Citation Nr: 21032423 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 10-33 945 DATE: May 27, 2021 ORDER Entitlement to an initial rating in excess of 30 percent for left knee instability is denied. Entitlement to an initial rating in excess of 20 percent for patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee based on limitation of extension is denied. Entitlement to an initial rating of 20 percent, but no higher, for patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee based on limitation of flexion is granted. FINDINGS OF FACT 1. The Veteran's left knee instability has been assigned a 30 percent rating, which is the maximum schedular rating authorized under the applicable criteria. 2. Even when considering functional impairment due to factors such as pain, weakness, fatigability, incoordination, pain on movement, or on flare-up, the Veteran's patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee has not manifested in limitation of extension to 20 degrees or greater. 3. When considering functional impairment due to factors such as pain, weakness, fatigability, incoordination, or pain on movement, the Veteran's patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee has manifested in flexion limited to 30 degrees, but no less, on flare-up. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 30 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 2. The criteria for entitlement to an initial rating in excess of 20 percent for patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee based on limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 3. The criteria for entitlement to an initial rating of 20 percent, but no higher, for patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee based on limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1993 to September 1995. This matter comes before the Board on appeal from a March 2009 Regional Office (RO) rating decision. In January 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge. In a December 2017 decision, the Board increased the rating for the left knee disability from 10 percent to 20 percent based on limitation of extension, effective for the entire appeals period. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In September 2018, the parties submitted a Joint Motion for Partial Remand requesting that the issues be vacated and remanded for compliance with the terms of the Joint Motion. The Court granted this motion in a September 2018 Order, and the case was returned to the Board for further adjudication. The Board again denied the claims at issue in April 2019. The Veteran again appealed to the Court. In March 2020, the parties submitted an Amended Joint Motion for Partial Remand requesting that the issues be vacated and remanded for compliance with the terms of the Joint Motion. The Court granted this motion in an April 2020 Order, and the case was returned to the Board for further adjudication. The Board remanded this claim in October 2020 for further development, and the case has been returned to the Board. Increased Rating Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Separate ratings may be assigned for limited knee motion in flexion (under Diagnostic Code 5260) and in extension (under Diagnostic Code 5261), as well as for instability (under Diagnostic Code 5257). VA Gen. Counsel. Prec 23-97 (July 1, 1997). A separate compensable rating may also be assigned for meniscal pathology under Diagnostic Code 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). Under Diagnostic Code 5260, a 0 percent (noncompensable) rating is assigned for leg flexion limited to 60 degrees. A 10 percent rating is assigned for leg flexion limited to 45 degrees. A 20 percent rating is assigned for leg flexion limited to 30 degrees. A maximum 30 percent rating is assigned for leg flexion limited to 15 degrees. Diagnostic Code 5261 provides a 0 percent rating for leg extension limited to 5 degrees. A 10 percent rating is warranted where 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 where extension limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. A 50 percent rating is warranted where extension is limited to 45 degrees. The Board notes that some of the rating criteria under 38 C.F.R. § 4.71a have recently changed, effective February 7, 2021. There has been no substantive change to the criteria of Diagnostic Codes 5260 or 5261. Thus, a higher rating is not warranted under the new rating criteria. Under Diagnostic Code 5257, a rating of 10 percent is warranted when there is slight recurrent subluxation or lateral instability; a 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted when there is severe recurrent subluxation or lateral instability. Words such as "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. In September 2008, the Veteran filed the instant claim for an increased rating. A September 2008 VA treatment record shows that the Veteran reported recently noticing an odd shape to his left knee. On examination, the Veteran had decreased range of motion of the left knee, and an x-ray showed tricompartmental