Citation Nr: 22014099 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 14-31 537A DATE: March 11, 2022 ORDER The rating reduction for the Veteran's left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur was not properly reduced from 10 percent to noncompensable, effective July 1, 2012, restoration of a 10 percent rating is granted. Entitlement to a disability rating in excess of 10 percent prior to November 19, 2020, and in excess of 20 percent from November 19, 2020 until February 6, 2021 for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur, is denied. From February 7, 2021, a 30 percent rating, but not higher, for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur is granted. An effective date of October 8, 2019 for a noncompensable rating for left knee (limitation of extension) associated with left femur fracture with residual shortening of the femur is granted. From October 8, 2019, entitlement to a compensable rating for left knee (limitation of extension) associated with left femur fracture with residual shortening of the femur is denied. FINDINGS OF FACT 1. The reduction of the disability rating for the Veteran's left knee instability from 10 percent to noncompensable, effective July 1, 2012, failed to comply with applicable law and regulations. 2. Prior to November 19, 2020, the Veteran's left knee disability was manifested by slight recurrent subluxation and lateral instability. 3. From November 19, 2020, the Veteran's left knee disability was manifested by moderate instability and incomplete/partial ligament tear. 4. From February 7, 2021, the Veteran was prescribed a brace, cane, and walker for his left knee meniscal tear, osteoarthritis and chondromalacia patella with instability. He also experienced persistent instability. 5. Throughout the appeal period, the Veteran's left knee disability was manifested by flexion, at worst, to 80 degrees. 6. As of October 8, 2019, the Veteran's left knee is shown to have limitation of extension to 5 degrees. CONCLUSIONS OF LAW 1. Reduction of the rating for the Veteran's left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur from 10 percent to noncompensable, effective July 1, 2012, was not proper. 38 U.S.C. § 5107; 38 C.F.R. § § 3.105, 3.344, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 5257. 2. The criteria for entitlement to a disability rating in excess of 10 percent prior to November 19, 2020, and in excess of 20 percent thereafter for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur, have not been met. 38 U.S.C. §§ 1155; C.F.R. §§ 4.3, 4.14, 4.40, 4.59, 4.71a, Diagnostic Code 5257. 3. From February 7, 2021, the criteria for entitlement to a 30 percent disability rating for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur, have been met. 38 U.S.C. §§ 1155; C.F.R. §§ 4.3, 4.14, 4.40, 4.59, 4.71a, Diagnostic Code 5257 (2021). 4. As of October 8, 2019, the criteria for an effective date for service connection for left knee limitation of extension have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.400, 4.71a, Diagnostic Code 5010-5261. 5. The criteria for entitlement to a compensable rating for left knee (limitation of extension) associated with left femur fracture with residual shortening of the femur from October 8, 2019 have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.3, 4.14, 4.40, 4.59, 4.71a, Diagnostic Codes 5010-5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from July 1980 to July 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In May 2017, the Veteran provided testimony before the undersigned Veterans Law Judge. A transcript of the record is associated with the claims file. This matter was previously remanded in March 2018, June 2020, November 2020, and April 2021 to the Agency of Original Jurisdiction (AOJ) for further development. The matter now returns to the Board for appellate consideration. During the pendency of the appeal, in a January 2021 rating decision, the Agency of Original Jurisdiction (AOJ) increased the rating for the Veteran's left knee chondromalacia patella, Grade III with instability, to 20 percent effective November 19, 2020. As the increase did not satisfy the appeal in full, the issue remains on appeal and has been characterized as shown above. See AB v. Brown, 6 Vet. App. 35 (1993). Also, in a November 2021 rating decision, the AOJ assigned a separate noncompensable disability rating from August 24, 2021 for left knee limitation of extension, as secondary to left femur fracture with residual shortening of the femur. As this rating is encompassed in the increased rating claim for left knee instability, the Board has added the issue of a compensable rating for left knee limitation of extension to the appeal. Furthermore, and as will be discussed below, the Board finds that a noncompensable evaluation for left knee limitation of extension is applicable for an earlier period of the staged ratings for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur. Rating