Citation Nr: 21032104 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 16-50 218 DATE: May 25, 2021 ORDER Entitlement to service connection for residuals of a traumatic brain injury (TBI), other than service-connected headaches, is denied. Entitlement to a 30 percent rating for right knee status-post cartilage restoration surgery with degenerative arthritis, but no higher, is granted from December 29, 2013. FINDINGS OF FACT 1. The Veteran does not have residuals of a TBI other than his already service-connected headaches. 2. Based upon facts found, including the Veteran's lay statements, the Veteran's right knee status-post cartilage restoration surgery with degenerative arthritis has more closely approximated the criteria for a 30 percent rating for limited flexion throughout the period on appeal. 3. Right knee status-post cartilage restoration surgery with degenerative arthritis is manifest by painful motion, swelling, weakness, fatigue, lack of endurance, and flexion limited to 15 degrees or less with repetitive use and flareups. Instability was not demonstrated before September 23, 2019. CONCLUSIONS OF LAW 1. Apart from already service-connected headaches, residuals of a TBI were not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.14. 2. From December 29, 2013, the criteria for a rating of 30 percent for right knee status-post cartilage restoration surgery with degenerative arthritis, but no higher, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1980 to October 1984. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a December 2018 decision, the Board granted service connection for headaches as due to multiple in-service head injuries, denied entitlement to service connection for non-headache residuals of a traumatic brain injury, and remanded entitlement to a rating in excess of 10 percent for a right knee disability to obtain a new VA examination. The Veteran appealed the portion of the Board's December 2018 decision that denied service connection for residuals of a TBI. In October 2019, the Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Partial Remand (JMPR) and vacated the denial of service connection for residuals of a TBI. The parties to the JMPR agreed that a May 2015 VA examination for TBI was inadequate and that a new medical opinion must be provided. The Board remanded the claim for service connection for TBI residuals in February 2020 to obtain new VA examinations and nexus opinions consistent with the terms of the JMPR. The new knee examination was provided in September 2019. In June 2020, the RO issued a rating decision increasing the rating for the Veteran's right knee disability to 30 percent and granting a separate evaluation for right knee instability effective September 23, 2019, the date of the examination. A Supplemental Statement of the Case (SSOC) was also issued in June 2020 denying a rating in excess of 10 percent for the period prior to September 23, 2019. A new VA examination and opinion for TBI residuals were provided in July 2020. Addendum opinions were obtained in February and March 2021, and a Supplemental Statement of the Case was issued in March 2021. The Board's prior remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). These matters return to the Board for further consideration. 1. Service connection for residuals of TBI. The Veteran seeks service connection for residuals of a head injury that occurred in service. Veterans are entitled to compensation from VA if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). 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; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In a December 2018 decision, the Board granted service connection for headaches as due to an in-service head injury. Evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Therefore, the Veteran is not entitled to service connection for headaches again as a residual of a TBI. He has already been granted service connection for headaches under a different, albeit related, theory. The issue for the Board is whether the Veteran has any current, non-headache disability of TBI or residuals of TBI that began during service or is at least as likely as not related to service. After considering the evidence, we conclude that the preponderance of the evidence is against finding any current, non-headache disability related to a TBI or TDI residuals. Service treatment records show the Veteran was found on the floor of a bathroom in April 1980 with complaints of severe abdominal pain. The Veteran has reported that he had passed out following a vaccination during bootcamp and hit his head during this incident. He complained of stomach pains, cramps, nausea, and vertigo in May 1981 and was assessed with an inguinal muscle strain. In November 1981 the Veteran reported severe chest pains and left arm numbness during physical training and was assessed with chest pain of unknown etiology. In May 1982 he complained of headaches following a car accident. He had headaches and diarrhea in July 1982, and was assessed with nausea, tension, and general malaise. In August 1983 he reported headaches and dizzy spells. February 1984 records show complaints of frontal and occipital headaches and nausea with no emesis and was assessed with tension headaches and borderline high blood pressure. In July 1984 he hit his head on the bottom of a truck and had a small laceration and edema on