Citation Nr: 22013746 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 15-20 473 DATE: March 10, 2022 ORDER An increased rating for a right knee sprain of 20 percent from July 21, 2012, through February 3, 2020, is granted. An increased rating for a right knee sprain in excess of 20 percent is denied. FINDING OF FACT Throughout the appeal period, the Veteran's right knee disability has resulted in painful or limited motion at times due to pain and other factors, with flexion limited to 30 degrees but higher than 15 degrees, and extension to greater than 10 degrees; with no recurrent subluxation, lateral instability including ligament sprain or tear, patellar instability; meniscal impairment; or other knee or leg impairment. CONCLUSIONS OF LAW 1. The criteria for an increased rating for a right knee sprain of 20 percent from July 21, 2012, through February 3, 2020, based on painful or limited motion are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 2. The criteria for an increased rating for a right knee sprain in an excess of 20 percent, or a separate rating, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256 through 5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1999 to September 2003, including in Iraq, and his decorations include the Combat Action Ribbon. This matter initially came before the Board of Veterans' Appeals on appeal from a July 2013 rating decision. The Veteran has been represented by the same attorney for his VA claims and appeals since 2011; his claim for a right knee increase was received July 21, 2012. In August 2018, the Board denied an increased rating in excess of 10 percent for his right knee strain, among other decisions, including dismissing a claim of entitlement to total disability rating based on individual unemployability (TDIU). On further appeal to the United States Court of Appeals for Veterans Claims (Court), in a June 2019 Order, the Court granted a Joint Motion for Partial Remand (JMPR) and vacated and remanded the August 2018 Board decision to the extent that it denied an increase for the right knee sprain. The JMPR noted that the Veteran was not appealing the dismissal of the TDIU issue. In December 2019, the Board remanded the right knee rating issue. An August 2020 rating decision increased the rating to 20 percent, effective February 4, 2020. In January 2021, the Board issued a decision that denied an increased rating for the right knee in excess of 10 percent prior to February 4, 2020, and in excess of 20 percent thereafter. The Veteran again appealed to the Court. In an October 2021 Order, the Court granted another JMPR and vacated the January 2021 Board decision to the extent it denied higher right knee ratings. The matter now returns to the Board for compliance with the terms of the JMPR, which found inadequate reasons and bases for several aspects of the prior Board decision. The October 2021 JMPR stated that the January 2021 Board decision improperly stated that the objective medical evidence did not support a higher rating, without further explanation. The Board errs when it favors "objective medical evidence over lay evidence, without any supporting reasons or bases for that finding." English v. Wilkie, 30 Vet. App. 347, 352 (2018). Objective medical evidence is not required to establish evidence of lateral knee instability under DC 5257 (effective prior to February 2021); and the Board must provide supporting reasons or bases. The October 2021 JMPR further stated that Board improperly failed to define the terms "minimal" and "slight," as the Board must provide "a standard for comparing and assessing terms of degree." Johnson v. Wilkie, 30 Vet. App. 245, 255 (2018). The January 2021 Board decision stated that the evidence showed "no more than minimal instability" and, thus, did not meet the 10 percent criteria for "slight" instability to warrant a separate rating under DC 5257. Finally, the October 2021 JMPR stated that the January 2021 Board decision did not sufficiently explain its decision regarding limitation of extension. In that decision, the Board stated that the evidence from the February 2020 VA examination was consistent with a noncompensable rating under DC 5261, with extension limited to 5 degrees, but did not provide further explanation as to why a separate rating for extension was not warranted despite this finding. The analysis below has been updated to address these JMPR concerns. 