osteoarthritis changes and "loose osseous fragments in the infrapatellar region." A September 2008 VA orthopedic consultation note shows that the Veteran reported worsening pain in his left knee that is exacerbated by walking, stairs, and sitting for long periods of time. He reported that his knee had a few minutes of stiffness after rising from a chair. He also reported grinding when he flexes or extends his knee. On examination, the Veteran had several prominent bony excrescences on the medial and lateral aspect of his knee, he was tender to palpation over the medial border of the patella, and he had 5 to 105 degrees of knee motion. X-rays showed extensive patellofemoral arthritis with some calcifications in the patella tendon. The impression was severe patellofemoral arthritis. In an October 2008 statement, the Veteran reported worsening left knee symptoms. He indicated that he could not fully extend his left knee, stand for long periods of time, or sit in cramped areas. The Veteran was afforded a VA examination in October 2008. He reported pain in his left knee at a severity of 6/10, with flare-ups of pain to 10/10 four to five days per week. He also reported that he can walk for approximately two blocks before he starts having a fair amount of knee pain. The Veteran reported that his left knee affects his daily activities in that he is unable to do prolonged driving or walking secondary to anterior knee pain, and he also reported some locking up of his knee at times. On examination, the left knee showed no effusion, but there were palpable osteophytes on the lateral border of the patella. Range of motion testing showed zero to 95 degrees of flexion with both active and passive movement. There was no decreased arc of motion or increasing amount of pain with three repetitions, but there was pain in the last 20 degrees of flexion. The examiner opined that it was "conceivable that pain could further limit function as described, typically after being on his feet all day." However, the examiner also indicated that "it was not feasible to express further functional limitations in additional limitation of motion." There was pain with patellofemoral grind, crepitus, and mild tenderness to palpation about the medial joint line. There was no instability with varus or valgus stress testing, anterior and posterior drawer testing, and Lachman's testing. McMurray's sign was negative, and the Veteran's gait was antalgic on the left. X-rays showed "significant patellofemoral and mild medial compartment arthritis." The impression was "status post patellar tendon rupture with residual patellofemoral degenerative joint disease, moderate." A November 2008 VA physical therapy note shows that the Veteran reported a constant, deep pain in the left knee at a severity of 4/10, worsening to 10/10 with prolonged standing or walking, sitting in tight spaces, or hanging the left leg on the edge of a chair or bed. On examination, there was mild crepitus noted during flexion and extension. The knee was stable, and no ligamental joint laxity or instability was noted during valgus/varus stress tests. Locking of the left knee was reported, but was not noted on examination. Range of motion was within normal limits for both extension and flexion, and strength was 4/5 with both extension and flexion. No swelling or palpable joint effusion was noted. X-rays showed spurring at the margin of the medial joint compartment, prominent spurring at the patella with calcifications in the region of the patellar ligament, and possible bipartite patella. Although soft tissues above the knee were not completely imaged, there was "no suggesting of pleural effusion." A February 2009 VA orthopedic surgery note shows that there was positive exostosis of the patella laterally. There was positive crepitus noted with flexion and extension, but there was no swelling, palpable effusion, or locking noted. Range of motion was 3-5 to 105 degrees with complaints of general discomfort. The knee was stable to varus or valgus stress, no joint laxity was noted, extensor mechanism was intact, anterior and posterior drawer tests were negative, and there was a negative McMurray's sign. The impression was tricompartmental knee arthritis and large, lateral exostosis of the patella. A January 2010 VA treatment record shows that the Veteran reported worsening pain and instability in his knee. Left knee x-rays from June 2010 showed narrowing of the patellofemoral joint, irregular articulating surface of the posterior patella, small marginal osteophytes at the distal femur and upper tibia, and no joint effusion. A November 2010 independent medical examination report shows that the Veteran's left knee lacked approximately 12 to 15 degrees of full extension. Flexion was to 100 degrees. The ligaments were stable, and there was approximately an inch and a half of atrophy of the left quadriceps that was measured three inches above the patella. An MRI of the left knee showed intact anterior and posterior cruciate ligaments, and no discreet meniscal tear was demonstrated. Medial collateral and lateral collateral