the competent evidence of record shows that the Veteran has moderate left knee instability; severe left knee instability and/or unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation has not been shown. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee DJD have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5260 (2020). 2. The criteria for an initial rating of 10 percent for right knee instability, for the appeal period prior to December 1, 2020, have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5257 (2020). 3. The criteria for a disability rating in excess of 10 percent for right knee instability, for the appeal period beginning to December 1, 2020, have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5257 (2020). 4. The criteria for an initial rating in excess of 10 percent for left knee DJD have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5260 (2020). 5. The criteria for a rating of 10 percent for left knee instability, for the appeal period prior to December 1, 2020, have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5257 (2020). 6. The criteria for a disability rating in excess of 20 percent for left knee instability, for the appeal period beginning to December 1, 2020, have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5257 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1982 to July 2002. These matters come before the Board of Veteran's Appeals (Board) from a May 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. By way of background, the Veteran first filed a claim of entitlement to service connection for a bilateral knee conditionthen claimed as acute bilateral quadricep tendonitisprior to her discharge in February 2002. In an August 2002 rating decision, the AOJ denied the claim. The Veteran appealed the decision and, ultimately, in February 2008, the Board remanded the claim to afford the Veteran a new examination. As a result of further development, the AOJ granted entitlement to service connection for left and right knee strain in March 2010, with a noncompensable rating, effective August 1, 2002 (the first day of the month following her discharge). In September 2010, within one year, the Veteran filed correspondence specifically titled, "Notice of Disagreement," in which she stated that she continued to have issues with her knees, and disagreed with her prior assessment by an examiner. She requested that her rating be reevaluated based on the other medical evidence submitted. The AOJ did not respond to this notice of disagreement. In an April 2012 statement, the Veteran continued to complain of pain in her knee and foot. The AOJ interpreted this statement as a claim for increased rating and issued a May 2013 rating decision denying entitlement to a compensable rating. The Veteran filed a notice of disagreement with the May 2013 rating decision. In August 2015, the AOJ issued a rating decision granting a rating of 10 percent for the left and right knees, effective the date of the Veteran's April 2012 statement. The AOJ also issued a statement of the case denying entitlement to a rating in excess of 10 percent for left and right knee disabilities. The Veteran then filed a timely appeal to the Board. Based on this procedural background, in an April 2019 decision, the Board observed that the March 2010 rating decision never became final as to the assigned initial noncompensable ratings for the Veteran's service-connected right and left knee disabilities. The Board also remanded the claims for additional development, which has been substantially completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must consider the extent to which a veteran may have additional functional impairment beyond the limitation of motion objectively demonstrated, such as when the symptoms are most prevalent due to the extent of the pain and painful motion, weakness, premature or excess fatigability, and incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The rating schedule is intended to recognize actually painful, unstable, or malaligned joints due to healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to cases of painful motion in which there is a finding of arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Case law and VA guidelines anticipate that VA examiners will use information procured from relevant sources, including lay statements, to estimate additional functional loss during flare-ups of musculoskeletal disability. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation. See 38 C.F.R. §§ 3.951, 3.957. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 49. Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). A recent CAVC decision highlighted that separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (DC 5260), limitation of extension (DC 5261), lateral instability or recurrent subluxation (DC 5257), and meniscal conditions (DCs 5258, 5259). See Lyles v. Shinseki, 29 Vet. App. 107 (2017). Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5256, a 30 percent rating is assigned for ankylosis of a knee with favorable ankle in full extension, or in slight flexion between zero and ten degrees and a 40 percent rating is assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 50 percent rating is assigned for ankylosis of a knee between 20 degrees and 45 degrees and maximum 60 percent rating is assigned for extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more. Diagnostic Code 5257 provides that an evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability. An evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Words such as "mild," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. 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. It should also be noted that use of descriptive terminology such as "severe" 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 regarding an increased rating. 