1. and 2. An increased rating for a right knee sprain in excess of 10 percent prior to February 4, 2020, and in excess of 20 percent thereafter The Veteran's claim for an increase for his right knee disability was received July 21, 2012. He has been assigned a 10 percent rating prior to February 4, 2020, and a 20 percent rating effective since that date, based on painful or limited flexion. The Veteran seeks a higher rating for his right knee due to frequent pain and swelling, and a separate rating under DC 5257 due to instability and use of a cane, with resulting functional impairment for daily activities and work. See, e.g., July 2014 statements from Veteran and lay witnesses, July 2014 notice of disagreement, June 2015 VA Form 9, October 2020 and January 2022 attorney appellate briefs. VA's percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. All reasonable doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A separate or higher rating may be assigned based on non-overlapping conditions and symptoms, if the compensable criteria under applicable diagnostic codes are met, including with consideration of additional functional loss after repetitive use or flareups for musculoskeletal conditions based on range of motion. See 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.71a; Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009); Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016). Pain itself does not constitute functional loss, and painful motion must result in functional loss to constitute limited motion for a rating under diagnostic codes that are based on limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be awarded if there are decreases or increases in symptomatology that meet the criteria for a different rating for a distinct period during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Effective dates should not be assigned based solely on the date of diagnosis. Swain v. McDonald, 27 Vet. App. 219, 224 (2015). Instead, all relevant facts should be considered to determine the date the increase in disability first manifested. DeLisio v. Shinseki, 25 Vet. App. 45, 58 (2011); see also 38 C.F.R. § 3.400. Preliminarily, the Board finds that adequate notice and development has been provided, and prior remand directives from the Board and Court (via JMPR) were substantially completed. The June 2019 JMPR remanded this matter for a VA examination consistent with Sharp v. Shulkin, 29 Vet. App. 26, 34-35 (2017). As noted in the January 2021 Board decision, as the February 2020 VA examination contains the required information under Sharp, there was substantial compliance. The October 2021 JMPR did not reference any inadequacies with the examination. There is no argument or indication that additional development is needed. In January 2020, the Veteran's attorney responded to a December 2019 duty to assist letter that the Veteran had no private treatment records to identify or provide. In addition to the February 2020 VA examination, VA treatment records were obtained from several facilities dated through July 2020. There is no argument or indication that the Veteran's right knee symptoms have increased since the last VA examination or other medical evidence in the claims file, or that his impairment and functional loss are otherwise not adequately described. Therefore, no additional records, examination, or medical opinion are needed for a fair appeal. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. Although the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, and recurrent subluxation or instability of the knee. A rating may also be assigned for meniscal impairment if there are non-overlapping symptoms. The Board will explore all possibilities in this case. VA amended some of the regulations for rating knee disabilities, including DC 5257 (subluxation and instability) and DC 5262 (tibia and fibula impairment), effective February 7, 2021. The codes for limitation of motion remain unchanged. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020). The criteria that are most favorable to the pending claim will apply; however, an award based on the amended regulations may not be made effective before the effective date of the change. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under DC 5003 for degenerative arthritis, when limitation of motion of the specific joint is noncompensable under the appropriate DC, a rating of 10 percent will be assigned for each major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. If there is no limitation of motion, ratings of 10 or 20 percent are available if there is x-ray evidence of two or more major joints or two or more minor joint groups, requiring occasional incapacitating exacerbations for a 20 percent rating. 38 C.F.R. § 4.71a. Normal knee range of motion is from 0 degrees of flexion to 140 degrees of extension. 38 C.F.R. § 4.71, Plate I. Under DC 5260, a 10 percent rating is assigned for limitation of flexion of the leg 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. Id. Under DC 5261, a 10 percent rating is assigned for limitation of extension of the leg 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. Id. VA's intention is 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. A rating based on this section must be applied in connection with the criteria found in a particular diagnostic code. Sowers v. McDonald, 27 Vet. App. 472, 479 (2016). Section 4.59 applies whether or not arthritis has been diagnosed, and regardless of whether the diagnostic code is predicated on range of motion measurements. Burton v. Shinseki, 25 Vet. App. 1, 5-6 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). As explained below, the evidence supports a rating of 20 percent throughout the appeal period, to include