Citation Nr: 22018690 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 11-07 444 DATE: March 30, 2022 ORDER Entitlement to an initial evaluation in excess of 10 percent for service-connected left knee strain is denied. Entitlement to an initial evaluation in excess of 10 percent for service-connected left knee instability is denied. FINDINGS OF FACT 1. The competent and credible evidence of record persuasively establishes a finding that the left knee strain is manifest by painful motion. 2. The competent and credible evidence of record persuasively establishes a finding that the left knee instability is manifest by mild severity. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation in excess of 10 percent for service-connected left knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.100, 4.104, Diagnostic Code 5260. 2. The criteria for entitlement to an evaluation in excess of 10 percent for service-connected left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.100, 4.104, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1988 to September 2008. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In December 2015, the Veteran testified at a hearing before a Veterans Law Judge (VLJ). A transcript of this hearing has been associated with the record. This VLJ has since become unavailable to participate in the appeal. In February 2020, the Board sent a letter to the Veteran providing them with an opportunity to present testimony at a new hearing before a different VLJ. The Veteran responded in March 2020 that they did not wish to appear at another Board hearing and asked the Board to consider the case on the evidence of record. This issue was previously before the Board in June 2016, May 2020, and March 2021, each time remanded for further development. That development was completed, and the case has since been returned to the Board for appellate review. Increased Rating 1. Entitlement to an initial evaluation in excess of 10 percent for service-connected left knee strain 2. Entitlement to an initial evaluation in excess of 10 percent for service-connected left knee instability Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). The Veteran's current knee disability is presently rated under diagnostic code 5260 based on painful motion, and diagnostic code 5257 left knee instability based on slight recurrent subluxation or lateral instability. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (DC 5260), limitation of extension (DC 5261), lateral instability or recurrent subluxation (DC 5257), and meniscal conditions (DC 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, DC 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, DC. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, DC; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can be assigned for knee instability or subluxation under Diagnostic Code 5257. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, DC 5257 (2020). "Slight," as relevant to a physical condition, is defined as "small of its kind or in amount." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). It is similar to "mild," which is defined as "not severe" or temperate; with "Temperate" being defined as "keeping or held within limits" and "not extreme or excessive." "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, "severe" represented the highest or most extreme level of disability. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. "Persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (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 10 percent rating is assigned for 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 or bracing for ambulation. Regarding patellar instability, 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 warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. 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 warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, DC 5257, 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., Note (2). Finally, ratings can be assigned for impairment of the tibia or fibula or genu recurvatum. 38 C.F.R. § 4.71a, DCs 5262, 5263. In this case the evidence does not reflect, nor does the Veteran allege, that they have tibia or fibula impairment or genu recurvatum of the knee. As such, those diagnostic codes are not for application. Evidence The Veteran underwent a VA examination in May 2008 where they reported weakness, stiffness, lack of endurance, fatigability, pain, and their knee giving away. They described the pain as burning, aching, and stiff, occurring three times per day, lasting one hour, precipitated by physical activity and descending stairs, and relieved by medication. The Veteran asserted a limited ability to jog, run, walk, or descend stairs easily. The examiner found no effusion, weakness, redness, heat, guarding, subluxation, locking pain, genu recurvatum, or crepitus. Initial range of motion testing demonstrated flexion to 140 degrees, and extension to 0 degrees. After repetitive use, the knee was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination. Medial and lateral collateral ligament stability, anterior and posterior cruciate ligaments, and medial and lateral meniscus were all within normal limits. In January 2021, a retrospective opinion was obtained to address additional findings. Regarding the May 2008 examination, the examiner opined that range of motion testing would demonstrate the same results for active and passive motion, and weight-bearing and non-weight bearing, that is, flexion to 140 degrees and extension to 0 degrees. August 2011 VA treatment