Citation Nr: 22012185 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 16-19 532A DATE: March 2, 2022 ORDER Entitlement to service connection for stable angina, due to service-connected hypertension, is granted. Entitlement to service connection for a right upper extremity neurological disability, to include carpal tunnel syndrome, is denied. Entitlement to service connection for a left upper extremity neurological disability, to include carpal tunnel syndrome, is denied. Entitlement to an initial rating higher than 10 percent for a right knee disability is denied. FINDINGS OF FACT 1. The evidence is at least in equipoise regarding whether the Veteran has a heart disability, diagnosed as stable angina, is related to service-connected hypertension. 2. The evidence of record persuasively weighs against finding that a right upper extremity neurological disability, to include carpal tunnel syndrome, began during active service, is otherwise related to any event, injury, or disease during service, or is related to a service-connected disability. 3. The evidence of record persuasively weighs against finding that a right upper extremity neurological disability, to include carpal tunnel syndrome, began during active service, is otherwise related to any event, injury, or disease during service, or is otherwise related to a service-connected disability. 4. Throughout the period of appeal, a right knee disability has been manifested by flexion limited to 65 degrees and extension, overall, to 0 degrees; it has not been manifested by flexion limited to 30 degrees or less, extension limited to 10 degrees or less, ankylosis, objective evidence of recurrent subluxation or lateral instability, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart disability, diagnosed as stable angina, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for service connection for a right upper extremity neurological disability, to include carpal tunnel syndrome, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a left upper extremity neurological disability, to include carpal tunnel syndrome, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3.310. 4. The criteria for entitlement to a rating higher than 10 percent for a right knee disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1997 to December 2005. The Veteran appeared at an April 2018 hearing before the undersigned Veterans Law Judge at the Manila, the Republic of the Philippines, Regional Office. A hearing transcript is of record. In August 2021, the Agency of Original Jurisdiction granted service connection for a left knee disability, a right ankle disability, a left ankle disability, right lower extremity neurological disability to include radiculopathy and sciatica, left lower extremity neurological disability to include radiculopathy and sciatica, radiculopathy of the right lower extremity femoral nerve, and radiculopathy of the left lower extremity femoral nerve. As those benefits sought have been granted in full, those issues are no longer on appeal and will not be addressed below. This case was previously remanded in December 2018 for further development. In light of the treatment records that have been obtained and associated with the record, the obtaining of the requested medical opinions, and the further adjudicatory actions taken by the Agency of Original Jurisdiction, the Board finds that there has been substantial compliance with the prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). Service Connection In general, service connection may be established for disability due to disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(d). To establish a service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163(Fed. Cir. 2004). A disability may be service connected if the evidence of record shows that the Veteran currently has a disability that was chronic in service or that was chronic as defined by regulation with continuity of symptomatology demonstrated after service. 38 C.F.R. § 3.303(a),(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a non-service-connected disability, which is aggravated by a service-connected disability. In such an instance, the Veteran is compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a heart disability, claimed as hypertensive cardiovascular disease As a preliminary matter, the Board notes the Veteran's concerns regarding the characterization of the present claim. In an October 2021 statement, the Veteran stated that he is claiming service connection for hypertensive cardiovascular disease due to the likely artery obstruction from arteriosclerosis brought on by service-connected hypertension, in contrast to a VA examiner whom the Veteran felt only considered "hypertensive heart disease." When a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board has characterized the current claim as broadly encompassing the Veteran's symptoms, regardless of terminology. At a January 2021 VA examination, the examiner diagnosed stable angina. The examiner noted the Veteran's report of easily tiring and being exhausted when walking too far. An echocardiogram found left ventricular ejection fraction of 69 percent. Wall motion and thickness were normal. The examiner specified that the Veteran's current heart condition (stable angina) was a new diagnosis related to hypertension based on echocardiogram review, examination, and medical records. The examiner stated that hypertensive heart disease was not diagnosed. Stable angina was diagnosed. The examiner opined that the Veterans diagnosis of stable angina was at least as likely as not proximately due to or the result of the service-connected hypertension. He explained that high blood pressure can cause damage to the coronary arteries, leading to blockages in the arteries and abnormal blood flow to the heart which caused angina or chest pain due to inadequate blood flow to the heart. Based on all the evidence of record and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran has a heart disability, diagnosed as angina, that was caused by or is due to service-connected hypertension. The January 2021 VA examiner both diagnosed a current disability and provided a clinical opinion linking that disability to a service-connected disability. The examiner had the medical training and experience necessary to offer a competent opinion. Significantly, no evidence of record contradicts the examiner's opinions. Accordingly, the Board finds that the evidence is at least in equipoise regarding whether currently diagnosed stable angina was caused by service-connected hypertension. Accordingly, the Board will resolve reasonable doubt in favor of the Veteran and find that entitlement to service connection for a heart disability, diagnosed as stable angina, as a result of service-connected hypertension, is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107. 