prior to February 4, 2020, and beginning as of the date of receipt of the Veteran's claim on July 21, 2012. However, a separate or higher rating is not warranted for limitation of motion or otherwise at any point. Throughout the appeal period, the lay and medical evidence reflects painful or limited right knee motion at times due to pain, stiffness, swelling, and other factors. The Veteran, his wife, and his mother submitted competent lay statements describing his observable symptoms and functional loss; these statements are credible, as they are generally consistent with each other and with medical records. Near the beginning and end of the appeal period, the Veteran and other lay witnesses described similar manifestations of difficulty or increased pain, swelling, a sensation of locking or stiffness, a sensation of instability or unsteadiness and falling at times. These sensations and difficulties occurred with activities including prolonged walking or ambulation, prolonged standing, standing from a sitting position, using stairs, squatting, kneeling, driving; and he was unable to run due to knee symptoms. These are essentially descriptions of the effects of flareups or repeated use over time. The lay witnesses described the Veteran using a brace and cane due to feeling unsteady and fearing that he would fall, and he placed most weight on his left leg due to right knee pain. See, e.g., statement from Veteran in October 2012 (to Social Security Administration (SSA)) and July 2014; notice of disagreement from attorney in July 2014; statements from wife (noted as girlfriend at the time) in October 2012 and July 2014; statement from mother in July 2014; VA knee examinations in June 2013 and February 2020; VA treatment records in September 2012, January 2013, December 2014, August 2018, and February 2019. Despite these symptoms, the Veteran's right knee motion was measured to 90 degrees of flexion in the June 2013 and February 2020 VA knee examinations. This is well beyond the 45 degrees required for even a 10 percent rating under DC 5260. Multiple other evaluations and medical records noted the Veteran's range of motion of the knee or lower extremities as good, within normal limits, or full range (0 to 140 degrees) despite pain, swelling, or increased pain. See, e.g., September 2012 SSA evaluation; VA treatment records in July 2012 (TBI evaluation), December 2012, June 2013, July 2013, August 2013, April 2014, and February 2019. However, the February 2020 VA examiner estimated additional loss of flexion to 40 degrees with repeated use over time and to 30 degrees during flareups based on the Veteran's descriptions similar to those summarized above. This was the basis of the award of a 20 percent rating effective the date of the VA examination. The June 2013 VA examiner did not give an estimate of additional loss during such episodes of increased symptoms because the examiner did not observe those episodes; this s inadequate under Sharp. The Veteran and other lay witnesses described similar symptoms and severity throughout the appeal period, and the Veteran's measured or observed limitation of flexion was the same in June 2013 and February 2020. Additionally, the Veteran repeatedly reported for VA treatment that his right knee pain ranged from 4 to 6 out of 10, and that it fluctuated and was worse at times. See, e.g., records in September 2012, October 2016, April 2017, February 2018, and December 2019. A June 2013 VA treatment record noted chronic right knee (and back) pain that was worsening since he started a new job where he was on his feet for 8 hours a day for 4 days a week. His knee would be sore or painful but not swollen in the mornings, and his knee would swell and become more painful as the day progressed. His pain was 4 out of 10 at best and 8 out of 10 at worst, and ibuprofen was not helping. During the February 2020 VA examination, the Veteran also reported pain of 4 out of 10 during the February 2020 VA examination. He summarized that flareups occurred 1 to 2 times a month, were severe and lasted 2 to 3 days, were precipitated by an increase in activity and weather, and were alleviated by rest and over-the-counter pain medication. The Veteran has taken NSAIDs or other pain medications at various times for his right knee, as well as for his back, as noted in lay statements, VA examinations, and VA treatment records. However, he reported at times that these medications were not working, or he had no relief and still had pain despite the medications, such as in June 2013. He also used rest, elevation, heat, ice, physical therapy and at-home exercises to alleviate increased symptoms. However, the records indicate that the Veteran was taking pain medications for his knee and back, not just his knee. Moreover, he had normal range of motion at times despite his continued pain. Therefore, even discounting any ameliorative effects of medications on his right knee, there is no suggestion of limitation of flexion to 15 degrees, as required for a 30 percent rating. The varying degrees of motion as noted in his treatment records