Citation Nr: 21040208 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 20-13 170 DATE: July 2, 2021 ORDER Entitlement to service connection for a heart disability is denied. Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. Entitlement to service connection for right knee degenerative arthritis is granted. Entitlement to a separate 10 percent rating under Diagnostic Code (DC) 5003 for left knee strain with shin splints and patellofemoral pain syndrome is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a heart disability began during active service, was otherwise caused by service, or was caused or aggravated by a service-connected disability. 2. The preponderance of the evidence is against finding that prostate cancer or residuals thereof began during active service or was otherwise caused by service. 3. The preponderance of the evidence is against finding that COPD began during active service or was otherwise caused by service. 4. Resolving doubt in the Veteran's favor, his right knee degenerative arthritis was caused by his service-connected left knee strain with shin splints and patellofemoral pain syndrome. 5. The Veteran's left knee disability is manifested by painful motion, locking, and effusion into the joint. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a heart disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2020). 2. The criteria for entitlement to service connection for prostate cancer have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2020). 3. The criteria for entitlement to service connection for COPD have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2020). 4. The criteria for entitlement to service connection for right knee degenerative arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; (2012); 38 C.F.R. § 3.159, 3.310 (2020). 5. The criteria for entitlement to a separate 10 percent rating under DC 5003 for left knee strain with shin splints and patellofemoral pain syndrome have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5003 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the United States Navy from April 1970 to April 1974. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated January 5 and 22, 2019 by a Department of Veterans Affairs (VA) Regional Office (RO). In an April 2020 decision, the Board granted a 20 percent rating under DC 5258 for the Veteran's left knee disability and remanded the above service connection claims for additional development. The Board denied service connection for diabetes mellitus and granted service connection for bilateral hearing loss. The Veteran appealed the left knee claim to the United States Court of Appeals for Veterans Claims (Court) and a February 2021 Order from the Court granted a February 2021 Joint Motion for Partial Remand (JMR) vacating and remanding the issue of entitlement to a rating for the left knee disability separate and distinct from the 20 percent rating assigned under DC 5258. The requested development for the service connection claims was completed and all issues are properly before the Board at this time. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110. Certain diseases, to include malignant tumors, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. There is no objective and/or credible evidence that any of the claimed disabilities manifested within one year of discharge from active service and, as such, further consideration of the foregoing provisions is not necessary. Alternatively, a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases shall be service connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Such diseases include, among others, ischemic heart disease (including coronary artery disease), prostate cancer, and respiratory cancers. 38 C.F.R. § 3.309(e). To establish a right to compensation for a present disability on a direct basis, 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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the alternative, service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 1. Entitlement to service connection for a heart disability 2. Entitlement to service connection for prostate cancer 3. Entitlement to service connection for COPD The Veteran contends that he has a heart disability, residuals of prostate cancer, and COPD due to his active service. Specifically, the Veteran alleges that he was exposed to Agent Orange due to transport as a passenger on a C-130 and a helicopter during service in Rota, Spain. He believes that his disabilities were caused by in-service exposure to herbicide agents, asbestos, or other hazardous materials from burn pits during his Mediterranean deployment, or hazardous materials, especially lead and sandblast grit, during his work at the Seabee area of the Naval Amphibious Base at Little Creek, Virginia. In the alternative, the Veteran also asserts that his heart disability was caused or aggravated by his diabetes mellitus, prostate cancer, and/or his COPD. In May 1970, the Veteran was treated for sinusitis, sore throat, and cough. His chest was clear on examination. X-rays were normal. The final diagnosis was viral acute respiratory disease with right otitis media. In January 1973, the Veteran reported chest pain when taking in a breath. The Veteran's chest was clear on examination. A chest x-ray ultimately showed moderate bronchitis. In July 1973, the Veteran