Citation Nr: 21042530 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-24 829A DATE: July 13, 2021 ORDER From November 4, 2011, to April 5, 2012, a 20 percent rating for residuals of a left knee meniscectomy is granted. From June 1, 2012, to May 16, 2019, a rating in excess of 10 percent for residuals of a left knee meniscectomy is denied. Beginning May 17, 2019, a 20 percent rating for residuals of a left knee meniscectomy is granted. From November 4, 2011, to April 5, 2012, a separate 10 percent rating for left knee osteoarthritis with limitation of motion is granted. Beginning June 1, 2012, a separate 10 percent rating for left knee osteoarthritis with limitation of motion is granted. From November 4, 2011, to April 5, 2012, a separate 30 percent rating for left knee instability is granted. Beginning May 17, 2019, a separate 10 percent rating for left knee instability is granted. REMANDED Entitlement to a separate compensable rating for left femoral nerve neuropathy is remanded. FINDINGS OF FACT 1. From November 4, 2011, to April 5, 2012, the Veteran's residuals of a left knee meniscectomy resulted in frequent episodes of locking, pain, and effusion. 2. From June 1, 2012, to May 16, 2019, the Veteran's residuals of a left knee meniscectomy were symptomatic but did not result in frequent episodes of pain, locking, and effusion. 3. Beginning May 17, 2019, the Veteran's residuals of a left knee meniscectomy resulted in frequent episodes of locking, pain, and effusion. 4. From November 4, 2011, to April 5, 2012, and beginning June 1, 2012, the Veteran's left knee osteoarthritis has been productive of limitation of flexion to no worse than 70 degrees, and limitation of extension to no worse than 5 degrees. 5. From November 4, 2011, to April 5, 2012, the Veteran's left knee disability resulted in severe lateral instability. 6. Beginning May 17, 2019, the Veteran's left knee disability has resulted in slight lateral instability. CONCLUSIONS OF LAW 1. From November 4, 2011, to April 5, 2012, the criteria for a 20 percent rating for residuals of a left knee meniscectomy are met. 38 U.S.C. § 1155 (2018), 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2020). 2. From June 1, 2012, to May 16, 2019, the criteria for a rating in excess of 10 percent for residuals of a left knee meniscectomy are not met. 38 U.S.C. § 1155 (2018), 38 C.F.R. § 4.71a, Diagnostic Code 5259 (2020). 3. Beginning May 17, 2019, the criteria for a 20 percent rating for residuals of a left knee meniscectomy are met. 38 U.S.C. § 1155 (2018), 38 C.F.R. § 4.71a, Diagnostic Code 5258 (2020). 4. From November 4, 2011, to April 5, 2012, the criteria for a separate 10 percent rating for left knee osteoarthritis with limitation of motion are met. 38 U.S.C. § 1155 (2018), 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020). 5. Beginning June 1, 2012, the criteria for a separate 10 percent rating left knee osteoarthritis with limitation of motion are met. 38 U.S.C. § 1155 (2018), 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020). 6. From November 4, 2011, to April 5, 2012, the criteria for a separate 30 percent rating for left knee instability are met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5257 (2020). 7. Beginning May 17, 2019, the criteria for a separate 10 percent rating for left knee instability are met. 38 U.S.C. § 1155 (2018); 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5257 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1989 to August 1993. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In May 2019, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In October 2019, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for additional development. The case has since been returned to the Board. The Veteran also appealed the issues of entitlement to service connection for psychiatric disability, a right knee disability, and a back disability. In August 2020 and November 2020 rating decisions, the AOJ granted service connection for an anxiety disorder, a back strain, and a right knee strain, which constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, those matters are no longer in appellate status. Increased Rating Left Knee Disability In a December 2012 rating decision, the AOJ continued a 10 percent rating for the Veteran's left knee disability. He appealed, requesting a rating in excess of 10 percent. In a November 2020 rating decision, the AOJ increased the rating to 20 percent effective October 2, 2020. Because the Veteran is presumed to seek the maximum available benefits, this issue remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Initially, the Board notes that the Veteran is service connected for residuals of a partial meniscectomy of the left knee with osteoarthritis. A January 2012 magnetic resonance