and medical evaluations is consistent with limitation at times. In other words, discounting the ameliorative effects of medications or treatment does not result in additional loss of motion beyond that noted in the records as stated above. Therefore, the evidence is at least in relative equipoise, and reasonable doubt is resolved in the Veteran's favor to find that he met the criteria for a 20 percent rating based on limitation of flexion to 30 degrees throughout the appeal period, when considering the increased functional loss during flareups and repeated use. Although the 20 percent criteria under DC 5260 are met, the descriptions by the Veteran and other lay witnesses of increased impairment or severity at times does not suggest limitation to 15 degrees or less to warrant a 30 percent or higher rating. Moreover, neither the Veteran nor his attorney has argued that degree of severity; instead, they assert that the 20 percent rating for limited flexion is appropriate. The Veteran's claim was received on July 21, 2012, and there was no factually ascertainable increase to the 20 percent level within one year prior to his claim. An August 2011 private treatment record noted right knee, but no new joint pains or swelling. In July 2014, the Veteran's wife wrote that in the five years she had known him (or since 2009), his condition had deteriorated. Similarly, the Veteran's mother wrote in July 2014 that, since his discharge from service, he had been able to go shorter and shorter amounts of time before needing stop and take breaks. These descriptions are consistent with a gradual increase in severity since the service connection date of 2003, but they do not suggest that the Veteran's right knee symptoms first increased to the 20 percent level, with limitation to 30 degrees during episodes of increased symptoms, within one year prior to his 2012 claim. Thus, the evidence reflects that the Veteran's right knee increased to the 20 percent level before one year prior to his claim, and the date of receipt of the claim is the proper effective date for the increase granted in this decision. 38 C.F.R. § 3.400(o). Considering other potentially applicable codes, the criteria are not met for a separate rating under DC 5261. The Veteran's right knee extension was measured to 0 degrees (full extension) in the June 2013 VA examination, there was full extension noted in multiple other evaluations and treatment records as summarized above, and extension was limited to 5 degrees during testing at the February 2020 VA examination. Although the 2020 examiner gave an estimate for significant additional loss of flexion during flareups and repeated use over time, as noted above, the examiner estimated that extension would still be to 5 degrees. The descriptions of additional impairment by the Veteran and other lay witnesses also do not reflect significantly limited extension to a compensable level of 10 degrees under DC 5261. Neither the Veteran nor his attorney has asserted that there is additional limitation of extension; instead, the JMPR found that the Board did not previously explain sufficiently why a separate rating was not warranted under DC 5261 at the 0 percent (noncompensable) level for limitation to 5 degrees. As noted above, DC 5003 for arthritis provides for a 10 percent rating when there is painful motion that does not meet the compensable criteria under the specific diagnostic codes for the joint. Section 4.59 similarly provides for a minimum rating under this circumstance, in conjunction with a diagnostic code, if there is no arthritis. However, a separate rating cannot be assigned for the same symptoms (including painful or limited motion) under DC 5003, as this would be impermissible pyramiding. Additionally, as the Veteran already has at least a minimum compensable rating, a separate rating is not appropriate for painful extension that does not meet the DC 5261 compensable criteria. Instead, the Veteran's 20 percent rating under DC 5260, including prior to February 4, 2020, as awarded in this decision, contemplates his painful motion with both flexion and extension. Thus, a higher or separate rating based on limitation of motion is denied. Concerning DC 5258 and 5259, as noted above, relevant to the full appeal period, in addition to pain and swelling, the Veteran and his wife reported that his right knee or leg feels stiff or "locks." DC 5258 states that a dislocated (or torn) semilunar cartilage (or meniscus) with frequent episodes of "locking," pain, and effusion into the joint will be assigned a 20 percent rating. DC 5259 provides for a 10 percent rating for a symptomatic knee post-meniscus. 