records indicate left lateral knee tenderness. April 2014 VA treatment records note that testing found no fracture, dislocation, or significant joint effusion of the left knee. The joint spaces were found to be maintained, and there were no focal soft tissue abnormalities. The Veteran underwent a VA examination in April 2014 where they reported worsening pain on the medial joint line, and while descending stairs. The Veteran stated that there was a consistent lateral achiness at the same level as the 2008 examination, but denied flare-ups. Initial range of motion testing demonstrated flexion to 140 degrees, and extension to 5 degrees. There was no objective evidence of painful motion. There was no additional loss of range of motion with repetitive-use testing with 3 repetitions. Less movement than normal, pain on movement, disturbance of locomotion, and the Veteran's subjective complaints were found to be contributing factors of the disability after repetitive-use testing. There was no pain on palpation. Joint stability testing was normal. There was no evidence of subluxation/dislocation, shin splints, any meniscal conditions, joint replacement, or arthroscopic surgery. The examiner noted that although there Veteran's subjective complaints were suggestive of patellofemoral syndrome, testing was negative for the condition. The January 2021 retrospective opinion found that for the April 2014 examination, range of motion testing would demonstrate the same results for active and passive motion, and weight-bearing and non-weight bearing, that is, flexion to 140 degrees and extension to 5 degrees. The Veteran underwent a VA examination in May 2015 where they reported worsening pain, and popping. They described daily pain, and indicated that they take over the counter medication to treat it. The Veteran asserted that walking and running were impacted enough to cause concern, and that descending stairs causes intense pain. Initial range of motion testing demonstrated flexion to 140 degrees and extension to 0 degrees, with pain on both motions. There was mild to moderate pain on palpation, and on weight-bearing, with evidence of crepitus. There was no additional loss with repetitive use testing. The Veteran was not examined immediately after repeated use over time. Although the examiner opined that pain would significantly limit function after repeated use over time due to less movement than normal, they declined to describe this in terms of range of motion. The Veteran reported flare-ups occurring 6 to 8 times per month, of moderate severity, and lasting 30 minutes. Although the examiner opined that pain and fatigue would significantly limit function during a flare-up due to less movement than normal, they declined to describe this in terms of range of motion. There was no ankylosis, recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing demonstrated normal posterior and medial instability, but with anterior and lateral instability with 1+ (0-5 millimeters). There was no recurrent patellar dislocation, shin splints, stress fracture, chronic exertional compartment syndrome, or genu recurvatum. The examiner noted mild meniscal conditions with frequent episodes of joint locking and pain, but did not diagnose a meniscal condition at this time. The Veteran did not have any history of knee surgery, and they did not require the use of assistive devices. The functional impact was noted as difficulty traveling by airplane as the Veteran's knees lock from sitting. There was also limited kneeling and walking. The January 2021 addendum opinion found that for the May 2015 examination, range of motion testing range of motion testing would demonstrate the same results for active and passive motion, and weight-bearing and non-weight bearing, that is, flexion to 135 degrees and extension to 0 degrees. An addendum opinion was acquired in August 2020 to address the meniscal findings of the May 2015 examination. The examiner explained that while the symptoms were consistent with a diagnosis of a meniscal condition, one was not diagnosed. They explained that the examination did not site any evidence from diagnostic testing with confirmatory findings of a meniscal condition, and that medical records did not contain any diagnostic finding either. The examiner stated that the Veteran does not have any objective evidence of a meniscal condition, nor did they have any objective physical examination findings consistent with one. They concluded that a meniscal condition was ruled out. An additional addendum opinion was acquired in October 2020 to address the meniscal findings of the May 2015 examination. The examiner opined that there was a left meniscal tear that was a progression of the sprained left knee. An additional addendum opinion was acquired in December 2021 to address the flare-ups noted on the May 2015 examination. The examiner noted the Veteran's subjective complaints, and opined that testing during a flare-up would demonstrate flexion to 135 degrees and extension to 0 degrees. At the December 2015 Board hearing, the Veteran reported that they have to hold onto the railing as they descend stairs as they cannot put any weight on the left knee due to the amount of pain, and that sometimes descending stairs is impossible altogether. They stated that it affects the quality of life in that running used to be their main form of exercise, and that they have gained weight as a result. The Veteran described the pain as significant, and stated that walking long distances or any running agitates it so that they can no longer run and that it has limited other