imaging (MRI) indicated that he was also diagnosed with an anterior cruciate ligament (ACL) tear and he underwent ACL reconstruction surgery in April 2012. There has been some dispute as to whether the ACL tear was incurred in or related to service. In October 2019, the Board found that the ACL tear was related to service and granted a temporary total evaluation for convalescence following the ACL reconstruction surgery. Thus, the Board will consider all of the Veteran's knee symptoms, including those related to the ACL tear and reconstruction surgery, in evaluating his service-connected left knee disability. A November 4, 2011 VA treatment record indicated that the Veteran presented for an annual examination. He reported that he was having quite a bit of left knee pain and was told he would eventually need surgery. It was noted that he had good range of motion and there was tenderness along the medial joint line. Updated films were ordered. A January 2012 VA orthopedic surgery consultation report noted that the Veteran was seen for left knee pain. It was noted that he tried Euflexxa, corticosteroid injections, nonsteroid anti-inflammatories, and a brace with only minimal relief. He stated that any time he climbed stairs it was very painful. Meniscal tests, including Apley's and McMurray's, were positive. Range of motion was from 0 degrees of extension to 135 degrees of flexion without pain. It was noted that he had lateral pain and that he might have an internal derangement. He was instructed to return after an MRI. In February 2012, the Veteran reported having left knee pain with activity, and instability. He stated that he used a brace in the past but that it was cumbersome. It was noted that the MRI showed mild joint effusion and an absence of the fibers of the ACL. The impression was ACL tear. The physician indicated that given his clinical instability and difficulty performing activities of daily life and his job, he should consider arthroscopy and possible reconstruction. He was referred for surgery. In March 2012, the Veteran filed a claim for an increased rating for his service-connected left knee disability. A March 2012 private treatment record noted that the Veteran injured his knee in the 1990s and had an arthroscopy and partial meniscectomy was performed. It was noted that he now had a repeated disability in the form of instability, which had progressed over the last decade. On examination, he had full range of the knee passively and actively. There was mild tenderness in the medial joint line. Lachman's testing was positive without firm endpoint. It was noted that the January 2012 MRI showed a complete tear of the ACL. In April 2012, the Veteran underwent arthroscopic ACL reconstruction with hamstring autograft, and microfracture of the lateral femoral condyle. The postoperative diagnoses were left knee ACL tear and focal grade 4 articular cartilage defect of the lateral femoral condyle. Following surgery, the Veteran underwent physical therapy. In June 2012, he reported that his knee was very sore that day and questioned whether he could perform the exercises. He rated the pain 7/10 in severity. In July 2012, he was discharged from physical therapy. It was noted that he reported having left knee pain, 5/10, and that going down stairs, his pain was 8-9/10. He had mild patellar numbness and no edema. Strength was 5/5. A June 2012 private treatment record indicated that the Veteran was seen for reevaluation of his knee following surgery. It was noted that the knee felt stable and that he had occasional pain at the proximal aspect of the anteromedial tibia. On examination, he displayed full range of motion with no effusion. There was mild tenderness on the medial tibial plateau over the pes bursa. Lachman's testing was negative with a firm endpoint. It was noted that he appeared to be progressing well. The physician recommended monitoring the proximal tibial pain. A July 2012 private treatment record indicated that the Veteran reported that he continued to improve. He stated that much of the pain that was around the proximal tibia was resolving. He stated that he had occasional popping in the anterior aspect of the knee. He denied instability. The physician indicated that he appeared to be progressing well. It was noted that he had obvious quadriceps atrophy compared to the contralateral leg and that he would continue to experience some mild popping until that resolved. There was no effusion. In August 2012, it was noted that he was doing well and had occasional ache. It was noted that he realized his weak quadriceps had been contributing to his pain and that he was working actively to correct this with his home exercises. On examination, he had full range of motion of the knee, nontender joint lines, and Lachman's testing