2. Entitlement to service connection for a right upper extremity neurological disability, to include carpal tunnel syndrome 3. Entitlement to service connection for a left upper extremity neurological disability, to include carpal tunnel syndrome In characterizing these issues on appeal, the Board recognizes that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the medical evidence of record indicates that the Veteran has been diagnosed with bilateral carpal tunnel syndrome and bilateral cervical radiculopathy, and he has made statements regarding the general presence of neurological symptoms in the bilateral upper extremities, the issue of entitlement to service connection for carpal tunnel syndrome of the right and left upper extremities have been expanded to include any neurologic disability of the upper extremities. A September 1999 service medical record shows that the Veteran experienced a blunt trauma to the right thumb while playing basketball. He was diagnosed with a right thumb sprain. A February 2000 service medical record shows that the Veteran was on a ski trip when he slipped and fell. The Veteran reported experiencing pain and swelling to the left thumb. The diagnosis given was thumb sprain. On December 2004 and September 2007 Reports of Medical History, the Veteran indicated that he did not experience numbness or tingling. A December 2015 MRI found bilateral cervical radiculopathy and bilateral carpal tunnel syndrome. At an April 2016 VA examination, the examiner diagnosed cervical radiculopathy and bilateral carpal tunnel syndrome. The Veteran reported experiencing numbness of both hands for several years, and he had a constant pain in the neck that radiated to the upper extremities. The examiner opined that it was less likely than not that bilateral upper extremity neurological disabilities were incurred in or caused by service. The examiner discussed the nature of carpal tunnel syndrome according to the National Institute of Neurological Disorders and Stroke. Many different factors that can contribute to carpal tunnel syndrome were discussed. The examiner noted that there was little clinical data to prove whether repetitive and forceful movements of the hand and wrist during work or leisure activities could cause carpal tunnel syndrome. Other disorders, such as bursitis, tendonitis, and writer's cramp had been associated with repeated motions performed in the course of normal work or other activities. The examiner commented that the Veteran had a history of a bilateral thumb injury during service. However, there was not enough evidence showing involvement of both wrists during the accidents the Veteran experienced during service that would warrant the diagnosis of a compression neuropathy at the level of the wrist resulting in carpal tunnel syndrome. The examiner cited a review of literature and the nature of carpal tunnel syndrome to support the opinion that it was less likely than not that the Veteran's carpal tunnel syndrome was incurred in or caused by service. At a January 2021 VA examination, the examiner diagnosed cervical radiculopathy of the bilateral upper extremities, and bilateral carpal tunnel syndrome. The examiner noted the Veteran's report of doing a lot of lifting while on active duty and experiencing numbness and tingling of the upper extremities, including the hands and fingers. The examiner stated that the Veteran's medical records did not support that any currently diagnosed right or left upper extremity neurological disability, to include carpal tunnel syndrome and cervical radiculopathy, was at least as likely as not incurred in or caused by active service. The examiner further opined that it was less likely than not that the right and left upper extremity neurological disability, to include carpal tunnel syndrome and cervical radiculopathy, was proximately due to, the result of, or aggravated beyond the natural progression by the service-connected disabilities, as they were due to different etiologies. The examiner found no causal relationship between the right and left upper extremity neurological disabilities and the service-connected disabilities. The examiner specified that it was not anatomically possible that the service-connected lumbosacral strain would affect the upper spinal nerves. The Board is not free to substitute its own judgment for that of a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The April 2016 and January 2021 VA examiners opined that it was less likely as not that bilateral upper extremity neurological disabilities were a result of or related to service. The January 2021 VA examiner opined that it was less likely as not that bilateral upper extremity neurological disabilities were proximately due to, the result of, or aggravated beyond the natural progression by the service-connected disabilities. The VA examiners specifically identified and discussed the Veteran's contentions and theory concerning service and the upper extremity neurologic disabilities. In particular, the examiners specifically discussed the service medical records and post-service records. The Veteran's lay statements were considered. The VA examiners did not use speculative language in the opinions. Accordingly, the April 2016 and January 2021 VA examiners' opinions are found to carry significant weight. The Board has considered the Veteran's statements and acknowledges that as a layperson, he is competent to diagnose and report on simple conditions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to report numbness and tingling, as such is observable through lay observation. However, determining whether the Veteran's neurological symptoms are attributable to service or to service-connected disability presents a complex medical question. The