the tip right side of his head. A report of medical history documents that the Veteran was admitted for observation due to a head injury that left no sequelae. The Veteran was afforded a VA TBI examination in May 2015. Regarding head injuries, the Veteran reported that headaches had begun after he was admitted to the hospital following inoculations during bootcamp, and that he had hit his head on the side of a truck in July 1984. No cognitive impairments or residuals of TBI were identified, although the examiner did note the Veteran had verbal and physical aggression in the late 1980s. The examiner concluded the Veteran had injured his head once in July 1984 and that the injury did not meet the criteria for a TBI. Regarding the May 2015 examination and opinion, in October 2019 the Court granted a September 2019 JMPR wherein the parties to the JMPR agreed the examination and opinion were inadequate. Specifically, the had examiner determined the Veteran only suffered one in-service head injury, although at least three were documented in the service treatment records. Furthermore, the examiner did not address numerous in-service reports of symptoms following the Veteran's in-service head injuries, including chronic diarrhea, nausea, vertigo, possible nerve pain, and malaise. As such, the May 2015 examination and opinion are inadequate, and the Board will not rely upon either in deciding the claim. We do note, however, that no residuals of TBI were identified. The Veteran was provided a VA examination for TBI residuals in July 2020. The examiner indicated that the claims file had been reviewed. The examiner noted a diagnosis of TBI in 1980 when the Veteran had a head blow from a fall during bootcamp and Parris Island, and that the TBI caused the Veteran's cervicogenic headaches. No cognitive impairments of TBI were identified. The examiner noted that the Veteran had reported memory issues that were not confirmed on the examination. The only additional residual of TBI identified was headaches. The examiner noted there were no demonstrated brain or memory problems, and that no PTSD or psychiatric issues were observed. The examiner provided a negative nexus opinion in October 2020 determining that headaches were not related to service. However, the Veteran is already service connected for headaches, and the opinion relied in part on finding no in-service head injuries, despite the examiner's finding that the Veteran had sustained a TBI in 1980. As such, this opinion is of lessened probative value. An addendum opinion was provided in February 2021. Regarding the reported symptoms of chronic diarrhea, nausea, vertigo, nerve pain, and malaise, the examiner noted that there was a head blow in 1980 that led to headaches, and no other evident brain damage was noted. The examiner explained the residual headaches correlate with the 1980 injury, and the normal neurological evaluation on examination makes the conclusion that there was no other brain damage a correct and valid conclusion. The examiner opined that the passing out after the inoculation was the entire cause of the headaches since 1980, and no other injuries are causative. The neurological examination was within normal limits, and there is no evidence of brain damage. The examiner concluded the headaches began right after the 1980 injury and no other problems. We note that another addendum opinion of record is dated March 2021. The rationales and opinions contained in the March 2021 addendum are the same as those contained in the February 2021 opinion. Specifically, the examiner clarified that there was a head blow in 1980 that led to headaches with no other evident brain damage noted, that passing out from the inoculation was the cause of headaches since 1980, that the neurological examination was within normal limits, and there is no evidence of brain damage. For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) be the product of reliable principles and methods; and (3) be the result of principles and methods reliably applied to the facts. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Id. at 304. Here, the Board finds the February and March 2021 VA opinions persuasive. The opinions were provided following a review of the record and examination of the Veteran. The provided rationale is consistent with the record and based on the facts of the case. The examiner considered the service treatment records and determined that the only TBI the Veteran had incurred was the 1980 fall during bootcamp, and addressed the symptoms listed in the September 2019 JMPR. Notably, the only symptom identified on the July 2020 examination that was associated with the Veteran's in-service head injuries were headaches. The remainder of the neurological examination was normal. Pertinently, there are no contrary nexus opinions of record addressing whether the Veteran has any non-headache TBI residuals. September 2016 and February 2019 private nexus opinions inion from a private physician attributes only headaches to the Veteran's in-service head injuries. We acknowledge March 2021 VA treatment records where the Veteran reported ongoing headaches, poor concentration and forgetfulness, poor sleep, anxiety, and depressed mood due to head injuries. Although the treating physician stated that he could not rule out TBI residual, he also noted that the symptoms are likely multifactorial from the Veteran's migraines disorder and chronic pain. See, e.g., Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the phrase "could not rule out" was too equivocal to establish medical nexus); see also 38 C.F.R. § 3.102 (finding of service connection may not be based on a resort to speculation or a remote possibility). The Board has considered the lay statements of record. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay people are competent to testify to visible or otherwise observable symptoms of disability. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In particular, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. However, the existence of disability of TBI and any residuals thereof is not subject to lay observation. Attributing current symptomatology to in-service head injuries would require knowledge of complicated diagnostic medical testing. Jandreau, 492 F.3d at1377, 1377 n.4. Although the Veteran is competent to report his prior diagnosis of TBI, his opinion is of no greater value than the evidence upon which it was based. Doctors have told the Veteran that his headaches are attributable to in-service head injuries. He is service connected for headaches and their associated symptoms, which include nausea and vomiting. See, e.g., October 2020 VA Headaches Examination. however, there is no competent evidence attributing any other current symptoms to in-service head injuries. The Board finds the July 2020 VA TBI examination report and the examiner's subsequent opinions to be far more probative than the Veteran's lay assertions that he has non-headache residuals of in-service head injuries. In reaching our decision, the Board acknowledges the September 2019 JMPR, in which the parties agreed that the Veteran had experienced in-service reports of symptoms following his head injuries, including chronic diarrhea, nausea, vertigo, possible nerve pain, and malaise. We note there is no medical evidence of record linking diarrhea or possible nerve pain to a head injury. Most pertinently, no symptoms or residuals of a TBI besides headaches were present upon reexamination in July 2020. The February and March 2021 VA nexus opinions are negative for non-headache TBI and head injury residuals. The private nexus opinions identify headaches as the only disability due to in-service head injuries. There is otherwise no competent, credible evidence that any non-headache symptom is attributable to in-service head injuries. Considering the above, the Board finds the Veteran does not have any residuals of his in-service head injuries beyond headaches, for which he is already service connected. There is little credible evidence that the Veteran currently experiences any other symptoms or residuals attributable to a TBI. Due to the absence of proof of a present disability, there is no valid claim for service connection as to non-headache residuals of TBI. Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability at any point during the claim or appeal period. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Given the lack of credible evidence of a nexus between service and residuals of TBI, the Board gives more probative weight to the medical evidence of record. Specifically, VA examiners have determined there are no other residuals of TBI. Consequently, the preponderance of the evidence is against finding the Veteran has any (non-headache) residuals from his in-service head injuries 2. Increased rating for right knee status-post cartilage restoration surgery with degenerative arthritis. The Veteran seeks a rating in excess of 10 percent for right knee status-post cartilage restoration surgery with degenerative arthritis from December 29, 2013 to September 23, 2019, and a rating in excess of 30 percent thereafter. Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155. Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45. Joint testing is to be conducted on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 170 (2016). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. The Veteran's right knee disability is rated under hyphenated Diagnostic Code 5003-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Diagnostic Code 5003 is for degenerative arthritis and instructs for evaluation on the basis of limitation of motion of the affected joints. Diagnostic Code 5261 pertains to limitation of extension of the leg. Diagnostic Code 5269 applies to limitation of flexion of the leg. Pursuant to Diagnostic Code 5260, flexion limited to 60 degrees or greater warrants a 0 percent rating. Flexion is limited to 45 degrees warrants a 10 percent rating is warranted. Flexion limited to 30 degrees warrants a 20 percent rating, while flexion limited to 15 degrees warrants the maximum 30 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Separate ratings may be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology. 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 disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Separate ratings may be awarded for limitation of flexion and limitation of extension of the same knee joint. VAOPGCPREC 09-04, 69 Fed. Reg. 59990 (2004). A precedential opinion by VA General Counsel held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260 and a compensable limitation of extension under Diagnostic Code 5261, provided that the degree of disability is compensable under each set of criteria. Id. Regarding limited extension, a 0 percent rating is warranted for extension limited to 5 degrees. 