ligament complexes were intact. There was thickening of the patellar tendon and excess bone formation along the lower pole of the patella. The patella tendon was intact. A small joint effusion was present. In a January 2012 statement, the Veteran reported that his left knee "aches, pops, locks, heats up, crackles, swells, and seems to move out of place at times." He also indicated that his left knee cap has been defined as deformed due to the size and bony knot on the side of his knee cap. He reported that the knot aches and pulls at his skin over the patella. He also reported that because of the knot, he cannot lie on his left side without something cushioning his left knee, and he indicated that his knee sometimes locks. A January 2012 private examination shows that the Veteran's left knee had 15 degrees of active extension and 115 degrees of active flexion, with pain at the extreme limits of the range of motion. There was no effusion, medial instability, or lateral instability. No anterior drawer or posterior drawer sign was present, a Lachman test did not demonstrate one plane anterior instability, and a McMurray's test was negative. There was a large bony prominence on the superior lateral aspect of the left patella. X-rays showed that the left patella was "significantly enlarged compared to the right." A July 2012 VA orthopedic surgery consultation note shows that the Veteran had a hardened lump in the upper lateral border of the patella. Range of motion was zero to 115 degrees with discomfort. There was evidence of patellofemoral crepitus, patella grind, and joint line tenderness. Strength was 5/5 for both flexion and extension. There was no evidence of effusion, erythema, locking or mechanical symptoms, or antalgic gate. Joint stability testing was negative. The Veteran was afforded a VA examination in March 2017. The Veteran reported that his left knee "hurts, flares, swells, and locks up." The Veteran reported functional impairment due to loss of agility and flexibility. Range of motion was from zero to 70 degrees. The examiner indicated that the abnormal range of motion contributed to functional loss. There was pain noted on the examination on rest/non-movement. There was severe pain over the patella and to the lateral aspect of the knee, and there was a large bony mass facing outward from the knee/patella. There was evidence of pain with weight bearing, and there was objective evidence of crepitus. There was also evidence of pain on non-weight bearing. The examiner indicated that passive range of motion was not medically appropriate because it could cause injury to the Veteran. After three repetitions, range of motion was zero to 60 degrees, and this additional functional loss was due to pain and fatigue. The examiner also indicated that pain, weakness, fatigue, and lack of endurance would significantly limit functional ability during flare-ups, with an estimated range of motion of 0 to 60 degrees. The examiner estimated the degree of functional loss as 0 to 60 degrees of range of motion during both repeated use over time and flare-ups. The examiner reported that less movement than normal, swelling, disturbance of locomotion, interference with sitting, interference with standing, and "locks up, gets stiff," were additional contributing factors of disability. Muscle strength testing was 4/5 for both flexion and extension. There was no evidence of muscle atrophy. The examiner indicated that there was a history of recurrent effusion, but there was no history of recurrent subluxation or lateral instability. Joint stability testing was normal. The examiner also indicated that the Veteran had a meniscal tear with frequent episodes of joint locking, pain, and effusion. The examiner noted that the Veteran used a left knee brace regularly. The examiner indicated that the Veteran's left knee disability impacted his ability to perform occupational tasks in that it affected him with prolonged sitting, standing, and walking. The examiner summarized that the Veteran "does have arthritis present as confirmed in x-ray and MRI reports but there is no evidence of lateral patellar instability." The examiner also noted that "Meniscal conditions exist on exam and has an abnormal knee on exam with documented loss of cartilage and degenerative joint disease." The September 2018 Joint Motion and Order vacated the December 2017 decision to the extent that it denied a rating in excess of 20 percent after it determined that the March 2017 VA examination report did not satisfy the duty to assist. It noted that "[t]he examiner recorded Appellant's report that 'the left knee is getting worse ... [his] knee hurts, flares, swells, and locks up' and that functional loss or impairment consists of 'loss of agility and flexibility.'" However, it also stated that "the examiner did not elicit relevant information as to Appellant's flares or ask him to describe the additional functional loss." It determined that, "[o]n remand, the Board shall obtain a new VA examination or seek clarification of the March 2017 examination to address the functional impact