Reduction The Veteran's left knee instability was reduced from 10 percent to noncompensable (0 percent) under Diagnostic Code 5257 in a June 2012 rating decision. Because this rating reduction did not change the overall combined disability rating, a proposed rating reduction decision was not required. The procedural requirements were met. See 38 C.F.R. § § 3.105 (e). Regarding rating reductions, the law provides that, when a rating has continued for a long period at the same level (i.e., five years or more), a reduction may be accomplished when the rating agency determines that evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344 (a). However, where a rating has been in effect for less than five years, the regulatory requirements under 38 C.F.R. § 3.344 (a) are inapplicable, as set forth in 38 C.F.R. § 3.344 (c). In such cases, an adequate reexamination that discloses improvement in the condition will warrant reduction in rating. 38 C.F.R. § 3.344 (c); 3.343(a). A rating reduction requires an inquiry as to "whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations." Brown v. Brown, 5 Vet. App. 413, 421 (1993). In this case, the Veteran's rating at issue had been in effect for less than five years at the time of the reduction. Thus, the heightened duty to show sustained material improvement as contemplated by 38 C.F.R. § 3.344 (a) and (b) are not for application. Nonetheless, the Board notes that for the Veteran's rating to be properly reduced, it must be determined not only that an improvement in the disability level has actually occurred, but also that such improvement reflects an improvement in the ability to function under the ordinary conditions of life and work. See Brown, 5 Vet. App. at 421. Turning to the evidence of record, the Board observes that a noncompensable rating was assigned for left knee instability as reflected in a June 2012 rating decision based on a January 2012 VA examination. This rating was pursuant to Diagnostic Code 5257. Under Diagnostic Code 5257, recurrent subluxation or lateral instability will be assigned a 10 percent rating where it is mild, a 20 percent rating where it is moderate, or a maximum 30 percent rating where it is severe. 38 C.F.R. § 4.71a. The RO assigned a noncompensable rating based on objective findings in the January 2012 VA examination for normal anterior, posterior, and medial-lateral instability and no history for recurrent subluxation/dislocation. The January 2012 VA examination indicated that the Veteran reported pain over the anterior left knee that worsened with prolonged standing, walking, and climbing and the inability to squat or kneel. The examination failed to demonstrate any evidence of joint instability or subluxation. While the January 2012 VA examination was full and complete and provided a basis for a decreased rating, 38 C.F.R. § §§ 4.2 and 4.10 provide that in any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but also that that improvement in a disability actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 421. 38 C.F.R. § § 3.344 (c). This analysis was not provided. Moreover, the Veteran's statements during the examination seem to suggest worsening of his left knee disability and more so reflective of milder symptoms. The Board finds that the lay and medical evidence suggests that the overall disability picture remained relatively consistent and that the Veteran's complaints for mild instability in his left knee continued through the time of reduction. As such, the Board concludes that the findings from the January 2012 VA examination report does not support that there has been an actual improvement in the Veteran's left knee instability. Thus, the Veteran's functional impairment associated with left knee instability does not reflect an overall improvement in the disability nor is it reasonably certain that any improvement shown would be maintained under the ordinary conditions of life. In sum, the evidence supports the restoration of the 10 percent rating for the Veteran's left knee instability. Resolving any reasonable doubt in the Veteran's favor, the Board finds that the rating reduction was not proper and restoration of a 10 percent rating for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur, from July 1, 2012 is warranted. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). In rating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Significantly, VA revised the rating criteria for the knees, effective February 7, 2021. With regard to the ratings concerning the knee, the revisions revised 38 C.F.R. § 4.71a, Diagnostic Codes 5055, 5257, and 5262. Diagnostic Codes 5258, 5260, and 5261 did not change. The amended criteria, if favorable to the Veteran's claim, can only be applied for the period from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The relevant rating criteria include Diagnostic Code 5010, which instructs the rater to rate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. For purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The Rating Schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. VA's General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). Under the criteria effective prior to February 7, 2021, Diagnostic Code 5257 provides that recurrent subluxation or lateral instability will be assigned a 10 percent rating where it is mild, a 20 percent rating where it is moderate, or a maximum 30 percent rating where it is severe. 