38 U.S.C. § 7104 (a); 38 C.F.R. §§ 4.2, 4.6. The Board does note, for reference and illustrative purposes, that the definition for "mild" includes not very severe. Webster's II New College Dictionary at 694 (1995). In addition, a synonym for "mild" is "slight" and definitions for "slight" include small in size, degree, or amount. Id. at 1038. The definitions for "moderate" include of average or medium quantity, quality, or extent. Id. at 704. Finally, definitions for "severe" include extremely intense. Id. at 1012. It is also noted that the term "moderately severe" indicates impairment that is considered more than "moderate" but not to the extent as to be considered "severe." Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of semilunar cartilage. Diagnostic Code 5260 provides a noncompensable rating for limitation of flexion to 60 degrees, a 10 percent rating for limitation of flexion to 45 degrees, a 20 percent rating for limitation of flexion to 30 degrees, and a 30 percent rating for limitation of flexion to 15 degrees. Diagnostic Code 5261 provides a noncompensable rating for limitation of extension to 5 degrees, a 10 percent rating for limitation of extension to 10 degrees, a 20 percent rating for limitation of extension to 15 degrees, a 30 percent rating for limitation of extension to 20 degrees, a 40 percent rating for limitation of extension to 30 degrees, and a 50 percent rating for limitation of extension to 45 degrees. Diagnostic Code 5262 provides that impairment of the tibia and fibula characterized by malunion with slight knee or ankle warrants a 10 percent rating; characterized by malunion with a moderate knee or ankle disability warrants a 20 percent rating; and characterized by malunion with marked knee warrants a 30 percent rating. Impairment of the tibia and fibula manifested by nonunion with loose motion and requiring a brace warrants a maximum 40 percent rating. Diagnostic Code 5263 provides that genu recurvatum warrants a 10 percent rating. The Board notes that the criteria concerning the rating of knee disabilities under Diagnostic Code 5257 was amended during the pendency of this appeal, effective from February 7, 2021. Specifically, the amendment changed the criteria for compensable ratings. 85 Fed. Reg. 76463 (Nov. 30, 2020) (eff. Feb. 7, 2020). When a regulation changes during the pendency of a claim, the version most favorable to the Veteran applies. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overruling in part Karnas v. Derwinski, 1 Vet. App. 308 (1991)). However, the amended version cannot be applied prior to its effective date. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; see also Green v. Brown, 10 Vet. App. 111 (1997). Under the amended Diagnostic Code 5257, for recurrent subluxation or instability a 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for (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 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 and bracing for ambulation. Diagnostic Code 5257 also provides that for a patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent warranty is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Factual Background In April 2002, the Veteran was afforded a VA examination. She reported bilateral knee pain and described a history of bilateral knee buckling after prolonged standing. She denied pain or swelling or locking of the knees, just that it gives way. On examination, the Veteran was found to have full range of motion (ROM) with pain on forward flexion of the knee. In a May 2003 VA treatment record, the Veteran had left knee crepitus and ROM was within normal limits, except there was tight flexion. In an August 2003 VA examination the Veteran reported bilateral knee pain. On examination, flexion and extension were to 140 degrees, there was no crepitus, no joint effusion, or tenderness, and reflexes were normal. In a May 2004 DRO hearing, the Veteran reported that her knee swelling with prolonged walking or standing. In September 2006 VA treatment records, the Veteran had normal movement in all extremities, no abnormalities in the knee were shown. In a July 2008 private treatment record, the Veteran reported discomfort in her knees. In December 2009, the Veteran was afforded a VA examination, the Veteran reported locking and her knee giving way. On examination, the Veteran was found to have instability, pain, stiffness, weakness, and several episodes of dislocation. There was no effusion, but the Veteran was reported to have flare-ups. There was crepitus and tenderness. ROM in the left and right knees included flexion to 120 degrees and normal extension. There was no objective evidence of additional limitation of motion or pain or joint ankylosis. In April 2012 VA treatment records show that the Veteran reported excruciating pain in her knee. Private treatment records from 2012 also show right knee pain and stiffness, but full range of motion. In a March 2013 VA examination, the Veteran reported buckling of both knees on occasion and flare-ups. On examination, initial ROM testing revealed flexion to 135 degrees and normal extension in the right knee and flexion to 130 degrees and normal extension in the left knee. no additional loss of ROM was noted with repetitions or functional loss. muscle strength was normal and joint stability tests was normal. There was no patellar subluxation or dislocation or meniscal conditions but there was slight swelling in the right knee. the Veteran did not use assistive devices. VA treatment records from April 2013 include a report with two views of bilateral knees. Indication was chronic pain and buckling. No acute fracture subluxation was identified in either knee. There was no joint effusion. In November 2013, the Veteran reported doing well but that she continued to have knee pain. ROM was within normal limits. In February 2014, the Veteran reported knee pain but there was no swelling and ROM was within normal limits. In a September 2015 