of flare-ups of Appellant's left knee disability." The Board denied entitlement to a rating in excess of 10 percent for patellofemoral and medial compartment arthritis of the left knee with patellar tendon rupture in an April 2019 rating decision, but the issue was vacated and remanded in a March 2020 Joint Motion. The Veteran underwent a VA examination in February 2021. As noted in the October 2020 Board remand, the March 2020 Joint Motion determined that the Board had relied on an inadequate VA examination in its April 2019 decision, and thus had not complied with the September 2018 Joint Motion. The Joint Motion notes that "Although the examiner included estimates of the range of motion losses during a flare-up, the examiner also opined that he could not provide an opinion as to the additional functional loss caused by flare-ups without resorting to speculation." Specifically, the examiner estimated range of motion to 60 degrees flexion and 0 degrees extension on flare-up, while noting that it "would be speculative [to attempt to estimate range of motion on flare-up] other than to say it would limit him further as the veteran could not replicate a flare-up...." The Joint Motion continues that "To that end, his opinion suggests that the included range of motion estimates do not fully and accurately estimate the functional loss caused by Appellant's flare-ups, and, therefore, clarification is needed." It concludes that a new opinion or clarification of the March 2017 examination is warranted. The Joint Motion states that the parties agreed that: [T]he examiner did not elicit relevant information about Appellant's flares or ask him to describe the additional functional loss, if any, he suffers during flares, and then either (1) estimate the functional loss[]due to flares based on all of the evidence of record including lay information, or (2) explain why he could not do so. The Board remanded this claim to obtain an opinion that addresses the Joint Motion's concerns. On remand, the Veteran underwent a VA examination and an opinion was obtained that addresses the flare-ups question in February 2021. With respect to the physical examination, the examiner noted that the Veteran cannot stand more than five minutes and cannot walk more than one block. He has moderate impairment bending, squatting, crawling, and climbing fewer than 10 steps. He has severe impairment climbing more than 10 steps, jogging, and running. He reported having five flare-ups per week that average 30 minutes to two hours with a maximum of one to two days. The pain is 10 out of 10 in severity and has sharp/dull throbbing joint pains, increased locking sounds when standing from prolonged sitting, and moderate associated swelling. Precipitating factors are cold weather, walking more than one block, standing more than 10 minutes, trying to do yard work, trying to squat without assistance while doing house work, working underneath the sink on plumbing issues, and reaching in the bathroom sink cabinet for items. Alleviating factors include ice therapy, heat therapy, left leg elevation, and bedrest for one to two days. On flare-up, he has limited mobility and is dependent on assistive devices or a friend or relative. He is impaired in his activities of daily living, such as needing assistance at times with putting on his pants unless he is sitting in a chair. He is high risk in bathroom settings. He has functional impairment in that he has loss of balance and is a high risk fall. He has decreased exercise tolerance. He has minimal ambulation in that he can only walk less than one block and cannot stand more than five minutes. He has mild loss of independence with his activities of daily living. The Veteran reported at his February 2021 VA examination that he has one to two episodes of buckling per week, and that these complaints were noted after the Veteran was diagnosed with a meniscus tear. He noted that it began worsening with the swelling of the left knee and with turning or twisting. He has had a few falls. Weakness is worsened with patellar exostosis. He had a history of patellar grinding and patellofemoral crepitus. He has been prescribed knee sleeves with daily compliance and mild relief. Anterior stability and posterior instability testing could not be performed due to the Veteran's decreased range of motion. Initial active range of motion was flexion to 55 degrees and extension to 10 degrees. Limitation of flexion to 60 degrees and extension to 15 degrees was attributable to factors such as pain, weakness, fatigability, or incoordination. Pain and swelling were limiting flexion and weakness and pain from meniscus tear were limiting extension. Passive range of motion was flexion to 60 degrees and extension to 15 degrees, with pain on both flexion and extension. There was evidence of pain on weight-bearing, non-weightbearing, active motion, passive motion, and on rest/non-movement. Pain caused functional loss in that it limited kneeling, bending, squatting, and climbing stairs. There was objective evidence of crepitus. There was objective evidence of localized