Citation Nr: 21042191 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 17-07 187 DATE: July 12, 2021 ORDER Entitlement to service connection for unspecified depressive disorder is granted. Entitlement to a rating increase of 20 percent, but not higher, for right knee arthritis is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to a rating increase of 20 percent, but not higher, for left knee arthritis is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial 10 percent rating, but not higher, for right knee instability is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial 10 percent rating, but not higher, for left knee instability is granted, subject to the laws and regulations controlling the award of monetary benefits. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's unspecified depressive disorder is related to service. 2. The Veteran's right knee limitation of motion symptomatology more nearly approximates flexion limited to 30 degrees. 3. The Veteran's left knee limitation of motion symptomatology more nearly approximates flexion limited to 30 degrees. 4. The Veteran's right and left knee instability more nearly approximate slight but not moderate recurrent lateral instability. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for persistent depressive disorder have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating increase of 20 percent, but not higher, for the Veteran's right knee arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, diagnostic code (DC) 5260. 3. The criteria for a rating increase of 20 percent, but not higher, for the Veteran's left knee arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 4. The criteria for an initial 10 percent rating, but not higher, for the Veteran's right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 5. The criteria for an initial 10 percent rating, but not higher, for the Veteran's left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1983 to July 2005. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, continued a 10 percent rating for both the right and left knee disabilities, and denied service connection for anxiety disorder. In July 2015, the Veteran filed her notice of disagreement, was issued a statement of the case in January 2017, and in February 2017, perfected her appeal to the Board. In February 2019, the Veteran testified during a hearing before a decision review officer. In April 2021, the Veteran appeared at a virtual Board hearing before the undersigned Veterans Law Judge. A copy of each transcript is of record. The Board notes that in a July 2019 statement, the Veteran indicated that she wished to withdraw her appeals for her left and right knee disabilities. However, during the April 2021 Board hearing, the Veteran testified as to the severity of her knee disabilities, confirming she wished to pursue the appeal. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Unspecified Depressive Disorder The Veteran testified that she started noticing issues with her mental health during service, but that she did not go to sick call as she did not want to be considered "weak", particularly while in a leadership position as a drill and platoon sergeant. She stated that her mental health issues started in 1996 when she found a soldier trying to commit suicide. She reported that prior to service, she was in good shape psychiatrically. The Veteran reported that since service, she has sought mental health therapy, and indicated that her therapists expressed that there's a connection between the in-service incident and her current psychiatric disability. While the initial decision denied service connection for anxiety, the record contains a diagnosis for persistent depressive disorder. Therefore, the Board has expanded the issue on appeal to include all psychiatric disorders consistent with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran's service treatment records do not reflect any treatment for, or complaints of a psychiatric disability. A March 1996 Army Achievement Medal reflected that the Veteran rendered assistance to a soldier who attempted suicide. The Veteran submitted an article regarding the incident during service where she intervened when a soldier attempted suicide. A May 2015 VA examination report indicated that the Veteran did not have a diagnosis of PTSD, but did have a diagnosis of unspecified depressive disorder. The Veteran reported seeing a "big bin of body parts" in a tent during her deployment in Desert Shield/Storm, stated she had a roommate who discussed gruesome topics, and that she was stationed in D.C. during 9/11 and the sniper attacks. The examining psychologist did not provide an opinion as to the etiology of the Veteran's unspecified depressive disorder. A July 2019 VA examination report reflects that the Veteran's symptoms of unspecified depressive disorder included depressed mood, anxiety, chronic sleep impairment, and mild memory loss. The examining psychologist opined that the Veteran's unspecified depressive disorder was less likely than not (less than a 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, stating that there is no evidence from the service treatment records that the Veteran ever complained of having depressive symptoms, or that she was diagnosed or treated for depression. The psychologist indicated that the medications the Veteran took