statement, the Veteran asserted that she had a limited range of motion of the right and left knees. November 2015 and January 2016 VA treatment records show reports of pain in the left knee for 3 months and that it sometimes gives out. January 2016 VA treatment records show full ROM of the right knee. In September 2016, the Veteran had right knee pain. On examination, she had slightly limping gait; mild weightbearing; swelling; no bruising or atrophy; alignment neutral; ROM with full extension and limited flexion. There was no effusion In February 2017, the Veteran was afforded a VA examination. She reported increased knee pain which was persistent and worse after sitting and flareups. On examination, initial ROM testing revealed flexion to 120 degrees and in the right knee, flexion to 95 degrees in the left knee, and normal extension in both knees. There was pain on weight bearing and localized tenderness. There was no additional functional loss after repetitive motion. For the left knee, ROM during flareups was estimated to be flexion to 90 degrees and normal extension. Muscle strength on flexion was normal and on extension was less than normal. There was no muscle atrophy. Joint stability testing was normal. June 2017 VA treatment records show the Veteran exhibiting a mild limp. Her left knee was tender to palpation, and right knee tender with slight pop medial side to ROM, there was no crepitus. In a December 2017 record, the Veteran had right pain along inferior patellar tendon and no laxity of ligaments was noted. A June 2018 VA treatment record shows right knee pain consistent with meniscal injury and PFS and a April 2019 record shows mild arthritis and complaints of swelling in bilateral knees. In December 2020, the Veteran was afforded a VA examination. The Veteran reported bilateral knee pain that was worsening and flareups of stabbing pain. Sometimes her knees lock, and she falls. Initial ROM testing of the right knee revealed flexion to 90 degrees and normal extension and of the left knee revealed flexion to 80 degrees and normal extension. There was pain with weight bearing and objective evidence of crepitus. During flareups the Veteran's right knee flexion was estimated to be limited to 65 degrees and left knee flexion was limited to 55 degrees. Functional loss was caused by pain and weakness. There was interference with sitting and standing and swelling. Muscle strength was active movement against some resistance and there was no muscle atrophy or ankylosis. Joint stability testing revealed only anterior instability of 1+ in the right knee and 2+ in the left knee. There were no meniscal conditions, but the Veteran did use a knee brace. Passive ROM testing was the same as active ROM. 1. Entitlement to an initial disability rating in excess of 10 percent for right knee DJD is denied. 2. Entitlement to a separate disability rating of 10 percent, and no higher, for right knee instability beginning August 1, 2002 is granted. 3. Entitlement to a disability rating in excess of 10 percent for right knee instability beginning December 1, 2020, is denied. The Veteran is seeking higher disability ratings for her right knee disabilities. Specifically, she contends that her disabilities are more severe than reflected by her currently assigned disability ratings because she experiences pain, swelling, and limitation of motion. See September 2015 VA Form 9. Here, the Veteran is currently assigned a 10 percent disability rating for right knee DJD under Diagnostic Code 5260, effective August 1, 2002, and a 10 percent disability rating for right knee instability, effective December 1, 2020. Following a review of the record and the applicable legal criteria, for the reasons detailed below, the Board finds that a higher disability rating for right knee DJD is not warranted and that an additional separate 10 percent disability rating for right knee instability is warranted from August 1, 2002 to December 1, 2020. With regard to whether a higher rating is warranted for the right knee under the currently assigned Diagnostic Code 5260, as noted above, a 10 percent disability rating is warranted where flexion is limited to 45 degrees and a 20 percent disability rating is warranted where there is flexion is limited to 30 degrees. Here, the evidence reveals that the Veteran has functional flexion better than 45 degrees. Specifically, the December 2020 VA examiner evaluated ranges of motion, pain, additional limitation of motion and functional loss upon repetitive testing, and limitation on weight-bearing, and found that the Veteran's flexion in the right knee was limited, at worst (i.e. during flareups), to 65 degrees. The Board notes that regarding the right knee limitation of motion, the December 2020 VA examination is the examination most favorable to the Veteran and is the only VA examination of record adequate for adjudicative purposes as it is consistent with Sharp, supra. Accordingly, the preponderance of evidence is against a disability rating of 10 percent, which contemplates flexion limited to at worse 45 degrees, under Diagnostic Code 5260 based on limitation of motion. The Board recognizes, however, that 'painful' motion under Diagnostic Code 5260 warrants at least a minimum compensable rating pursuant to provisions of 38 C.F.R. § 4.59. Here, the evidence shows that the Veteran has painful motion. See, e.g., December 2020 VA Examination. As such, the currently assigned disability rating of 10 percent for right knee DJD under Diagnostic Code 5260 most closely approximates the Veteran's disability picture. The Board next acknowledges, as noted above, that the Veteran has been assigned a 10 percent disability rating under Diagnostic Code 5257, for instability, effective December 1, 2020. Therefore, the Board will consider whether a separate rating is warranted prior to December 1, 2020, and/or a higher rating is warranted for the entire period under