tenderness or pain on palpation at the bilateral borderlines of the anterior knee joint/patellar area, which is where there were extensive athletic processes/lateral patellar area at the site of bone deformity. On three repetitions, flexion was to 40 degrees and extension was to 15 degrees with pain, fatigability, and weakness causing functional loss. The examiner estimated that, on flare-up, the Veteran would be limited to 33 degrees of flexion and 15 degrees of extension, with functional loss due to pain, fatigability, weakness, lack of endurance, and incoordination. Additional factors contributing to disability were interference with sitting, interference with standing, swelling, disturbance of locomotion, deformity, less movement than normal, weakened movement, and instability of station. The Veteran constantly used a brace and regularly used a cane. It was noted that the Veteran had a bow-leg gait due to severe degenerative changes of the left knee. He was apprehensive on examination, and there was patellofemoral crepitus. The examiner noted bony growth along lateral patellar area, and there was effusion. As noted above, the February 2021 VA examiner was able to provide an estimate of the Veteran's additional impairment on flare-up. She provided a highly detailed explanation of the factors that are to be considered when providing such an estimate. The Board finds the February 2021 examination report, in particular, to be highly probative, as it was authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It contains detailed findings from examination and describes the Veteran's own testimony. The examiner also provided a detailed explanation as to how she calculated the additional limitation of motion on flare-up. Review of the Veteran's post-service medical records reveals that there are no additional VA medical records reflecting greater or additional impairment due to left knee instability or limitation of motion. 1. Entitlement to an initial rating in excess of 30 percent for left knee instability is denied. The Veteran is in receipt of a 30 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5257. This is the maximum rating that is available for instability of the knee. The Veteran underwent VA examinations in connection with this claim in October 2008, July 2016, March 2017, and February 2021, and he has received medical treatment for his knee. The October 2008, July 2016, and March 2017 VA examination reports note that there is no instability. As noted above, the Veteran reported at his February 2021 VA examination that he has one to two episodes of buckling per week, and that these complaints were noted after the Veteran was diagnosed with a meniscus tear. He noted that it began worsening with the swelling of the left knee and with turning or twisting. He has had a few falls. Weakness if worsened with patellar exostosis. He had a history of patellar grinding and patellofemoral crepitus. He has been prescribed knee sleeves with daily compliance and mild relief. Anterior stability and posterior instability testing could not be performed due to the Veteran's decreased range of motion. As noted above, the Veteran is in receipt of the maximum rating for his left knee instability for the entire appeals period. The Veteran does not contend that his left knee instability manifests in any symptoms that are not contemplated by the rating criteria of Diagnostic Code 5257. Therefore, a rating in excess of 30 percent is not warranted. The Board notes that some of the rating criteria under 38 C.F.R. § 4.71a have recently changed, effective February 7, 2021. However, none of the changes to Diagnostic Code 5257 provide a rating in excess of 30 percent. Thus, a higher rating is not warranted under the new rating criteria. The Board will consider whether increased or separate ratings are warranted for limitation of motion below. The Veteran has already been assigned a separate rating based on dislocated semilunar cartilage under 38 C.F.R. § Diagnostic Code 5258. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim of entitlement to an initial rating in excess of 30 percent for left knee instability must be denied. 2. Entitlement to an initial rating in excess of 20 percent for patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee based on limitation of extension is denied. 