38 C.F.R. § 4.71a. Although the Veteran and other lay witnesses are competent to describe observable sensations of locking or catching, pain, and effusion or swelling, they are not competent to identify the underlying etiology of these sensations. This question requires medical expertise to interpret the Veteran's history and tests due to the complex nature of the knee joint and multiple potential causes of symptoms. Thus, the medical evidence is the most probative, which finds no meniscal diagnosis. The June 2013 examination report checked that there was a meniscus condition on the right side with symptoms of frequent locking and pain, but no meniscectomy. No detail or support was provided for this assessment, and the June 2013 x-rays noted normal soft tissues, with no reference to any meniscus abnormality. The 2013 examiner's assessment also conflicts with other evidence that found no meniscal condition, including close in time to the examination. Significantly, an August 2013 MRI of the right knee found no meniscus injury or abnormalities. There was mild prepatellar soft tissue swelling and edema, but the medial and lateral menisci were within normal limits, and there was no evidence of joint effusion. This objective and contemporary imaging is highly probative as to whether there was any meniscal abnormality at that time or a few months earlier at the VA examination. Additionally, there also was no effusion at an April 2014 VA consultation, and the February 2020 VA examination stated that there was no current or past meniscus condition. This evidence is more probative than the brief notation in the June 2013 VA examination, and the 2013 notation is outweighed. For the above reasons, a separate rating under DC 5258 or 5259 is denied. The Veteran's complaints are contemplated by his rating for painful or limited motion. Other than limitation of motion, the Veteran and his attorney primarily focus on a rating under DC 5257. As noted above, the Veteran and other lay witnesses reported him having a feeling of unsteadiness or instability with use at times, that he had fallen several times, and that he used a brace and cane for support and stability of his right knee. These complaints may be contemplated by DC 5257 (before and after February 2021) for recurrent subluxation, lateral instability, or patellar instability. However, the evidence is against finding that these sensations are due to subluxation or instability, including lateral or patellar instability. Per English, supra, medical evidence is not automatically more probative than lay evidence. The Veteran and other lay witnesses are competent to describe his observable sensation of instability or unsteadiness and that he has fallen at times, and there is no reason to discredit these reports. However, they are not competent to identify the underlying etiology of this sensation. This question requires medical expertise to interpret the Veteran's history and tests due to the complex nature of the knee joint and multiple potential causes of symptoms. Therefore, the medical evidence is the most probative, which finds no instability or subluxation, ligament tear or sprain, or abnormality of the quadriceps tendon, patella, or patellar tendon. As noted above, the criteria under DC 5257 in effect prior to February 7, 2021, address recurrent subluxation (or patellar dislocation) and lateral instability. They do not give specific definitions of mild, moderate, or severe conditions. Instead, the Board must make the determination based on consideration of all evidence. In addition to the lay reports from the Veteran and other witnesses as summarized above, a July 2012 VA TBI consultation indicates that the Veteran reported a "balance disturbance" every once in a while due to his knee. A September 2012 VA neurologic consult noted that he had good motor power and normal muscle tone, he guarded his right knee with chronic arthralgia and used a cane for support, but his gait had a stable stance and pace. Also in September 2012, a SSA examiner observed that the Veteran brought a cane to the examination, but it was not required for ambulation; he had a steady gait but limped on the right leg. Although the Veteran reported using a cane constantly for his knee during the June 2013 VA examination, an August 2013 VA emergency department record noted that he ambulated with a cane but had a steady gait without the cane. In February 2019, the Veteran sought VA treatment for pain in both knees and lower legs or shins after falling when he "missed a step" outside his home; and he stated that he was "using a cane now." This suggests that he had not been using a cane before that episode. However, earlier records such as in December 2014 and August 2018 noted that he was ambulating with a cane. During the February 2020 VA examination, the Veteran stated that he had a "few times" where his knee gave out, and that he used a right knee sleeve brace occasionally and a cane regularly. Despite the complaints of instability and falling, the June 2013 and February 2020 VA examiners found no objective joint instability on testing for all types of stability. The MRI in 2013 also found intact ligaments with no ligamentous injury. Moreover, the Veteran reported at times that he used the cane for his back alone, or for his back and knee together. For example, an August 2013 TDIU claim (VA Form 21-8940) and November 2014 VA spine examination stated that he used a cane due to his back; although he reported in VA knee examinations that he used a cane and brace for