38 C.F.R. § 4.71a. Under the criteria effective February 7, 2021, Diagnostic Code 5257 provides that recurrent subluxation or instability will be assigned a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating will be assigned if there is one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating requires an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Id. There are also new criteria for patellar instability under Diagnostic Code 5257. A 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. at Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id. at Note (2). Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Codes 5260 or 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis can also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). VA's General Counsel has subsequently held that separate ratings can also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Analysis The Veteran contends that his left knee condition is more severe than contemplated by the assigned evaluations. The Veteran's left knee is currently evaluated 10 percent disabling prior to November 19, 2020, and 20 percent disabling thereafter under Diagnostic Code 5257. In November 2021, the AOJ granted service connection for limitation of left knee extension and assigned a noncompensable evaluation under Diagnostic Codes 5010-5261, effective August 24, 2021. The Veteran's appeal is construed to encompass the possibility of an earlier effective date and an increased rating for this disability. The Board also notes the Veteran is in receipt of a 10 percent rating for limitation of flexion with pain under Diagnostic Codes 5010-5260 from October 18, 2002. VA treatment records from September 2012 to February 2016 demonstrated the Veteran's complaint for chronic knee pain and use of a knee brace to help alleviate knee pain. The Veteran reported occasional buckling of the while working as a postman with the United States Postal Service. A January 2012 VA examination revealed flexion limited to 130 degrees and extension at 0 degrees in the left knee. Repetitive use testing demonstrated the same range of motion. The examination revealed no additional limitations upon range of motion testing, but functional loss characterized as less movement than normal and pain on movement in the left knee. Flare ups were not noted in the examination report. The Veteran reported pain over the anterior left knee that increased in severity with standing, walking, and climbing; he also reported the inability to squat or knee. The examination did not demonstrate evidence of muscle atrophy, joint instability, subluxation, or meniscus condition. Regular use of a cane was noted. In September 2014, the Veteran indicated that he experienced a great deal of instability and pain in the left knee, particularly with climbing stairs. A February 2016 VA treatment record reflected the Veteran's reports of chronic knee pain and occasional buckling during work. An August 2016 VA examination revealed flexion limited to 90 degrees and extension to 0 degrees in the left knee. The Veteran reported chronic pain and instability in his left knee that worsened over the years; and crackling sensations in his knees, increased warmth, and grinding pain. He also reported flare ups characterized as a sense of tightness and swelling that occurred once per month. The examiner noted that there were no additional functional limitations with repeated use over time and flare ups; disturbance of locomotion and interference with standing were noted though. There was no evidence of muscle atrophy, a meniscal tear, or ankylosis. There was slight recurrent subluxation and slight medial instability in the left knee. The examiner reported the presence of small effusion in the left knee but no evidence of pain with passive range of motion. Upon functional impact, the Veteran reported difficulty with prolonged standing and walking, and having missed six weeks of work due to his knee condition. During the Veteran's May 2017 hearing, he reported worsened left knee pains since his August 2016 VA examination and daily use of over the counter (OTC) medications to manage pain. A May 2018 VA examination demonstrated flexion limited to 130 degrees and extension to 0 degrees in the left knee. An opinion on functional limitation with repeated use and flare ups was not provided as the examiner indicated that they were unable to say without speculation. The Veteran continued to report increased pain, stiffness, and