physical activities. They asserted that arthritis is now an issue and that they use anti-inflammatory medication. The Veteran underwent a VA examination in February 2019 where they reported that the knee had gotten progressively worse, and that the knee causes difficulty running and prolonged sitting. Initial range of motion testing demonstrated flexion to 115 degrees and extension to 0 degrees. Range of motion did not contribute to functional loss, but pain noted on flexion did. There was no evidence of pain on weight-bearing, non-weight-bearing, or passive motion. There was mild to moderate pain on palpation, but no crepitus. Repetitive use testing did not cause any additional loss of function or range of motion. The Veteran was not examined immediately after repetitive use over time. The examiner opined that pain would significantly limit functional ability, but did not describe in terms of range of motion, stating that it would be limited based on the severity of the symptoms. The Veteran reported flare-ups, describing pain stopping them from moving until the pain is tolerable enough. The examiner opined that pain would significantly limit functional ability, but did not describe in terms of range of motion, stating that it would be limited based on the severity of the symptoms. There was no ankylosis, recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was normal. There were findings of shin splints, but they did not affect range of motion. There was no evidence of recurrent patellar dislocation, stress fracture, chronic exertional compartment syndrome, genu recurvatum, leg length discrepancy, any meniscal conditions, or history of any surgical procedures. The Veteran did not report the use of any assistive devices. The examiner opined that the functional impact included limited capacity for carrying heavy objects, reduced capacity for tasks that require repeat knee bending, increased pain with prolonged standing, walking, sitting, weight-bearing, and ambulating on uneven ground. The Veteran underwent a VA examination in August 2020 where they reported sharp stabbing pain on the outside of the knee, with additional sharp pain on touch. They asserted that 2 to 4 times per week they are unable to place any weight on it, and that they treat it with medicine, rest, and cold water. The Veteran reported functional loss to include an inability to walk or run, and that it affects their quality of life. Initial range of motion testing demonstrated flexion to 105 degrees and extension to 0 degrees, although range of motion itself did not contribute to functional loss. Pain was not noted on examination, to include weight-bearing, non-weight-bearing, and passive motion, although there was mild pain on palpation. There was no crepitus. There was no additional loss of function or range of motion after repetitive use testing with three repetitions. The Veteran was not examined after repetitive use over time, but the examiner opined that pain would cause functional loss, and that testing would demonstrate flexion to 100 degrees and extension to 0 degrees. The Veteran reported severe flare-ups that last up to 30 minutes, precipitated by walking and running, and alleviated by rest and cold water. They were not examined during a flare-up, but the examiner opined that pain would cause functional loss and testing would demonstrate flexion to 100 degrees and extension to 0 degrees. There was no ankylosis, recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was normal. There was no recurrent patellar dislocation, shin splints, stress fracture, chronic exertional compartment syndrome, genu recurvatum, leg length discrepancy, any meniscal condition, or history of any surgical procedures. The Veteran reported the use of arch supports for pes planus, but did not identify any assistive devices for the knee. The examiner opined that functional impact would include difficulty squatting. The Veteran underwent a VA examination in April 2021 where they reported constant, sharp pain, rated as 6 out of 10 on average with locking or the inability to move the knee for up to one minute. They stated that it interferes with activities such as running, climbing, descending stairs, and activities of daily living. The Veteran stated that it is alleviated with rest and prescription medication. They reported a history of instability or recurrent subluxation, but denied a history of frequent effusion. Initial range of motion testing demonstrated on active and passive motion flexion to 130 degrees and extension to 0 degrees. Range of motion itself did not contribute to functional loss, but pain on flexion and extension did. There was pain on active and passive motion, but not on weight-bearing or non-weight-bearing. There was pain on palpation, but no crepitus. The examiner noted the pain as mild. There was no additional loss of function or range of motion after repetitive use testing with three repetitions. The Veteran was not examined immediately after repeated use over time, but the examiner opined that pain, fatigability, and weakness would cause functional loss, and testing would demonstrate flexion to 120 degrees and extension to 0 degrees. The Veteran denied flare-ups. There was recurrent subluxation or persistent instability, but no ankylosis, ligament tear, prescribed assistive devices, recurrent patellar instability, stress fracture, genu recurvatum, recurrent patellar dislocation, shin splints, leg length discrepancy, any meniscal conditions, or history of any surgical procedures. The examiner opined that the Veteran is limited in