to "feel better" were prescribed shortly after her return from Desert Storm, and only lasted a few months. The period during which this particular medication was prescribed was also noted to not line up with her prescription for a mental health medication which was prescribed several years later, and could have been prescribed for psychosis and anxiety, or non-psychiatric symptoms. The psychologist reported that there is no indication in the service treatment records that the medication was prescribed for mental health reasons. The psychologist concluded that the Veteran's depression is primarily related to post-military stressors, including frustration with her children, self-doubt, unresolved grief, and job stress. The evidence is at least evenly balanced as to whether entitlement to service connection for unspecified depressive disorder is warranted. The Veteran has provided evidence of an in-service incident wherein she witnessed an attempted suicide, and the May 2015 VA examination report reflects a diagnosis of unspecified depressive disorder. Therefore, the first 2 elements for service connection have been met, and the dispositive issue is whether there is a nexus between the two. While the July 2019 psychologist opined that the Veteran's unspecified depressive disorder was less likely than not due to service, he based his opinion on the fact that there was no evidence of depressive symptoms in the service treatment records which is an impermissible basis upon which to find that the Veteran's disability was not related to service. Additionally, the psychologist failed to consider the Veteran's reports of witnessing a soldier attempting suicide, or of seeing body parts during service when providing his opinion. Therefore, the July 2019 examination report is inadequate and afforded no probative weight. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on lack of evidence in service medical records to provide negative opinion). The Veteran has competently and credibly stated that she first started having issues with her mental health during service, but indicated that she did not seek treatment for fear of being considered "weak". Additionally, she testified that her mental health therapist has expressed that there is a connection between the in-service incident and her current mental health disability. The Veteran is competent to relate what a physician has stated to her regarding a possible nexus, and there is no indication that she lacks credibility. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). This evidence is thus entitled to some probative weight. While the Board could remand for an additional VA opinion, a request for another opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Andrews v. McDonough, __ Vet. App. __, No. 19-0352 (June 22, 2021) ("Remand is inappropriate where the predominant purpose is not to allow the Board to make a fully informed decision unencumbered by error but to allow VA to obtain more evidence so that it can properly deny the claim"). For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's unspecified depressive disorder is related to service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for unspecified depressive disorder is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. Right and Left Knee The Veteran testified that her knees stay swollen and constantly hurt on a day to day basis, and that she has to take medication every day or the pain would be worse. She stated that her knees have given out resulting in her falling and injuring her ankle and foot, and that they continue to give out occasionally, her right knee more than her left, causing her to be reluctant to carry her grandchildren. She reported being unable to bend down due to the pain. The Veteran stated that she does not use a walker anymore, but has a cane that she uses every now and then. She also indicated that she wears a brace when her knees swell a lot, but she has things to do. The Veteran reported that if she drives for over 15 or 20 minutes, she has to stop to stretch and rub her knees. She testified that she sometimes has to call out of work due to knee swelling, and that the pain can be as bad as a 10 out of 10. The Veteran stated that her knees flare-up pretty often, particularly during inclement weather which makes them hard to bend and heavy, but that she just tolerates the pain. The Veteran's left and right knee arthritis with limitation of flexion are each rated 10 percent disabling under DC 5003-5260. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. While the Veteran is currently in receipt of 10 percent ratings pursuant to DC 5003-5260, the Board has also considered other potentially relevant diagnostic codes. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021 and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. DC 5256 assigns a 30 percent evaluation for knee ankylosis with a favorable angle in full extension, or in slight flexion between 0 and 10 degrees; a 40 percent rating for knee ankylosis in flexion between 10 and 20 degrees; a 50 percent rating for knee ankylosis in flexion between 20 and 45 degrees; and a 60 percent rating for extremely unfavorable knee ankylosis in flexion at an angle of 45 degrees or more. Prior to February 7, 2021, DC 5257 assigns a 10 percent evaluation for slight recurrent subluxation or lateral instability; a 20 percent evaluation for moderate recurrent subluxation or lateral instability; and a 30 percent evaluation for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. As of February 7, 2021, under the amended criteria, DC 5257 assigns a 10 percent rating for recurrent subluxation or instability for sprain, incomplete ligament tear, or complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device, or bracing for ambulation; a 20 percent evaluation for sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or unrepaired or failed repair of complete ligament tear causing persistent instability, and medical provider prescribes either an assistive device or bracing for ambulation; and a 30 percent evaluation for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes both an assistive device and bracing for ambulation. Under DC 5258, a 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under DC 5259, a 10 percent evaluation is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a. Under DC 5260, limitation of flexion of the leg is noncompensable where flexion is limited to 60 degrees. A 10 percent evaluation is warranted where flexion is limited to 45 degrees; a 20 percent evaluation is warranted where flexion is limited to 30 degrees; and a 30 percent evaluation is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, limitation of extension of the leg, a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a. VA General Counsel provided guidance in VAOPGCPREC 23-97 (July 1997) that a veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under DC 5257, the Veteran must also have limitation of motion under DC 5260 or 5261 in order to obtain a separate rating for arthritis. If the Veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also clarified, if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under DC 5003 in light of sections 4.40, 4.45, 4.59 must be considered. Absent x-ray findings of arthritis, limitation of motion should be considered under DCs 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under DCs 5260 or 5261. In addition, the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004. Id. Specifically, where a Veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. The limitation of flexion and extension must be compensable in both planes in order to warrant separate ratings. Id. There is no prohibition of separate evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5257 or 5261 and a meniscal Diagnostic Code, i.e., Diagnostic Codes 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). A June 2015 VA examination report reflects that the Veteran reported constant, severe, throbbing bilateral knee pain, which was worse in the right knee at night. The Veteran stated that her knees feel heavy and sore, and that walking, sudden movements, bending, or squatting makes the pain worse. The Veteran did not report flare-ups. Right knee flexion was to 80 degrees, and extension to 0 degrees with pain noted that did not result in, or cause functional loss. There was evidence of pain with weight bearing, moderate tenderness with palpation over the entire knee, and objective evidence of crepitus. Left knee flexion was to 100 degrees, and extension to 0 degrees, with pain noted on examination that did not result in or cause functional loss. There was no evidence of pain with weight bearing, no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, but there was evidence of crepitus. No additional functional loss was noted with repetitive use testing. The Veteran reported that swelling and disturbance of locomotion were contributing factors of disability. Muscle strength was normal, and there was no muscle atrophy, or ankylosis noted. The examination report reflected no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was not performed in the right knee due to swelling and moderate tenderness over the entire knee. Joint stability testing was performed in the left knee, and no joint instability was noted. The Veteran did not have, and had never had any tibial and/or fibular impairment, but had had a meniscal tear on both the left and right sides, and underwent arthroscopic surgeries and meniscectomies in both knees. The examiner noted that the Veteran did not use any assistive devices as a normal mode of locomotion, and stated that the Veteran's knee disabilities impact her ability to work as she would not be able to do work that required prolonged standing, walking, kneeling, squatting, lifting, or carrying over 20 lbs. February 2019 VA treatment records reflect that the Veteran reported her knee gave out when she was walking to her car, and she fell and broke her right ankle and foot. In a June 2019 VA examination report, the examiner noted that the Veteran did not report flare-ups of pain in either knee, but did report that she cannot stand, or walk for long periods of time, that it hurts to use stairs, and that she cannot bend, or squat. Right knee flexion was to 70 degrees, and extension to 0 degrees with pain noted on flexion that did not result in, or cause functional loss. There was evidence of pain with weight-bearing, and diffuse, mild tenderness, but no erythema. There was also evidence of crepitus noted. Left knee flexion was to 90 degrees, and extension to 0 degrees, with pain noted on flexion that did not result in, or cause functional loss. There was no evidence of pain with weight