was negative. It was noted that he had decreased quadriceps tone. During a November 2012 VA examination, the Veteran reported that he was symptom-free for 10 years following his initial meniscectomy in 1991. He stated that pain in his left knee progressed since that time, specifically over the last few years. He stated that while playing sports, he felt that his knee would "come out at times." It was noted that he was seven months postoperative ACL repair and still has some tenderness around the surgical site. He complained of constant pain, which he described as aching and 4-5/10 in severity. He also described having intermittent sharp pain to both sides of the knee, which he rated as 10/10 on the pain scale. He indicated that flare-ups occurred approximately twice per week and required him to sit and rest for 30 to 40 minutes. He stated that his knee swelled during flare-ups and that he limped the rest of the day. It was noted that he had less tolerance to prolonged walking, climbing stairs, and walking downhill. He stated that his left knee gave way easily and that he had to catch himself. He also described experiencing crepitus and it was noted that he used a knee brace, but no assistive devices. One examination of the left knee, the Veteran had full extension to 0 degrees with evidence of painful motion at the endpoint. Flexion was limited to 125 degrees without objective evidence of painful motion. There was no additional limitation of motion or functional impairment with repetitive use testing. The examiner noted that functional impairment included interference with sitting, standing, and weight-bearing. There was tenderness to palpation. Muscle strength was normal, i.e., 5/5. Stability testing was normal. It was noted that there was no evidence or history of recurrent patellar subluxation or dislocation. It was noted that the Veteran had a meniscus condition with frequent episodes of joint pain. The examiner noted that residuals signs and/or symptoms due to the meniscectomy including aching joint pain and easy giving way. Regarding functional impact on the Veteran's ability to work, the examiner noted that he had difficulty with prolonged walking, climbing stairs, and kneeling. A November 2012 private treatment record indicated that the Veteran continued to have pain localizing anteriorly and medially. He denied instability. He had persistent quadriceps weakness that had not resolved since surgery. On examination, he had full range of motion of the knee. He had minimal, if any, tenderness on the joint line. He did have obvious quadriceps atrophy and 5-/5 quadriceps strength. Lachman's testing was negative. The physician stated that he had reviewed radiographs and MRI. The hardware appeared intact. The ACL appeared to be anatomically located without evidence of defect. There was no evidence of meniscal tear. The physician indicated that the Veteran's persistent knee pain and quadriceps atrophy could be related to the block that was performed at the time of surgery. He was advised that this would generally resolve in time. Electrodiagnostic testing was ordered. A December 2012 VA treatment record indicated that the Veteran was still having issues after knee surgery. Electrodiagnostic testing was ordered for further evaluation. In February 2013, it was noted that the Veteran had atrophy of the left quadriceps and decreased sensation along the anterior, lateral aspect of the left thigh. Electrodiagnostic testing showed evidence of left femoral neuropathy. A March 2013 private treatment record indicated that the Veteran reported that his knee was doing great and that he had no instability. His only issue was some persistent quadriceps weakness. It was noted that he was having a difficult time rehabbing and that he also had some numbness in the anterior thigh region. On examination, he had full range of motion of the knee. Lachman's testing was negative. There was no effusion. His ligaments were stable. He did have decreased quadriceps tone compared to the contralateral side. The physician advised him that it was possible that it would resolve over time and did not think any current intervention was warranted. In July 2013, at a VA neurology consultation, it was noted that the Veteran complained of left leg weakness and numbness over the left thigh, which he stated started after a nerve block given for the ACL repair. On examination, his left hip flexors were weaker than the right and there was decreased sensation to light touch and pinprick over the left lateral thigh. Reflexes were symmetrical and his gait was normal. The Veteran also reported that he had trouble walking downhill, that his left knee buckled/gave way, and that he had many falls. A January 2014 VA treatment noted that the Veteran still had knee pain and that it was