appeal, under Diagnostic Code 5257 under the regulations in effect both prior to and following February 7, 2021. Here, the evidence indicates that an initial disability rating, effective August 1, 2002, is warranted for the Veteran's right knee disability under Diagnostic Code 5257. Specifically, in a December 2009 VA examination the examiner found instability and the Veteran has competently and credibly reported instability, pain, her knee giving way, and falls throughout the appeal period. Accordingly affording the Veteran the benefit of the doubt, the Board finds that a separate 10 percent disability rating under Diagnostic Code 5257 for slight or mild instability, effective August 1, 2002 (the first day of the month following her discharge), is warranted. The Board further finds that the record does not indicate that the Veteran's instability was "moderate" or of medium quantity. Indeed, aside from in the December 2009 VA examination, the Veteran's VA examinations during this period on appeal show no joint instability. In addition, although the Veteran uses a brace an assistive device, the evidence of record does indicate that the Veteran experienced a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability or that a medical provider has prescribed a brace for her knee. As such, a disability rating higher than 10 percent under Diagnostic Code 5257, for the entire period on appeal, under the regulations in effect both prior to and following February 7, 2021, for the right knee is not warranted. The Board next considered whether higher or separate ratings were warranted under another appropriate Diagnostic Code. Here, there is no evidence in the claims file showing ankylosis so as to warrant a disability rating under Diagnostic Code 5256. Regarding Diagnostic Code 5258, the Board acknowledges that the Veteran has competently and credibly reported popping and locking symptoms throughout the record. There is, however, no indication of effusion or semilunar dislocated cartilage. Moreover, the Veteran's symptoms of popping and locking are associated with her additional complaints of knee pain and falls. As such, the Board finds that a disability rating under 5258 is not warranted, but, as explained above, a separate disability rating under Diagnostic Code 5257 has been assigned and is warranted for those symptoms. There is also no evidence of record indicating symptomatic removal of semilunar cartilage, limitation of extension, impairment of the tibia or fibula, or genu recurvatum warranting a rating under such Diagnostic Codes. As such, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5258, 5259, 5261, 5262, or 5263 respectively for her right knee disability. In reaching the above determinations, the Board has considered the Veteran's competent lay assertions, to include her reports of pain and difficulty standing and walking, limitation of motion, and instability. The Veteran is certainly competent to describe her observations and the Board finds that her statements are credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that personal knowledge is "that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted"). However, the Board finds that the objective medical findings by skilled professionals, which incorporate the Veteran's competent assertions, provide the most persuasive evidence regarding the limitations posed by the Veteran's knee disability. Based on the foregoing, entitlement to a disability rating in excess of 10 percent for right knee DJD is not warranted. Entitlement to a separate disability rating of 10 percent, and no higher, under Diagnostic Code 5257, for instability of the right knee, effective August 1, 2002, is warranted. Entitlement to a disability rating in excess of 10 percent beginning December 1, 2020, is not warranted. The Veteran has not raised any other issues with respect to the higher initial rating claim, nor have any other assertions 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). 4. Entitlement to an initial disability rating in excess of 10 percent for left knee DJD is denied. 5. Entitlement to a separate disability rating of 10 percent, and no higher, for left knee instability from August 1, 2002 to December 1, 2020 is granted. 6. Entitlement to a disability rating in excess of 20 percent for left knee instability beginning December 1, 2020, is denied. The Veteran is seeking higher disability ratings for her left knee disabilities. Specifically, she contends that her disabilities are more severe than reflected by her currently assigned disability ratings because she experiences pain, swelling and limitation of motion. See September 2015 VA Form 9. Here, the Veteran is currently assigned a 10 percent disability rating for left knee DJD under Diagnostic Code 5260, effective August 1, 2002, and a 20 percent disability rating for left knee instability, effective December 1, 2020. Following a review of the record and the applicable legal criteria and for the reasons detailed below, the Board finds that a higher disability rating for left knee DJD is not warranted and that an additional separate 10 percent disability rating for left knee instability is warranted from August 1, 2002 to December 1, 2020. With regard to whether a higher rating is warranted for the left knee under the currently assigned Diagnostic Code 5260, as noted above, a 10 percent disability rating is warranted where flexion is limited to 45 degrees and a 20 percent disability rating is warranted where there is flexion is limited to 30 degrees. Here, the evidence reveals that the Veteran has functional flexion better than 45 degrees. Specifically, the February 2017 and December 2020 VA examiners evaluated ranges of motion, pain, additional limitation of motion and functional loss upon repetitive testing, and limitation on weight-bearing, and found that the Veteran's flexion in in the left knee was limited, at worst (i.e. during