10 percent rating is warranted when extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted with extension limited to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 Effective September 23, 2019, the Veteran was assigned a separate 10 percent rating under Diagnostic Code 5257 for slight instability of the right knee. Diagnostic Code 2557 provided a 10, 20, or 30 percent ratings for slight, moderate, or severe recurrent subluxation or lateral instability of the knee. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. The diagnostic criteria applicable to semilunar cartilage are found at 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under that code, a maximum 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Symptoms due to the removal of the semilunar cartilage of either knee warrant a 10 percent rating, which is the maximum rating under the diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5259. An evaluation of a knee disability under Diagnostic Code 5257 or 5261 or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under Diagnostic Code 5258 or 5259, and vice versa. Lyles v. Shulkin, 29 Vet. App. 107 (2017). Rather, a separate evaluation in a given case depends on whether manifestations for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different diagnostic code; and that, in evaluations of musculoskeletal disabilities based on limitation of motion, a manifestation has not been compensated, for separate evaluation and pyramiding purposes, if that manifestation did not result in an elevation of the evaluation under 38 C.F.R. §§ 4.40 and 4.45, pursuant to principles set forth in DeLuca. Id. at 11819. Analysis The Veteran seeks a rating in excess of 10 percent for his right knee status-post cartilage restoration surgery with degenerative arthritis for the period from December 29, 2013 to September 23, 2019. As noted above, the knee is assigned a 10 percent rating under hyphenated Diagnostic Code 5003-5260 for limited flexion during this time frame. After considering the evidence, the Board concludes that a uniform 30 percent evaluation for the left knee for limited flexion is warranted from December 29, 2013 (the entire period on appeal). The Veteran was provided a VA examination for the right knee in May 2015. He reported a right knee cartilage restoration surgery in 1996, that he had flareups in his knee weekly, and that he had difficulty running, climbing stairs, and walking for long periods of time. Range of motion testing showed flexion was initially limited to 135 degrees, but to 120 degrees after repetitive use and during flareups. Pain caused the initial limitation of motion, and repetitive use and repeated use over time were reduced by pain and weakness. There was pain with weight bearing and moderate patellar tenderness, and muscle strength of the right leg was reduced. Stability testing was normal. In the July 2015 Notice of Disagreement, the Veteran reported constant pain in the right knee that increased with any prolonged activity. In the October 2016 VA Form 9, the Veteran stated that the May 2015 examiner had bent and flexed his right knee past the point of discomfort and pain and that the examination did not provide an objective portrait of his disability. In a January 2017 statement, the Veteran's representative requested a new VA examination for the right knee in part due to the Veteran's reports that the disability had worsened. As noted above, the Board remanded the claim in December 2018 to obtain a new VA examination for the right knee. He was provided a new VA examination in October 2019. The examiner noted multiple right knee diagnoses, including knee strain, tendonitis/tendinosis, a meniscus tear, instability, cartilage restoration surgery, shin splints, and degenerative arthritis. The Veteran reported constant right knee pain that had continued to worsen, with daily right knee flareups. The flareups were severe, lasted 3 to 4 hours, and caused by sitting for too long, using stairs, and standing for long periods of time. he had difficulty standing for longer than 20 to 30 minutes, walking, driving, and sitting for more than 10 to 15 minutes, using stairs, bending down and squatting, kneeling, doing household chores, and doing yard work. He could no longer run or jog. Range of motion testing showed flexion was initially limited to 60 degrees, but to 15 degrees after repetitive use and with 0 degrees of flexion during flareups. Pain caused the initial limitation of motion. The additional limitations with repetitive, repeated use over time, and during flareups were caused pain, fatigue, weakness, and lack of endurance. There was pain with weight bearing and non-weight bearing, and severe localized tenderness on the anterior, lateral, medial, posterior, and superior aspects of the knee. Swelling contributed to the disability, and muscle strength was reduced. Here, the in the Veteran reported severe flareups in the July 2015 Notice of Disagreement. He reported multiple times that the old May 2015 VA examination report did not accurately reflect severity of his right knee disability, and first requested a new VA examination in the October 2016 VA Form 9 because his right knee had worsened. He was finally provided a new VA examination in September 2019, in which the examiner estimated that repeated use would limit flexion to 15 degrees and flareups would cause loss of flexion. We note that the current 30 percent rating, effective September 23, 2019, was assigned as of the date of the VA examination. Here, the Veteran provided lay testimony that his right knee disability was worse than indicated in the May 2015 VA examination report, particularly with repeated use and during flareups. On reexamination, repeated use limited flexion to 15 degrees and flareups caused flexion to drop to zero degrees. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno, 6 Vet. App. at 469. Lay people are competent to testify to visible or otherwise observable symptoms of disability. Jandreau, 492 F.3d at 1376-77; Buchanan, 451 F.3d at 1336. Here, the Veteran provided competent and credible statements that his right knee disability was worse than shown in May 2015, later confirmed upon examination in in September 2019. As such, the Board will grant the Veteran's claim and assign a 30 percent rating effective December 19, 2013, the effective date of the original rating. We acknowledge the objective findings of the May 2015 examination show a level of impairment warranting only a 10 percent rating pursuant to 38 C.F.R. § 4.59. However, given the Veteran's contemporaneous reports that the May 2015 VA examination did not accurately reflect the level of disability, especially repeated use and during flares, we find a higher 30 percent rating is warranted for the entire period on appeal. A rating more than 30 percent for limited flexion of the right knee is not warranted. The Veteran is in receipt of the maximum schedular rating under Diagnostic Code 5260 for limited flexion of the knee. The rating contemplates pain on motion and is consistent with limitation of flexion to 15 degrees or less. Even considering functional loss due to pain and other factors, more than the maximum 30 percent assignable under Diagnostic Code 5260 for limited flexion of the right knee is not assignable. See Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology. First, we note that the Veteran is currently in receipt of a separate 10 percent rating under Diagnostic Code 5257 for slight instability of the right knee, effective September 23, 2019. The Veteran has not indicated that he disagrees with this rating, or that an earlier effective date is warranted. The issue of whether a higher evaluation is warranted under Diagnostic Code 5257 is not currently before the Board. Furthermore, that the evidence does not show that the Veteran had instability in his right knee prior to the current effective date, and he has not contended otherwise. In the absence of such instability, a separate evaluation under Diagnostic Code 5257 is not warranted prior to September 23, 2019. A separate evaluation under any other applicable diagnostic code is not warranted. Diagnostic Code 5256 is inapplicable as the Veteran does not have ankylosis of the right knee or the functional equivalent of same. The record does not show malunion or nonunion of the tibia and fibula or genu recurvatum, and as such, separate disability ratings under Diagnostic Codes 5262 and 5263 are also not warranted. A separate rating under Diagnostic Code 5261 would only be permitted where limitation of extension was compensable, which is not the case here. See VAOPGCPREC 9-04 (2004). No limitation of flexion of the right knee has been shown. VA examinations show the Veteran retains extension to zero degrees in the right knee, and there is no evidence to the contrary. A noncompensable rating under Diagnostic Code 5261 requires extension to be limited to 5 degrees, which has not been shown. Extension has not been noted to have been painful. We note that the Veteran is already in receipt of at least the minimum compensable rating for painful motion under Diagnostic Code 5003-5260. See 38 C.F.R. § 4.59 ("It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint."). A separate rating under Diagnostic Code 5261 is therefore not warranted Diagnostic Code 5258 provides a 20 percent evaluation for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides a 10 percent evaluation for symptomatic removal of the semilunar cartilage. Here the Veteran had surgery to remove cartilage from his right knee, and the most recent VA examination showed episodes of locking, pain, and effusion of the right knee. However, the pain, swelling, and symptoms related to removal of knee cartilage have been noted as causing the reduced range of motion of the right knee, which is contemplated by the 30 percent rating under Diagnostic Code 5260. Compensating the Veteran pursuant to Diagnostic Code 5258 or 5259 would constitute impermissible pyramiding because the Veteran is already being expressly compensated for pain causing limited flexion, which are among the symptoms of his cartilage removal and documented meniscal injury. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In sum, the preponderance of the evidence is in favor of awarding a 30 percent rating for limited, painful flexion of the right knee for the entire period on appeal. This is the schedular maximum rating available for limited flexion of the knee under Diagnostic Code 5260. A separate rating besides the 10 percent evaluation for instability assigned from September 23, 2019, is not warranted. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morse 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.