weakness. The examination did not demonstrate any evidence of muscle atrophy, meniscal condition, ankylosis, subluxation, or joint instability in the left knee. The examiner indicated that the examination revealed mild bilateral knee stiffness, left knee tenderness, and bilateral weakness, but no evidence of laxity or instability. A September 2019 VA examination demonstrated flexion limited to 90 degrees and extension to 0 degrees in the left knee. Pain and lack of endurance limited functional ability upon repeated use over time and flare-ups, and was expressed as flexion limited to 80 degrees and extension to 0 degrees. The Veteran reported long standing pain, swelling, instability, locking, and the use of brace/cane. The examination did not evidence muscle atrophy, a meniscal condition, or ankylosis but there was slight recurrent subluxation, recurrent effusion, and slight lateral instability in the left knee. An October 8, 2019 private disability benefits questionnaire (DBQ) demonstrated left knee flexion to 85 degrees and extension to -15 degrees. Additional limitations in range of motion were noted upon repetitive use testing and described as flexion limited to 80 degrees and extension to -20 degrees; contributing symptoms included less movement than normal, weakened movement, pain, swelling, disturbance of locomotion, and interference with standing and sitting. Additional limitations in range of motion were recorded as both flexion and extension limited to 5 degrees. (The Board notes that a finding for flexion limited to 5 degrees is a significant deviation and inconsistent with prior range of motion measurements in flexion). The examination did not demonstrate evidence of muscle atrophy, subluxation, or ankylosis. There was evidence of slight lateral instability in the left knee and frequent episodes of joint locking, pain, and effusion. The examiner indicated that the Veteran continued to have difficulty with walking rapidly, pushing heavy equipment, and lying on his side. A November 2019 MRI of the left know demonstrated a tear of the body and posterior horn of the medial meniscus with inferior articular surface extension, MR stage III-IV chondromalacia changes involving the medial facet of the patellofemoral compartment, and fluid around the inferior half of the medial collateral ligament complex. A November 2020 VA examination reflected abnormal ranges of motion in the left knee, with flexion limited to 120 degrees and extension to 0 degrees. The examination also reflected sharp pain within all ranges of motion in the left knee with evidence of pain on weight bearing, localized tenderness medially and posteriorly, moderate subluxation, and moderate lateral instability but no evidence of ankylosis or meniscal condition in the left knee. The examiner also indicated that there was pain on passive range of motion testing but no pain on non-weight bearing. It was noted that during flare ups, flexion would decline from 0 to 90 degrees as a result of his left knee giving out. Regular use of a cane and brace was noted. Passive range of motion measurements were not provided. An August 2021 VA examination reflected abnormal ranges of motion in the left knee, with flexion limited to 100 degrees and extension to 5 degrees, both in active and passive testing. The examination also reflected pain within all ranges of motion in the left knee, with evidence of pain on weight bearing, localized tenderness, crepitus, and functional loss characterized as decreased kneeling capacity. The Veteran reported intermittent but frequent anterior knee pain that interfered with prolonged standing, walking, and knee shifting with pivots that interfered with weightbearing on his knee. He indicated flare ups occurred twice a week lasting 20 minutes at a time. Upon repetitive use over time, pain, fatigability, weakness, and lack of endurance limited functional ability. Similarly, with flare ups, pain, fatigability, and weakness caused functional loss. The examiner indicated upon speculation range of motion would be less than 50 percent of normal range of motion both during repeated use over time and flare ups. There was no evidence of muscle atrophy, ankylosis, or tibial/fibular impairment, but evidence of recurrent subluxation/persistent instability, incomplete/partial ligament tear. The Veteran had a medical prescription for cane, walker, and brace; patellar instability was not noted. The examination also demonstrated a meniscal tear with frequent episodes of joint "locking" and pain. Lastly, the examiner noted the Veteran's knee may impair his capacity to perform occupational tasks that required repetitive kneeling, squatting, climbing, or prolonged standing/walking. In an August 2021 addendum opinion, the examiner clarified that non-weight bearing range of motion measurements were the values recorded in the knee DBQ and that weight bearing range of motion measurements in flexion were not possible to obtain