thought to be from femoral neuropathy. It was noted that he saw neurology and that nothing further was recommended at that time if medication was not helpful. He was instructed to just continue with his exercise program. He stated that Gabapentin did not help. In July 2014, he stated that he was still having left knee pain, which had not improved, and that he now had numbness in in his left great toe. During a July 2014 orthopedic consultation, he reported that he was using an ACL brace, but that it fit poorly. He also stated that he had some numbness of his great toe on the left side that had been present for about two months. It was noted that a MRI of the lumbar spine demonstrated no disc herniation. On examination of the left knee, there was no effusion. The quadriceps showed no further atrophy with good contraction and definition. There was 5/5 motor power in the ankle and hindfoot. The assessment was left knee ACL construction with fair result; left femoral nerve dysfunction, for which he appeared to be compensating reasonably well; great toe numbness, which was noted might be the result of some pressure from the ACL brace on the common peroneal nerve and that a consultation was ordered to adjust the brace; and chronic pain, for which it was noted he might benefit from a pain consultation. An April 2015 VA pain management record noted that the Veteran had a femoral nerve block during his ACL surgery and that he has had left-sided anterior thigh numbness and quadriceps wasting since then. He complained of burning and numbness in the left thigh consistent with a nerve irritation following the femoral nerve block. It was noted that he tried low-dose Gabapentin in the past with no significant improvement. On examination muscle strength was +5/5 with the exception of left knee extension at +4/5. Deep tendon reflexes were +2/4 with the exception of the patellar reflex on the left, which was absent. Light touch sensation was intact with the exception of the anterior aspect of the left thigh consistent with a femoral nerve distribution. He walked with just a slight left leg limp. He was started on an escalating regimen of Gabapentin and Baclofen, and referred to physical therapy for a TENS unit and Thera Cane. In May 2015, he reported that he could not use the TENS unit while working and that the muscle relaxer made him too sleepy. He stated that he could not tell if Gabapentin did anything. In August 2015, he reported that the nerve pain in his left big toe was gone but that he had pain with the left knee that shot to the left hip, which was new. In December 2015, he continued to complain of left thigh and knee pain. A May 2017 VA treatment record indicated that the Veteran complained of left knee pain, which he rated 5/10 in severity. He inquired about a Synvisc injection. It was noted that he had a knee brace, which he wore at times. He reported that his knee gave way at times, that he was very active, and that his knee swelled when he was doing a lot of work around the house. In May 2017, at an orthopedic consultation, he reported that he had left knee pain and discomfort on occasion. He stated that he was going up and down a ladder recently and noticed increased swelling in his left knee. He stated that he used a brace for stability and support. He denied any gross instability or catching sensation. On examination, there was no effusion. Strength was 5/5 in the hamstrings and quadriceps. Range of motion was 0 to 120 degrees. It was noted that his knee was stable. He was given a Synvisc injection. An April 2019 VA treatment record indicated that the Veteran was seen for a pain assessment. He reported pain in the low back and left hip. He also reported numbness of the left thigh to the knee with pins and needles sensation in his left leg and foot. The assessment was chronic left femoral neuralgia and new onset of left low back disturbance in skin sensation in the left lower extremity. In June 2019, he reported a flare-up of left knee pain about a month ago. He stated that it felt like his meniscus was injured and his knee kept locking up and had been really swollen but that it was slightly improved. In July 2019, he stated that he had noticed more left knee pain, swelling, giving way, and a popping noise over the past few months. He also stated that he noticed some muscles shrinking in his left leg. He was given a Monovisc injection. At a July 2019 orthopedic consultation, it was noted that he had some degree of quadriceps function but with significant atrophy. It was noted that there was some degree of swelling and mechanical symptoms as well, which were new. On examination, range of motion of the left knee was from 5 degrees of extension to 120 degrees of flexion, actively, and to 135 degrees of flexion, passively. Effusion was