bearing, and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, but there was evidence of crepitus. No additional functional loss was noted with repetitive use testing, there was no muscle atrophy, no reduction in muscle strength, and no ankylosis. There was a slight history of lateral instability in the right knee, but no recurrent subluxation in either knee, and no history of recurrent effusion. There was no joint instability in either knee, and the Veteran did not have, and had never had any tibial and/or fibular impairments. The Veteran reported occasional use of a cane, and the examiner reported that there was no evidence of pain in non-weight bearing. The examiner also noted that passive range of motion testing was not medically appropriate due to increased risk of injury. Based on the foregoing, the Board finds that a higher 20 percent rating for the Veteran's right and left knee arthritis limitation of motion is warranted. The previously discussed examination reports show that the Veteran was able to perform range of motion of the left knee for flexion to 90 and 100 degrees, with extension to 0 degrees, and right knee flexion to 70 and 80 degrees, with extension to 0 degrees, including with repetitive use testing, and reflect that the Veteran did not suffer flare-ups of either knee. However, the Veteran has provided competent and credible evidence that she experiences increased bilateral knee pain and swelling, particularly during inclement weather, which makes it hard to bend them. She described the knee pain as "a 10 out of 10" when they swell up badly, and stated that she takes medication to deal with the pain. The Veteran is competent to report the symptoms associated with her right and left knee arthritis, and the Board has no reason to challenge the credibility of her contentions. Jandreau, 492 F. 3d at 1377. While the Veteran did not report flare-ups while being administered her examinations, it is reasonable to conclude that as she was not experiencing flare-ups at the time of the examinations, thus she did not feel it necessary to describe the symptoms during a flare-up. It is also reasonable to conclude that the Veteran's right and left knee arthritis symptomatology as reported by the Veteran is significantly worse during a flare-up than as described during the examinations, and would be even worse but for use of medication. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) ("the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria"). Accordingly, considering the competent and credible evidence provided by the Veteran, the Board finds that her left and right knee arthritis symptomatology more nearly approximates flexion limited to 30 degrees as contemplated by a 20 percent rating under DC 5260. However, even considering the Veteran's statements regarding her right and left knee arthritis symptomatology, a rating higher than 20 percent is not warranted. In this regard, the weight of the evidence shows that even considering the indications of decrease in quality of life due to knee pain, the Veteran's symptoms were not shown to be so disabling to actually or effectively result in limitation of flexion to 15 degrees or less, or limitation of extension to 20 degrees or greater. Moreover, the examination reports show that the Veteran did not have ankylosis of the either knee. Thus, a rating higher than 20 percent is not warranted under DC 5260, 5261, or 5256. However, while joint stability tests were normal with a slight history of lateral instability in the right knee noted in the June 2019 examination report, the Veteran has competently and credibly reported use of a cane and a brace, and stated that her knees "give out" on occasion. Therefore, the evidence is at least evenly balanced as to whether the Veteran's right and left knee symptomatology more nearly approximates slight recurrent lateral instability, thus separate 10 percent ratings for both the Veteran's right and left knee lateral instability under DC 5257 is warranted. However, given the normal stability test findings, a rating higher than 10 percent for moderate recurrent subluxation or lateral instability is not warranted. Although the evidence of record reflects an arthroscopic meniscectomy procedure of each knee, there is no evidence of residual signs or symptoms, thus the Veteran' right and left knee disabilities do not more nearly approximate dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, or symptomatic removal of semilunar cartilage, and separate ratings under DCs 5258, and 5259 are not warranted. The Board has considered the Veteran's claim and decided entitlement based on the evidence. Neither the Veteran nor her attorney has raised any other related issues, nor have any other such issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). For the foregoing reasons, the preponderance of the evidence reflects the symptoms of the Veteran's left and right knee arthritis with limitation of motion more nearly approximate the criteria for a 20 percent rating, but not higher, under DC 5260, and more nearly approximate the criteria for separate 10 percent ratings, but not higher, under DC 5257. Therefore, a 20 percent rating for both right and left knee arthritis, and a separate 10 percent ratings for both left and right knee instability, is warranted. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.