passed out during inspection that morning. He denied any history of passing out. In an April 1974 discharge physical examination and an April 1976 Naval Reserve reenlistment physical examination, the Veteran stated that he was in good health. He denied a history of asthma, shortness of breath, pain or pressure in the chest, chronic cough, palpitation or pounding heart, heart trouble, frequent or painful urination, bedwetting, or kidney stones. The Veteran underwent a VA examination in July 1980 for his low back. At that time, the Veteran's heart was normal and lungs were clear. A May 1983 private treatment record documented that the Veteran had a history of emphysema. The Veteran indicated that he had smoked 1.5 packs per day and had smoked since the age of 13. The Veteran reported that he did have problems with coughing and wheezing, but denied any shortness of breath problems or chest illness in the last 3 years. Private treatment records note diagnoses of coronary artery disease (from April 2015), malignant neoplasm of the prostate (from June 2015), chronic bronchitis (from July 2017), and moderate COPD (from July 2017). In support of his claim, the Veteran submitted an October 2017 private sleep study that showed obstructive sleep apnea. In May 2018, the Veteran submitted a document evidencing lead contamination at Little Creek, Virginia. The Veteran also submitted prior Board decisions in the appeals of other veterans. A September 2018 VA email stated, "There is no scientific evidence available to VA showing that being in the vicinity of aircraft or equipment previously used in Vietnam can be considered as exposure to active Agent Orange or can result in long-term health effects. All evidence shows that any herbicide use the claimant or others observed, or were associated with, was the commercial variety, not Agent Orange. Therefore, Compensation Service can provide no evidence to support the claim." (Emphasis in original.) An online article submitted by the Veteran in October 2018 indicated that risk factors for prostate cancer included age, ethnicity, family history, diet, and asbestos exposure. Another article submitted by the Veteran at the same time stated that the main cause of COPD was smoking, but that exposure to environmental toxins, such as pollution, chemical fumes, asbestos, and other toxic workplace dust could also trigger the disease. The Veteran was afforded November 2018 VA examinations for each of the claimed disabilities. The April 2020 Board determination concluded that each of these examination reports were inadequate, as well as the January 2019 addendum opinion as to the right knee. As such, the Board will not consider these reports further. In a January 2020 statement, the Veteran discussed his work duties at Little Creek and how he may have been exposed to asbestos on the USS Fort Snelling when "They then tore down the systems that had failed and replaced all the necessary components. This took several days and Asbestos lined valves were laying all over the deck." The Veteran did not explain his participation in machinery and piping repairs by the ship's crew when his rating was as a Seabee equipment operator embarked for transport by the ship. He also discussed being exposed to dust, soil and sandblast grit during work with different pieces of equipment, including cranes, on the waterfront pier Seabee area ACB-2. A September 2020 medical opinion noted that coronary artery disease was documented as having its onset in 2008. A stress test in August 2017 showed exercise tolerance of 8.5 METS, a normal LV function, and no evidence of indicable ischemia. The documented risk factors included a smoking history, mixed hyperlipidemia, hypertension, and obesity. The opinion noted that the USS Fort Snelling participated in Project SHAD (Shipboard Hazard and Defense) in which various vessels were exposed to different benign organisms or substances to simulate chemical or biological warfare agents. The Fort Snelling, specifically, participated in event 69-10 that utilized tri (2-ethyl hexyl) phosphate. According to PubChem and other sources, that chemical was not known to be a carcinogen and the only toxicity noted was irritation of the skin or eyes with high levels of exposure. ATSDR Public Health Assessment for Naval Amphibious Base Little Creek, Virginia, dated in September 2003 concluded "that soil contaminants do not pose a public health hazard." They also found levels of lead above safe limits off-base at Water Tower 1553. The medical professional noted that the limits of the document was that it did not address base conditions 30 years prior, which would correspond to the Veteran's service at Little Creek. There was no specific information on potential work site exposures and specifically exposure at sites where the Veteran worked. The opinion noted that the Veteran submitted a statement that he traveled on a C-130 aircraft that "may" have transported Agent Orange. He also reported that he was on a helicopter that "may" have been contaminated by Agent Orange. He was a passenger in these aircraft operating in the Mediterranean Sea. The examiner could not find evidence that herbicides were transported by C-130 aircraft and in any event, potential exposure by a potential contaminated aircraft or helicopter was highly speculative and not included in recognized sources of