noted at 1+. Lachman's testing was 1+ with good endpoint. There was medial joint line tenderness. X-rays showed stable medial joint space narrowing and ACL reconstruction. A MRI was ordered. Later that month in July 2019, the physician discussed the results of the MRI with the Veteran. He was advised that given the new onset of symptoms and evidence of some meniscal pathology on MRI, it was reasonable to proceed with arthroscopic evaluation of the joint and proceed as indicated. He stated that he would consider that option and discuss it with his employer. He stated that the Monovisc injection was not helpful. During an October 2020 VA examination, the Veteran reported that he continued to have symptoms of constant left knee pain and instability. He stated that his symptoms had progressed over the past few years. He reported that pain was worse with repetitive activity such as walking the stairs and prolonged standing. He stated that he left knee felt unstable at times with popping, snapping, and catching. He indicated that flare-ups occurred with prolonged ambulation and standing, and increased symptoms with stair usage, pushing, and pulling items. On examination, left knee range of motion was from 0 degrees of extension to 80 degrees of flexion with pain. Repetitive use testing did not result in any additional loss of function or range of motion. The examiner indicated that range of motion itself did not contribute to functional loss. There was objective evidence of localized tenderness or pain on palpation of the medial left knee, which was described as moderate. There was no evidence of pain with weight bearing. There was evidence of crepitus. The examiner indicated that the Veteran was not being examined immediately after repetitive use over time or during a flare-up; that pain would significantly limit functional ability with repeated use over time or during a flare-up; and that flexion would be additionally limited to 70 degrees with no change in extension. Muscle strength testing was 4/5 with flexion and extension with muscle atrophy noted. There was no ankylosis. The examiner indicated that there was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing of the left knee was normal. The examiner indicated that the Veteran had a meniscus condition with frequent episodes of joint locking and joint pain, noting that he also described popping of the left knee. The examiner noted that the Veteran regularly used a knee brace. Meniscus/Cartilage Impairment The Veteran's left disability has been rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5258 and 5259. Under Diagnostic Code 5259, symptomatic removal of semilunar cartilage warrants a 10 percent rating. Under Diagnostic Code 5258, dislocated, semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. In this case, the Board finds that a 20 percent rating under Diagnostic Code 5258 is warranted from November 4, 2011, to April 5, 2012. During that time period, the Veteran reported frequent episodes of joint pain, and a February 2012 VA treatment record noted that there was mild effusion. Furthermore, the April 6, 2012, postoperative diagnoses included a focal grade 4 articular cartilage defect of the lateral femoral condyle. A grade 4 cartilage defect is the most severe, indicating that the cartilage tear was full thickness and exposed the underlying (subchondral) bone. For these reasons, the Board finds that the Veteran's symptoms more closely approximated the criteria for a 20 percent rating under Diagnostic Code 5258 during that time period. The Board notes that the Veteran filed a claim for an increased rating in March 2012, within one year of when it was factually ascertainable that an increase in disability had occurred. See 38 C.F.R. § 3.400(o)(2). A November 4, 2011 VA treatment record indicated that the Veteran reported an increase in his left knee symptoms, which led to the diagnosis of an ACL tear and surgery. Therefore, a 30 percent rating is warranted beginning November 4, 2011. Following surgery on April 6, 2012, which included microfracture of the lateral femoral condyle, the evidence indicates that the Veteran's left knee showed improvement for a period of time. In June 2012, there was no effusion and the Veteran reported only occasional pain. In July 2012, he complained of only occasional popping and there was no effusion. In August 2012, he complained of only occasional ache. Although the November 2012 VA examiner indicated that there were frequent episodes of joint pain, there were no frequent episodes of locking or effusion in the joint. In March 2013, the Veteran reported that his knee was doing great and on examination, there was no effusion. A January 2014 X-ray showed suprapatellar joint effusion; however, in March 2014 there was no joint effusion or locking. In July 2014, there was no joint effusion on examination. In May 2017, the Veteran reported that he had noticed increased swelling, but denied locking of the knee. On examination, there were no signs of edema or effusion. Therefore, the Board finds that a rating in excess of 10 percent for residuals of meniscectomy are not warranted during this time period, i.e., April 6, 2012, to May 16, 2019. Beginning May 17, 2019, the Board finds that the Veteran's left knee symptoms more closely approximated a 20 percent rating under Diagnostic Code 5258. 