Board finds that the statements from the April 2016 and January 2021 VA medical examiners outweigh the lay statements from the Veteran, as the medical examiner have the training and expertise necessary to make such a medical determination. Further, to whatever extent the Veteran's statements can be construed as asserting a continuity of symptoms from the time of his service through the present, those statements are contradicted by the Veteran's own markings on Reports of Medical History completed in December 2004 and September 2007, on which he indicated that he did not experience numbness or tingling. The Board finds the December 2004 and September 2007 Reports of Medical History to be more credible that the Veteran's present assertions, as they were completed contemporaneously with the conclusion of the Veteran's service, and as such, are more likely to accurately indicate his symptoms, or lack thereof, at the time. The evidence of record clearly establishes that the Veteran has current bilateral upper extremity neurologic disabilities. However, the record does not establish that those disabilities are medically related to any incident of service or to the service-connected disabilities. The Board notes that service connection has previously been established for a lumbar spine disability, but not for a cervical spine disability. The Veteran has asserted that a private examiner told him that the degenerative changes in the lumbosacral spine region led to the onset of cervical spine injuries which led to cervical radiculopathy. However, that assertion is not supported by a review of the private treatment records submitted by the Veteran and obtained by VA. None of the post-service medical records showing a diagnosis of a bilateral upper extremity neurological disability indicate that the disability is at least as likely as not a result of service or a service-connected disability, and neither the Veteran nor his representative has presented or specifically identified any such existing medical opinion. Without such an etiology opinion, service connection cannot be established. Hickson v. West, 12 Vet. App. 247 (1999). Service connection for cervical radiculopathy cannot be established secondary to a cervical spine disability as the Veteran has not established service connection for any cervical spine disability. In sum, the most persuasive evidence of record weighs against the claim for service connection for either a right or left upper extremity neurological disability. Accordingly, the Board finds that the claim for service connection for neurological disabilities of the right and left upper extremities must be denied. In reaching this conclusion, the Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). The rating of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. When rating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, limitation of flexion of the knee is rated 10 percent for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the knee is rated 10 percent for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004);VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). 4. Entitlement to an initial rating higher than 10 percent for a right knee disability At a July 2014 VA examination, the examiner diagnosed right knee sprain and right knee pain. The Veteran reported that he experienced constant sharp pain on the superolateral aspect of both knees. He stated that the pain rated a five to eight on a zero (low) to 10 (high) pain scale. Sitting down relieved the pain. He also used pain relievers. The Veteran reported that flare-ups could occur once a week. During flare-ups, the Veteran walked with discomfort. Flare-ups did not result in additional limitation to the range of motion, but there was more pain on motion. The examiner measured right knee flexion to 140 degrees or greater with pain at 110 degrees. Right knee extension was to 0 degrees with pain at 45 degrees or greater. Left knee flexion was to 140 degrees or greater with pain at 90 degrees. Left knee extension was to 0 degrees with pain at 45 degrees or greater. Following repetitive use testing, right knee flexion was to 130 degrees, and extension was to 0 degrees. Left knee flexion was to 130 degrees, and extension was to 0 degrees. The Veteran experienced additional pain following repetitive use testing. Muscle strength testing found normal strength. Joint stability testing had normal results for both knees. There was no evidence or history of recurrent patellar subluxation or dislocation. The examiner opined that the right knee disability had a mild to moderate impact of the Veteran's ability to stand or walk for prolonged periods. A March 2015 MRI taken by a private facility found a horizontal tear of the medial meniscus with no evidence of ligamentous injury. There was mild narrowing of the medial compartment of the femorotibial joint compatible with early osteoarthropathic changes. At an April 2018 Board hearing, the Veteran reported experiencing flare-ups on average of about two to three times a month. He stated that he could not stand for very long, and he could not walk far distances. He reported wearing a knee brace. At a January 2021 VA examination, the Veteran described experiencing intermittent flare-ups of the knee and/or lower leg that lasted for one day. The flare-ups were caused by too much walking and standing, and they were alleviated by rest and ibuprofen. He stated that at times he could hardly walk. The Veteran described having problems with going up and down the stairs. For the right knee, active range of motion testing showed that flexion was to 75 degrees, and extension was to 0 degrees. Passive range of motion testing showed that flexion was to 75 degrees, and extension was to 0 degrees. Pain was noted on flexion and extension. Pain was also noted with weight-bearing. There was objective evidence of crepitus and localized pain on palpation of the joint. The Veteran described having problems with going up and down the stairs. For the left knee, active range of motion testing showed that flexion was to 70 degrees, and extension was to 0 degrees. Passive range of motion testing showed that flexion was to 70 degrees, and extension was to 0 degrees. Pain was noted on flexion and extension. Pain was also noted with weight-bearing. There was