exposure by VA. The medical professional concluded that it was less likely than not that the Veteran's coronary artery disease was due to or aggravated by toxic exposures in service. The rationale stated, "There is insufficient evidence ton conclude veteran was exposed to Agent Orange. There is very little evidence as to veteran's toxic exposures at Little Creek. It is unknown when the activities at Water Tower 1553 took place and there is no evidence that veteran took part. Veteran has multiple well known risk factors for coronary artery disease noted above. Other potential toxic exposures are unknown and the above document does not assist in identifying such exposures. The chemical exposure related to Project SHAD is not known to be a cause of coronary artery disease." A September 2020 medical opinion concluded that it was less likely than not that the Veteran's prostate cancer was due to toxic exposures in service. The rationale noted that the only toxin recognized as related to prostate cancer was Agent Orange, but there was insufficient evidence of any such exposure during service. There was no evidence the Veteran was exposure to related herbicides. A September 2020 medical opinion concluded that it was less likely than not that the Veteran's COPD was due to toxic exposures in service. In addition, to the evidence discussed with respect to the heart disability above, the medical opinion noted that the Veteran also reported a period of service onboard ship working with asbestos tile. That service and asbestos exposure was unconfirmed but work with asbestos tiles is consistent with his Navy construction duties. The available evidence showed a normal CT scan without any changes suggestive of asbestos-related disease and pulmonary function tests were inconsistent with the restrictive changes seen in asbestos-related disease. The rationale indicated that the Veteran's smoking history was "entirely sufficient to explain his COPD." Chest x-rays, CT scan, and pulmonary function tests all failed to show evidence of asbestos-related disease. There were a limited number of industrial chemicals that could cause COPD, but there was no evidence that the Veteran was exposed to any such chemicals. As to granting any of the Veteran's claims based on in-service onset, to the extent that the Veteran now claims in-service onset of symptoms the Board finds such a contention not credible. As noted above, in April 1976, the Veteran stated that he was in good health. He denied a history of asthma, shortness of breath, pain or pressure in the chest, chronic cough, palpitation or pounding heart, heart trouble, frequent or painful urination, bedwetting, or kidney stones. Had the Veteran been experiencing ongoing heart, respiratory, or the prostate symptoms, the Board finds it reasonable to expect that he would have so reported symptoms and problems with these systems had he been experiencing ongoing problems. As such, the Board finds any current contentions of ongoing symptoms of any of these systems from service to be of extremely limited probative weight. As to granting the claims based on exposure to herbicide agents, the Board has considered the Veteran's contentions of herbicide exposure from traveling on a C-130 and helicopter during service about the USS Fort Snelling in Rota, Spain. As discussed above, there is no evidence that exposure to aircraft demonstrates exposure to herbicide agents, including Agent Orange. In addition, the VA correspondence discussed how commercial herbicides were not governed under the regulations for Agent Orange exposure at 38 C.F.R. § 3.307(a)(6)(i). The Veteran has offered no specific argument regarding exposure to herbicide agents other than the general contention that he was exposed by riding on a C-130 and helicopter in Rota, Spain. The medical evidence is against associating any of the Veteran's claimed disabilities to exposure to herbicide agents, including Agent Orange. As such, the Board finds no basis for granting the claim on this basis. As to granting the claims based on in-service toxic exposure, including lead, the September 2020 VA medical opinions specifically considered whether toxic exposure could be the cause of the Veteran's heart disability, prostate cancer, and COPD. The medical professional noted that while there was evidence of toxic exposure at Little Creek in soil, it was unclear when that exposure occurred and it was unclear that it either was when the Veteran was stationed there or, if it did occur when he was there, that he was involved or exposed. Some general contact with soil, paint, and grit while moving materials is consistent with the duties of a Seabee equipment operator but the nature, frequency, and concentration of the substances is a factor in the development of disease which the medical professional considered. Moreover, as to the prostate cancer, there was no medical evidence suggesting any association with toxic exposure other than Agent Orange, to which there was no evidence the Veteran was exposed. The Veteran also had multiple known risk factors for both heart disease and COPD, including the Veteran's smoking history. As to the Veteran's claimed asbestos exposure, the September 2020 VA medical professional noted that multiple pulmonary function tests had not shown any evidence of asbestosis or other evidence of asbestos exposure to the