his back and right knee. In his July 2014 statement, the Veteran reported that his problems standing were due to his right knee and his back. His wife also reported in July 2014 that the Veteran had lots of treatment for severe right knee and back pain. Similarly, A July 2014 statement from a friend also noted that he had observed the Veteran having trouble walking and the Veteran told him he had numbness in his back and left knee problems, and his pain was causing trouble walking. In July 2017, a message from the Veteran's wife to his VA primary care provider noted that he was constantly falling at home due to being unstable on his knees and back. Treatment records also frequently reflect complaints of right knee and back pain, rated as 4 or 5 out of 10 together, including in August 2011, June 2013 (noting an increase to 8 out of 10 for knee and back pain after workdays), July 2017, and May 2020. He took pain medications for his back and knee. Medical evidence also reflects significant back and associated right lower extremity radiculopathy symptoms. For example, a November 2014 VA spine examination noted moderate to severe right lower extremity pain, numbness, and paresthesias or dysesthesias; decreased sensation, and absent reflexes. Any unsteadiness, weakness, or instability in the right lower extremity due to the Veteran's back and radiculopathy may not be considered as part of his knee rating. Overall, the evidence does not show at least slight recurrent subluxation (patellar dislocation) or lateral instability, as required for a minimum 10 percent rating under the prior version of DC 5257. A feeling of weakness or giving way, to include during flareups and repeated use, does not necessarily equate to subluxation or instability under either version of the rating code, as there are multiple potential causes. Moreover, a rating based on subluxation or instability under DC 5257 should not consider the effects of pain and other factors during flareups or repeated use over time because this code is not based on limitation of motion. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). The above evidence reflects that the Veteran's sensations in this regard were due to pain or other factors other than subluxation or lateral instability, to include non-knee related symptoms. Thus, a rating for the right knee under the prior version of DC 5257 is not warranted. Under the criteria since February 7, 2021, a rating under DC 5257 for recurrent instability expressly contemplates the claimant being prescribed an assistive device such as a cane, crutches, and/or a walker. However, those criteria require a ligament sprain, incomplete tear, or complete ligament tear, which is not shown in this case. The new criteria for patellar instability under DC 5257 require a diagnosed condition involving the patellofemoral complex, which includes the quadriceps tendon, the patella, and the patellar tendon. No such diagnosis is shown here. Thus, a separate rating is not warranted under the new criteria for DC 5257. Concerning the remaining knee codes, there is no argument or indication of ankylosis or impairment approaching ankylosis for a rating under DC 5256, as the Veteran retained significant flexion and extension of the left knee. The evidence also does not warrant a rating under DC 5262 based on impairment of the tibia or fibula. The June 2013 VA examiner noted multiple bone islands of the distal femur and proximal tibia, but there was no indication of nonunion or malunion of the tibia or fibula, and the examiner stated that this condition was independent and separate from the service-connected right knee disability. Moreover, there is no argument or suggestion from the Veteran or his attorney or in medical records that this condition has any manifestations or functional impairment to support assignment of a rating for non-overlapping symptoms. VA treatment records include February 2019 x-ray reports for pain in the proximal tibia, and there was right greater than left tibial tuberosity traction spurring. However, a letter to the Veteran concerning those results stated that the x-rays did not show any reason for his knee pain. Additionally, the February 2020 VA examiner found no impairment involving the tibia or fibula. Finally, there is no suggestion of acquired genu recurvatum under DC 5263. In summary, reasonable doubt has been resolved in the Veteran's favor to award a higher 20 percent rating prior to February 4, 2020; the appeal is granted to this extent. However, the Veteran's disability remained relatively stable throughout the period on appeal. Although he had increased pain and limitation or other impairment at times, those manifestations were insufficient to meet the criteria for an even higher or separate rating at any point. As the evidence is not at least in relative equipoise or approximate balance as to an even higher or separate rating, there is no reasonable doubt to be resolved, and the appeal is otherwise denied. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wheatley 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.