because the knee would have to be in extended to bear weight. Additionally, the examiner noted that weight bearing range of motion for both knees was full extension (0 degrees). In a subsequent email, the examiner also clarified that he was not able to provide estimated range of motion without undue speculation because he did not have a basis to provide one. Rating Under 5257 for left knee instability The Veteran is assigned a 10 percent disabling prior to November 19, 2020, and 20 percent disabling thereafter for left knee instability under Diagnostic Code 5257 evaluated as As referenced above regarding Diagnostic Code 5257, if the former version of a diagnostic code is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110 (g). Here, the Veteran had to wear a brace most times to stabilize and balance. During the January 2012 VA knee examination, the examiner noted that medial and lateral collateral ligament tests were normal. Although the Veteran reported occasional bucking at the January 2019 VA examination, he did not specifically report any instability of the knees. The August 2016, May 2018, September 2019, and October 2019 VA examinations evidenced slight lateral instability and recurrent subluxation in the left knee. For these reasons, the Board finds that a higher rating under Diagnostic Code 5257 is not warranted prior to November 19, 2020, as the evidence does not demonstrate moderate or severe levels of lateral instability and/or recurrent subluxation and that the weight of the evidence supports the current rating of 10 percent for slight lateral instability in the left knee. The November 2020 examination demonstrated moderate subluxation and lateral instability, which is commensurate with the currently assigned 20 percent disability rating. As of February 7, 2021, the Board finds that the Veteran is entitled to a 30 percent disability rating for his left knee instability under the revised rating criteria of Diagnostic Code 5257. To receive a 30 percent disability rating, the Veteran's left knee disability must demonstrate, "[a] diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker." 38 C.F.R. § 4.71a, Diagnostic Code 5257 (effective February 7, 2021). The Veteran was diagnosed with left knee meniscal tear, osteoarthritis and chondromalacia patella with instability. He was prescribed a brace, cane, and walker that he continues to use on a regular basis. He also experienced persistent instability as he reported "shifts" in his knee whenever he pivoted and pain with prolonged standing or walking. See August 2021 VA examination. Thus, he meets the criteria for a 30 percent disability rating as of February 7, 2021. This is the highest rating available. In conclusion, the Board finds that the weight of the evidence is against the Veteran's claim for entitlement to a disability rating in excess of 10 percent prior to November 19, 2020, and in excess of 20 percent thereafter until February 6, 2021 for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur. Beginning February 7, 2021, a 30 percent rating under the revised criteria is warranted for the left knee instability. Flexion and Extension Upon consideration of the evidence, the Board finds that the disability picture for the Veteran's left knee disability does not warrant a disability rating in excess of 10 percent under Diagnostic Codes 5010-5260 (flexion). A review of range of motion testing performed throughout the rating period shows that flexion of the left knee was limited to, at worst, 80 degrees. This is not commensurate with flexion limited to 30 degrees to warrant a 20 percent rating. As such, a rating in excess of 10 percent for the left knee is not warranted. As indicated above, the AOJ has assigned a noncompensable rating under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5261, effective August 24, 2021. Under Diagnostic Code 5261 a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension of the leg is limited to 10 degrees. The Board finds that a noncompensable rating is warranted as of October 8, 2019. This is the earliest date in the medical evidence to show that the left knee had a limitation of extension to 5 degrees. See October 2019 DBQ. The effective date of an award for an increased rating is the earliest date when it is factually ascertainable that an increase in disability occurred, if the application for an increase is received within one year from the date of increase. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2). Accordingly, an effective date of October 8, 2019 for service connection for left knee limitation of extension is granted. As indicated above, the evidence demonstrated that range of motion testing of the left knee in extension was, at worst, limited to 5 degrees. See October 2019 DBQ. However, this is not commensurate with extension limited to 10 degrees to warrant a compensable rating under Diagnostic Code 5261. Accordingly, a compensable rating is not warranted. The Board also considered whether higher ratings are warranted based on additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, at 204-7. During the January 2012 VA examination, the Veteran did not have decreased range of motion in the left knee following repetitive use testing. During the September and October 2019 VA examinations, the Veteran had decreased range of motion in the left knee following repetitive use testing; however, range of motion measurements during repeated use did not warrant a higher rating and are already contemplated in the assigned evaluations. Although the September and October 2019 VA examinations noted pain, weakness, fatigability, incoordination, and interference with sitting or standing; this did not significantly limit functional ability. During the November 2020 VA examination, the Veteran had decreased range of motion upon flare ups. While the Veteran's statements regarding painful motion are credible and also supported by the medical evidence, the effect of pain in the Veteran's knees are contemplated in the currently assigned 10 percent and noncompensable ratings based on painful motion under the corresponding diagnostic codes for flexion and extension. The consistent medical evidence and physical findings do not demonstrate flare ups productive of such impairment as to more closely approximate limitation of flexion to 30 degrees or less or limitation of extension to 10 degrees or more. In summary, the evidence of record supports an earlier effective date of October 8, 2019 for the grant of service connection for left knee extension but does not support a compensable rating for left knee limitation of extension from October 8, 2019 or a rating in excess of 10 percent for limitation of flexion. Other Considerations Upon review of all the evidence of record, the Board finds that the Veteran is not entitled to a separate 20 percent rating under Diagnostic Code 5258 for a dislocated semilunar cartilage (meniscal tears). The Veteran denied locking of the knees during the January 2012 VA examination report. While the October 2019 VA examination demonstrated that the Veteran complained of frequent episodes of joint locking, pain, and effusion, there was nothing evidencing meniscal dislocation. The August 2021 VA examination showed that the Veteran had a meniscus condition in the left knee. The Veteran reported intermittent but frequent anterior knee pain and shifting of the left knee during periods of pivot. While the August 2021 VA examination demonstrated frequent episodes of joint locking and pain, there was no evidence of effusion or meniscal dislocation. In any case, meniscus symptoms have manifested in pain and instability for which the Veteran has been rated 10 percent under Diagnostic Code 5260 (flexion) and 20 percent under Diagnostic Code 5257 (instability) from November 19, 2020. Therefore, a separate rating under Diagnostic Code 5258 is not warranted. The Board has considered entitlement to a higher rating under Diagnostic Codes such as 5256, 5259, 5262, and 5263. Ankylosis, symptomatic removal of semilunar cartilage, tibia and fibula impairment, and genu recurvatum are simply not shown nor contended. The Board finds the numerous VA examiners' medical opinions highly probative regarding the severity of the Veteran's left knee disability. Specifically, the examiners interviewed the Veteran and conducted a physical examination. Moreover, the examiners had the requisite medical expertise and sufficient facts on which to base their conclusions. As such, the Board accords the VA examination opinions great probative weight. The Board has also considered the statements submitted by the Veteran in support of the claims, specifically that his functional capacity is limited upon weight bearing and intermittent flare ups in his left knee. The Board finds that the Veteran is a lay person and is competent to report observable symptoms he experiences through his senses such as pain, popping, and weakness. Layno v. Brown, 6 Vet. App. 465 (1994). However, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. The identification of a knee disability and the determination of the range of motion of the knee require medical expertise that the Veteran has not shown he possesses. Determining whether the Veteran meets some of the criteria for a higher rating requires medical diagnostic testing. Competent evidence concerning the nature and extent of the Veteran's left knee disability has been provided by the medical personnel who have examined him and who have made pertinent clinical findings in conjunction with the examinations. The medical findings, as provided in the examination reports, directly address the criteria under which his disability is rated. The Board finds that evidence is the most persuasive and outweighs the Veteran's statements in support of his claims. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Asfaw, Associate 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.