38 C.F.R. § 4.71a, Diagnostic Code 5258. On June 17, 2019, the Veteran reported a flare-up of left knee pain that began approximately one month prior. He stated that it felt like his meniscus was injured and his knee kept locking up and had been swollen. In July 2019, it was noted that noted that there was some degree of swelling and mechanical symptoms as well, which were new. Effusion was also noted. Furthermore, the October 2020 VA examiner indicated that the Veteran had a meniscus condition with frequent episodes of joint locking and joint pain, noting that he also described popping of the left knee. Therefore, the Board finds that a 20 percent rating is warranted beginning May 17, 2019. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Osteoarthritis The Veteran is also service connected for left knee osteoarthritis, which the AOJ rated together with the residuals of a left knee meniscectomy. The Board notes that while separate ratings may not be assigned for the same disability or the same manifestation of a disability under different diagnostic codes, separate ratings may be assigned if the symptomatology for the disability is not duplicate or overlying with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14. In this case, the ratings assigned for the Veteran's residuals of a left knee meniscectomy under Diagnostic Codes 5258 and 5259 contemplate pain, locking, and effusion; however, the criteria do not contemplate left knee limitation of motion. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion for the specific joint; however, when limitation of motion is noncompensable, the rating criteria indicate that a 10 percent rating should be assigned for each major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5260, flexion of the leg limited to 60 degrees warrants a 0 percent rating, and flexion limited to 45 degrees warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. At worst, flexion of the Veteran's left knee flexion was limited to 80 degrees. The October 2020 VA examiner indicated that flexion would be additionally limited to 70 degrees during flare-ups or with repetitive use over time. The Board notes that limitation of flexion to 70 degrees warrants a noncompensable rating under Diagnostic Code 5260. At worst, extension of the Veteran's left knee was limited to 5 degrees on active range of motion testing in July 2019. The Board notes that limitation of extension to 5 degrees warrants a noncompensable rating under Diagnostic Code 5261. Although the Veteran's left knee limitation of motion is noncompensable under the applicable rating criteria, Diagnostic Code 5003 provides the assignment of a 10 percent rating when there is X-ray evidence of arthritis and limitation of motion is noncompensable. Therefore, the Board finds that a separate 10 percent rating is warranted for osteoarthritis of the left knee. As the Veteran received of a total temporary evaluation for the period of convalescence following left knee surgery, he has been fully compensated for his left knee symptoms during that time period, i.e., from April 6, 2012, to May 31, 2012. Therefore, the 10 percent rating for left knee osteoarthritis is granted from November 4, 2011, to April 5, 2012, and beginning June 1, 2012. The Board notes that the Veteran filed a claim for an increased rating in March 2012, within one year of when it was factually ascertainable that an increase in disability had occurred. See 38 C.F.R. § 3.400(o)(2). Therefore, a 10 percent rating is warranted beginning November 4, 2011, the date of the VA treatment record indicating that that his symptoms had increased. The Board has also considered the effects of repeated use over time and flare-ups in light of the Court of Appeals for Veterans' Claims (Court's) holdings in Correia and Sharp. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). As noted above, the October 2020 VA examiner indicated that left knee flexion would be additionally limited to 70 degrees during flare-ups and with repeated use over time, which warrants a noncompensable rating under Diagnostic Code 5260. Although the Veteran had left knee extension limited to 5 degrees on active range of motion testing in July 2019, at all other times during the relevant time period, he exhibited no limitation of extension. In October 2020, the VA examiner indicated that he had full range of extension to 0 degrees, and that there would be no additional limitation of extension during flare-ups or with repeated use over time. Therefore, the Board finds that any functional loss with repeated use over time and during flare-ups is consistent with the 10 percent rating assigned above. Instability The Board finds that a separate 30 percent rating is warranted for severe left knee instability from November 4, 2011, to April 5, 2012. The Veteran complained of increased knee problems during an annual physical on November 4, 2011, which led to the discovery that he had a complete ACL tear that required reconstruction surgery on April 6, 2012. This evidence suggests that the instability was severe and therefore a 30 percent rating is warranted during that time period. See 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board notes that the Veteran filed a claim for an increased rating in March 2012, within one year of when it was factually ascertainable that an increase in disability had occurred. See 38 C.F.R. § 3.400(o)(2). Therefore, a 30 percent rating is warranted beginning November 4, 2011. Following ACL reconstructive surgery on April 6, 2012, the evidence shows that the Veteran's knee was stable for a period of time. In June 2012, Lachman's testing was negative with firm endpoint. In July 2012, he denied instability. In August 2012, Lachman's testing was negative. During a November 2012 VA examination, he reported that his knee gave way easily; however, stability testing was normal. Furthermore, a November 2012 private treatment record indicated that he denied instability and Lachman's testing was negative. In March 2013, he stated that his left knee was doing great. He denied instability, Lachman's testing was negative, and it was noted that his ligaments were stable. In May 2017, he reported that his knee gave way at times but denied any gross instability or catching sensation. On examination, the knee was stable. Therefore, the Board finds that a separate rating for left knee instability is not warranted during this time period, i.e., from April 6, 2012, to May 16, 2019. Beginning May 17, 2019, the Board finds that a separate 10 percent rating, but no higher, is warranted for slight left knee instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. On June 17, 2019, the Veteran reported a flare-up of knee symptoms approximately one month prior. In July 2019, he complained of giving way and Lachman's testing was positive at 1+ with good endpoint, which is consistent with slight instability. During the October 2020 VA examination, the Veteran also complained of left knee instability; however, stability testing was normal, and the examiner indicated that he did not have recurrent subluxation or lateral knee instability. Therefore, the Board finds that the Veteran's symptoms are consistent with a 10 percent rating, but no higher, for slight instability beginning May 17, 2019. A higher, 20 percent rating is not warranted because the evidence does not indicate that he had moderate instability during this time period. REASONS FOR REMAND As discussed above, the evidence indicates that the Veteran has left femoral nerve neuropathy, which resulted from a nerve block during the ACL reconstruction surgery. In October 2019, the Board determined that the ACL tear and reconstruction were more likely than not a result of his service-connected left knee disability, and injury sustained during service. Consequently, the Board granted a temporary total evaluation for convalescence related to that surgery. Although the Veteran's left femoral nerve neuropathy was mentioned during the October 2020 VA examinations for his service-connected left knee and low back disabilities, the examiner did not indicate the severity of the disability. Therefore, a remand is necessary for an additional VA examination. The matter is REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Then, schedule the Veteran for an appropriate VA examination to determine the current level of severity of all impairment resulting from his left femoral nerve neuropathy. The claims file must be made available to and reviewed by the examiner. All indicated tests should be performed and all findings should be reported in detail. The examiner should provide all information required for rating purposes and describe the effects of the disability on the Veteran's ordinary activity, including his ability to work. 3. Confirm that the VA examination report and all opinions provided comport with this remand and undertake any other development found to be warranted. 4. Then, readjudicate the issue remaining on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.