lungs. The Board has considered the Veteran's lay contentions that his current heart disability, prostate cancer, and COPD was caused by in-service exposure to Agent Orange, lead, asbestos (as to the COPD), or other toxic substances. The Veteran is competent to report physically observable symptoms, but, as discussed above, there is no evidence of in-service exposure to herbicide agents and it is unclear whether the toxic exposures at Little Creek occurred prior or during the Veteran's service and to what extent the Veteran had exposure to any of those substances. Moreover, even assuming "exposure" (meaning some unquantified physical contact) to any of the claimed substances, given the medical complexity of linking a heart disability, prostate cancer, or COPD and the Veteran's lack of medical training, education, and experience the Board finds his contentions of extremely limited probative weight. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As such, the Board finds the September 2020 VA medical opinions to be the most probative evidence of record, given the greater level of education, training, and experience of the medical professional. As to the contentions that his heart disability was caused or aggravated by his diabetes mellitus, prostate cancer, and/or his COPD, service connection is not established for those disabilities herein or otherwise. As such, service connection may not be established for any of the claimed disabilities as secondary to service-connected multiple myeloma as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). 4. Entitlement to service connection for a right knee disability The Veteran was afforded a VA examination in September 2020. Following examination, the examiner concluded that it was less likely than not that the Veteran's right knee disability was due to or aggravated by his service-connected left knee or back disabilities. The rationale noted that medical literature did not support the theory of "favoring" one limb as a cause or aggravator of arthritis. Indeed, individuals with amputations were not more prone to degenerative arthritis in the remaining limb. If such a proposition were true, it would be expected that the arthritis would be worse in the right knee than the left knee, but the arthritis was symmetric. In support of his claim, the Veteran submitted a January 2021 letter from a VA nurse practitioner. The letter indicated that as the pain associated with the Veteran's service-connected left knee disability increased, "he developed significant gait disturbances resulting in increased weight bearing on the [right] knee. He now has moderate to severe arthritis of the [right] knee. Research supports the adverse effects of antalgic gait on opposite weight-bearing joint. Pain of one weight bearing joint, increases the load bearing on the unaffected joint in attempts to relie[ve] that pain and treatment focuses on relief of that pain []. This increased dynamic loading in the contralateral knee can result in the development of [osteoarthritis] in that knee []. This is supported further in a [further study] which noted that the secondary gait changes in patients with knee [osteoarthritis] of the affected knee result in an increased loading rate in he lower extremity joints may lead to faster onset of [osteoarthritis] at joints adjacent to the knee." Based on this evidence, the nurse practitioner concluded that the Veteran's right knee degenerative arthritis was at least as likely as not a result of the altered gait and weight-bearing on the right knee due to the chronic pain from the service-connected left knee strain, shin splints, patella-femoral pain syndrome, and meniscus tear. Thus, there is evidence both for and against the right knee claim. The VA medical opinions concluded that the right knee disability was not proximately due to or the result of the left knee. By contrast, the January 2021 VA nurse practitioner concluded that the Veteran's right knee arthritis was caused by his service-connected left knee disability. The nurse practitioner provided an extensive rationale for the opinion, discussing multiple medical studies that had shown a link between an antalgic gait due to one extremity resulting in load bearing on the unaffected joint that resulted in disability in the previously unaffected joint. As such, the Board concludes that the evidence is at least in relative equipoise as to whether the Veteran's diagnosed right knee arthritis was caused by his service-connected left knee disability. Increased Rating 5. Entitlement to a rating separate for the 20 percent rating under DC 5258 for left knee strain with shin splints and patellofemoral pain syndrome The Veteran contends that a separate rating in addition to the 20 percent rating assigned under DC 5258 is warranted for his left knee disability, as the current disability does not accurately reflect the severity of his disabilities. As noted above, the April 2020 Board decision granted a 20 percent rating under DC 5258 for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. The February 2021 JMR concluded that the Board erred in that the decision "did not consider whether [the Veteran's] limitation of motion could be rated under DC 5003. This is despite that in addition to [the Veteran's] meniscus disability, the November 2018 VA examination report documented arthritis and that the range of motion of [the Veteran's] knee was limited, at most, to 70 percent for both flexion and extension." Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. VA must consider whether the Veteran is entitled to "staged" ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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. DC 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. Effective February 7, 2021, 38 C.F.R. § 4.71a was changed to clarify that DC 5003 was for degenerative arthritis, other than post-traumatic. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate DCs, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate DCs, the compensable limitation of motion should be rated under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a. The general rating schedules for limitation of motion of the knee are 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). The Board also finds that a separate 10 percent rating is warranted under DC 5003 for the Veteran's left knee for the entire appellate time period. The Board finds that such a rating is warranted in light of the holding of the Court of Appeals for Veterans Claims in Lyles v. Shulkin, 29 Vet. App. 107 (2017) that evaluation of a knee disability under DCs 5257 or 5261 or both did not, as a matter of law, preclude a separate evaluation of a meniscal disability of the same knee pursuant to DC 5258 or 5259. The Court explained 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 DC." In Lyles, the Court also advised that "where a certain manifestation of a disability has not been compensated via an assigned evaluation under a particular DC, evaluation of that manifestation under another DC would not constitute pyramiding." In this case, and as discussed in the JMR, the November 2018 VA examination report showed both a left knee meniscal disability and left knee arthritis with painful motion limiting flexion to 85 degrees and further limited to 75 degrees following repetitive motion testing. While the left knee arthritis has not been specifically attributed to the Veteran's service-connected left knee disability, as there is no evidence that it is unrelated the Board will presume the arthritis is due to the service-connected left knee strain with shin splints and patellofemoral pain syndrome. Moreover, the Board notes that DC 5258 contemplates pain in the knee due to dislocated meniscal cartilage. It is unclear from the regulation whether the meniscal pain is due to active or passive motion or pain at rest. In this case, there is evidence of pain in the left knee with all types of motion (active, passive, weight-bearing, and non weight-bearing), as well as pain even at rest following activities. Given the evidence of arthritis, painful motion of the left knee joint with decreased motion, and that it is unclear to what extent the left knee pain has been attributed to the arthritis as opposed to the dislocated meniscal cartilage, the Board will afford the Veteran the benefit of the doubt and finds that a separate 10 percent rating under DC 5003 is warranted and does not constitute impermissible pyramiding. In addition, no higher or alternative rating under a different DC can be applied for either knee. The Board notes that there are other DCs relating to knee disorders, such as DC 5256 (ankylosis of the knee), DC 5257 (recurrent subluxation or lateral instability), DC 5259 (removal of semilunar cartilage, symptomatic), DC 5262 (impairment of the tibia and fibula), and DC 5263 (for genu recurvatum). The Veteran's left knee disability is not manifested by nonunion or malunion of the tibia and fibula, or genu recurvatum. Ankylosis is "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran is able to move his left knee, albeit with some limitation of motion, so it is clearly not ankylosed. There is no lay or medical evidence of recurrent subluxation or lateral instability. As there is no evidence that the Veteran has had any meniscal cartilage removed from the left knee, the Board finds that a rating under DC 5259 would not be warranted and, in any case, that such a rating would constitute impermissible pyramiding based on the overlapping nature of the symptoms contemplated by DCs 5258 and 5259. There is no evidence of left knee symptoms not fully contemplated in the currently assigned ratings. The Board notes that the Veteran's functional loss was considered, as the medical evidence shows that the Veteran has consistently complained of pain in the left and right knees. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). However, the limitation of motion documented in the medical records as resulting from pain is already contemplated in the disability ratings currently assigned. Consequently, the Board finds that a higher disability rating based on functional loss is not warranted. As shown above, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds that a separate 10 percent rating is warranted for the entire appellate time period for the Veteran's left knee disability under DC 5003. Otherwise, the Board finds no provision upon which to assign ratings greater than those listed above. Furthermore, the Board concludes that based on the foregoing evidence assignment of further staged ratings is not for application. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. J. Houbeck, 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.