3. Entitlement to an initial rating of 20 percent, but no higher, for patellofemoral and medial compartment arthritis with patellar tendon rupture of the left knee based on limitation of flexion is granted. The Board finds that a rating in excess of 20 percent is not warranted for limitation of extension, as the maximum limitation of extension that is noted above is to 15 degrees. Specifically, these readings were found on November 2010 and January 2012 private examinations and on the February 2021 VA examination. These readings included consideration of functional impairment due to factors such as pain, weakness, fatigability, incoordination, or pain on movement of a joint. The Board finds, however, that a separate rating of 20 percent, but no higher, is warranted based on limitation of flexion for the entire appeals period. As noted above, the February 2021 VA examiner estimated that the Veteran's flexion would be limited to 33 degrees on flare-up. The Board notes that these readings are usually not expressed in a number that is not evenly divisible by 5. Given that this rating is fewer than 5 degrees above the criterion for the 20 percent rating, the Board will resolve reasonable doubt in favor of the Veteran and find that his flexion would be limited to 30 degrees on flare-up. This measurement satisfies the criteria for a rating of 20 percent, but no higher. This rating includes consideration of functional impairment due to factors such as pain, weakness, fatigability, incoordination, or pain on movement of a joint. The Board finds that this 20 percent rating is warranted throughout the appeals period. The Board has considered whether assigning a separate rating under Diagnostic Code 5260 based on limitation of flexion constitutes impermissible pyramiding with the Veteran's rating under Diagnostic Code 5258. The Board notes that Diagnostic Code 5258 may contemplate limitation of motion due to locking of the knee. While VA's General Counsel has held that Diagnostic Code 5259 (pertaining to removal of the semilunar cartilage) may contemplate limitation of motion, it has never addressed whether Diagnostic Code 5258 for dislocation of the cartilage similarly encompasses limited motion of the knee. See VAOGCPREC 9-98 (Aug. 14, 1998) (explaining that limitation of motion is a relevant consideration under Diagnostic Code 5259 for the symptomatic removal of cartilage because removal of cartilage may result in complications producing loss of motion). The Court has held that evaluation of a knee disability under Diagnostic Codes 5257, 5260, or 5261 (or all three) does not, as a matter of law, preclude a separate evaluation of a meniscal disability of the same knee under diagnostic codes 5258 or 5259, and vice versa. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Court further held that entitlement to a separate evaluation in a given case depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different diagnostic code. Id. The Board finds that in this case, the Veteran's limited flexion is not contemplated by his rating under Diagnostic Code 5258. In this regard, the Veteran's left knee disability has been manifested by objective evidence of cartilage damage, crepitus, locking, effusion, instability, and limited range of motion. The Board finds that the additional symptoms of cartilage damage, crepitus, locking, effusion, and instability are sufficient such that separate evaluations under Diagnostic Codes 5257, 5258, 6260, and 5261 avoid impermissible pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). As noted above, when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. In this case, a higher rating under Diagnostic Code 5260 based on these grounds is not warranted. The assigned 30 percent rating assigned under Diagnostic Code 5257 and the assigned 20 percent ratings under Diagnostic Codes 5258, 5260, and 5261 already contemplate the entirety of the Veteran's symptoms, including the Veteran's reports of pain, flare-ups, weakness, instability, and fatigability. The Veteran did not report, nor were there objective findings of, excess fatigability or incoordination. Thus, the newly-assigned 20 percent rating under Diagnostic Code 5260 already takes into account his functional loss due to pain and weakness, to include during flare-ups. In the absence of evidence of limitation of flexion to 15 degrees or less, entitlement to a rating in excess for limitation of flexion of 20 percent is not warranted. In short, entitlement to a rating in excess of 20 percent for limitation of extension of the left knee is not warranted at any time during the appeals period, while entitlement to a separate rating of 20 percent, but no higher, is warranted for limitation of flexion of the left knee throughout the entire appeals period. The Board notes that, with the above grant, the Veteran is in receipt of the following ratings for his left knee disabilities: (1) a 30 percent for instability under Diagnostic Code 5257; (2) a 20 percent rating for dislocated semilunar cartilage under Diagnostic Code 5258; (3) a 20 percent rating for limitation of flexion under Diagnostic Code 5260; and (4) a 20 percent rating for limitation of extension under Diagnostic Code 5261. These ratings combine to 64 percent, which is rounded to a 60 percent rating. 38 C.F.R. § 4.25. A combined rating in excess of 60 percent for the knee is prohibited because it would violate the "amputation rule," which prohibits a combined rating for musculoskeletal disabilities that would be in excess of that provided for amputation at the level of the subject joint. 38 C.F.R. § 4.68. Thus, the Veteran is in receipt of the maximum combined rating for disabilities of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5164. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, 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.