objective evidence of crepitus and localized pain on palpation of the joint. There was no additional loss of function or range of motion of either knee following repetitive use testing. The examiner estimated that following repeated use over time, flexion of the right knee would be to 70 degrees, and flexion of the left knee would be to 65 degrees with extension of both knees to 0 degrees. The examiner estimated that during a flare-up, flexion of the right knee would be to 65 degrees, and flexion of the left knee would be to 65 degrees with extension of both knees to 0 degrees. There was no atrophy or ankylosis of either knee. There was no recurrent subluxation or persistent instability of either knee. There was no recurrent patellar instability of either knee. The Veteran was noted to have a meniscal tear of both knees. The Veteran did not use any assistive devices as a normal mode of locomotion. The examiner opined that the Veteran would have difficulty in occupations that required prolonged standing and walking, frequent bending of the knees, running, climbing, and jumping. The Board finds that the preponderance of the evidence is against the assignment of any higher or separate rating under Diagnostic Code 5260 for limitation of flexion of the right knee at any time during the course of the appeal. Concerning the right knee, the evidence shows that flexion of the knee was limited, at worst, to 65 degrees, with consideration of pain. The flexion measurements are consistent with no more than a 0 percent rating under Diagnostic Code 5260. The Board also finds that the weight of the evidence is against assigning a higher rating throughout the period of appeal under Diagnostic Code 5261 for limitation of extension for right knee. The evidence shows that extension of the right knee was to 0 degrees throughout the period of appeal. Considering the record as a whole, the extension measurements are consistent with no more than a 0 percent rating under Diagnostic Code 5261. While the July 2014 VA examination found pain at 45 degrees of extension, the examiner also found that extension was possible to 0 degrees, including during flare up and after repetitive motion. The examiner did not find any additional limitation of function. The Veteran has repeatedly reported that he experiences pain. He has reported pain to each medical examiner, and he has additionally discussed the pain in repeated submissions to VA. Because of the Veteran's painful limitation of knee motion, and other symptoms, the presently assigned disability rating of 10 percent based on painful motion for the right knee is warranted. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40, 4.45, 4.59. However, the Board finds that the preponderance of the evidence is against the assignment of any higher or additional separate rating for limitation of motion of the right knee as the evidence does not show, even when considering painful motion and other limiting factors, that knee movement is limited so as to warrant any higher or separate rating. The rating assigned has considered additional functional loss due to pain and other factors. Turning to instability, the Board concludes that a separate compensable rating is not warranted at any time throughout the period of appeal for the right knee. Significantly, all of the VA examiners indicate that the Veteran's knees were stable on objective observation. To whatever extent the Veteran may assert that the right knee is unstable, the Board finds that the objective medical evidence outweighs the subjective complaints, as the medical evidence was created by trained health care providers objectively performing professional duties following objective testing, which determined there was not objective evidence of recurrent lateral instability or subluxation. The Board finds that those objective medical findings are more persuasive because of the training and experience of the medical professionals. In light of those medical records, the Board finds that a separate disability rating is not warranted at any time during the period of appeal for instability of the right knee. In addition, subluxation of the right knee is not shown. None of the treatment records, to include X-ray and MRI findings, show dislocated or removed semilunar cartilage of either knee. Thus, Diagnostic Codes 5258 and 5259 cannot serve as a basis for an increased or separate rating. Even if a meniscal tear is present in the right knee, the evidence does not show frequent episodes of locking or effusion that would warrant any higher rating. The pain experienced is already compensated under the limitation of motion rating, and a separate rating cannot be assigned for the same symptomatology using a difference diagnostic code. 38 C.F.R. § 4.14. Finally, in considering the applicability of other diagnostic codes, the Board finds that Diagnostic Codes 5256 (ankylosis of the knee), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum) are not applicable, as the medical evidence does not show that the Veteran has any of those conditions. The Board notes that the Veteran's functional loss was considered as the medical evidence shows that the Veteran has consistently complained of pain. 38 C.F.R. §§ 4.40, 4.45. However, the limitation of motion and functional loss documented in the medical records as resulting from pain, including flare-ups, is contemplated in the disability rating currently assigned. Moreover, although the Veteran had pain on repetitive motion, that pain did not result in limitation of flexion or extension to the level that any separate or higher rating would be warranted. There is otherwise no evidence of additional significant impairment of motor skills, muscle function, or strength attributable to the Veteran's knee disability, beyond what is already being compensated. Consequently, the Board finds that a higher rating based on functional loss is not warranted for the right knee. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher or separate rating for the right knee disability and the claim must be denied. The Board finds that the evidence is not in relative equipoise and there is no reasonable doubt to be resolved in favor of the Veteran. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Layton, 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.