flareups), to 55 degrees. Accordingly, the preponderance of evidence is against a higher disability rating of 20 percent, which contemplates flexion limited to, at worse, 45 degrees, under Diagnostic Code 5260 based on limitation of motion. The Board recognizes, however, that 'painful' motion under Diagnostic Code 5260 warrants at least a minimum compensable rating pursuant to provisions of 38 C.F.R. § 4.59. Here, the evidence shows that the Veteran has painful motion. See, e.g., December 2020 VA Examination. As such, the currently assigned disability rating of 10 percent for left knee DJD under Diagnostic Code 5260 most closely approximates the Veteran's disability picture. The Board next acknowledges, as noted above, that the Veteran has been assigned a 20 percent disability rating under Diagnostic Code 5257, for instability, effective December 1, 2020. Therefore, the Board will consider whether a separate rating is warranted prior to December 1, 2020, and/or a higher rating is warranted for the entire period under appeal, under Diagnostic Code 5257 under the regulations in effect both prior to and following February 7, 2021. Here, the evidence indicates that an initial disability rating of 10 percent, effective August 1, 2002, is warranted for the Veteran's left knee disability under Diagnostic Code 5257. Specifically, in a December 2009 VA examination, the examiner found instability and the Veteran has competently and credibly reported instability, pain, her knee giving way, and falls throughout the appeal period. Accordingly affording the Veteran the benefit of the doubt, the Board finds that a separate 10 percent disability rating under Diagnostic Code 5257 for slight or mild instability, for the period on appeal from August 1, 2002 (the first day of the month following her discharge) to December 1, 2020, is warranted. The Board additionally finds that for the period on appeal prior to December 1, 2020, the record does not indicate that the Veteran's instability was "moderate" or of medium quantity. Indeed, throughout this appeal period VA examinations show no joint instability. In addition, although the Veteran uses a brace an assistive device, the evidence of record does indicate that the Veteran experienced a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability or that a medical provider has prescribed a brace for his knee. As such, a disability rating higher than 10 percent under Diagnostic Code 5257, for the period on appeal prior to December 2020 is not warranted. Regarding the period on appeal beginning December 1, 2020, the Board also finds that a disability rating in excess of 20 percent is not warranted. The record does not indicate that the Veteran's instability was "severe" or of extremely intense. Rather, at worst, in her December 2020 VA examination, the Veteran was found to have only anterior instability of 2+ in the left knee. In addition, although the Veteran uses a brace an assistive device, the evidence of record does indicate that the Veteran experienced unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. As such, a disability rating higher than 20 percent under Diagnostic Code 5257, for this period on appeal, under the regulations in effect both prior to and following February 7, 2021, for the left knee is not warranted. The Board next considered whether higher or separate ratings were warranted under another appropriate Diagnostic Code. Here, there is no evidence in the claims file showing ankylosis so as to warrant a disability rating under Diagnostic Code 5256. Regarding Diagnostic Code 5258, the Board acknowledges that the Veteran has competently and credibly reported popping and locking symptoms throughout the record. There is, however, no indication of effusion or semilunar dislocated cartilage. Moreover, the Veteran's symptoms of popping and locking are associated with her additional complaints of knee pain and falls. As such, the Board finds that a disability rating under 5258 is not warranted, but, as explained above, a separate disability rating under Diagnostic Code 5257 has been assigned and is warranted for those symptoms. There is also no evidence of record indicating symptomatic removal of semilunar cartilage, limitation of extension, impairment of the tibia or fibula, or genu recurvatum warranting a rating under such Diagnostic Codes. As such, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5258, 5259, 5261, 5262, or 5263 respectively for her left knee disability. In reaching the above determinations, the Board has considered the Veteran's competent lay assertions, to include her reports of pain and difficulty standing and walking, limitation of motion, and instability. The Veteran is certainly competent to describe her observations and the Board finds that her statements are credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that personal knowledge is "that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted"). However, the Board finds that the objective medical findings by skilled professionals, which incorporate the Veteran's competent assertions, provide the most persuasive evidence regarding the limitations posed by the Veteran's knee disability. Based on the foregoing, entitlement to a disability rating in excess of 10 percent for left knee DJD is not warranted. Entitlement to a separate disability rating of 10 percent, and no higher, under Diagnostic Code 5257, for instability of the left knee, from August 1, 2002 to December 1, 2020, is warranted. Entitlement to a disability rating in excess of 20 percent for left knee instability, effective December 1, 2020, is denied. The Veteran has not raised any other issues with respect to the higher initial rating claim, nor have any other assertions 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). KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Kaufer, 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.