bending, stooping, pushing, pulling, carrying, lifting moderate objects, standing, sitting, walking, climbing stairs, running, squatting, and standing walking driving for long periods. Analysis The Board finds that the service-connected left knee is already adequately compensated with a 10 percent evaluation under Diagnostic Code 5260 based on painful motion, and a 10 percent evaluation under Diagnostic Code 5257 left knee instability based on slight recurrent subluxation or lateral instability. Under Diagnostic Code 5260, an even higher 20 percent evaluation is warranted when flexion is limited to 30 degrees, which has not been demonstrated here, even following extended use over time, or during a flare-up. At worst, flexion was only limited to 100 degrees. The Board acknowledges that although the February 2019 examiner did not describe in terms of range of motion the functional loss following extended use over time or during a flare-up, testing has been largely consistent throughout this lengthy appeal period, and at no point has the range of motion come close to being limited to 30 degrees. In fact, the symptoms at the August 2020 examination were more severe than at the February 2019 examination. Given the above, higher or separate ratings are not warranted for the left knee based on limitation of motion. 38 C.F.R. § 4.71a, DC 5260, 5261. The Board recognizes the Veteran's statements regarding the requirement of medication. The Board may not consider the ameliorative effects of medication where such effects are not explicitly contemplated by the rating criteria. See Jones v. Shinseki, 23 Vet. App. 122, 126 (2009). However, these statements do not demonstrate that flexion would be limited to 30 degrees or less at these times, or even the functional equivalent of ankylosis. Under Diagnostic Code 5257, an even higher 20 percent evaluation is warranted when there is unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation under the new criteria; 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 under the new criteria; or recurrent subluxation of moderate severity under the old criteria, which has not been demonstrated here. The Veteran has consistently denied the use of assistive devices, and the record does not demonstrate otherwise. The evidence also does not show surgical repair involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon). Joint instability was first noted at the May 2015 examination with anterior instability and lateral instability noted only at 1+ (0-5 millimeters). Joint stability testing was normal at the February 2019, and August 2020 examinations. Recurrent subluxation or persistent instability were confirmed at the April 2021, but there were no findings inconsistent with the above. Given that the tests performed are generally recognized in the medical community as diagnostic for instability, the results are afforded high probative value. The Veteran's statements are not in significant conflict with the examination findings. Notably, the examiners were well aware of the Veteran's reports but still found that, overall, the Veteran's left knee instability did not rise to a level of impairment necessary for a higher rating. The medical opinions were fully informed and based on diagnostic testing results and consideration of the Veteran's statements. Thus, regarding the version of Diagnostic Code 5257, a higher or separate rating is not warranted as the evidence is against a finding of the presence of moderate lateral instability or patellar instability. The Board notes that the requirement of establishing ankylosis for purposes of assigning a higher rating can be met with evidence of the functional equivalent of ankylosis during a flare-up. Chavis v. McDonough, No 18-2928 (2021). In this regard, ankylosis is defined as immobility of a joint, which, in essence, is complete limitation of motion. Id. Thus, an evaluation based on ankylosis may be assigned if there is functional loss that is the equivalent of ankylosis. Id. The VA examination reports show that the Veteran did not have the functional equivalent of ankylosis. Accordingly, the criteria for a higher rating under Diagnostic Code 5256 is not warranted. The Board acknowledges the findings of a meniscal tear in the left knee; however, despite there being frequent episodes of locking, there is no effusion into the joint, or removal of semilunar cartilage, to warrant a rating under Diagnostic Codes 5258 or 5259. Under 38 C.F.R. §§ 4.40 and 4.45, and the decision in DeLuca, the Board is required to consider the Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate disability evaluation for a disability using the limitation of motion diagnostic codes. The pain that the Veteran has reported and that the examiner noted would be present with flare-ups and repetitive use over time is contemplated in the currently assigned rating for the knee. Finally, the Board has considered whether a higher or separate rating is warranted under any other diagnostic criteria but has found none. The Board is sympathetic to the Veteran's lay statements that the condition is worse than currently evaluated and those statements have been considered. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to them through their senses. Layno, 6 Vet. App. 465. They are not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disability have been provided by the medical personnel who have examined them during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disability is evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability rating. (Continued on the next page) Accordingly, the claims of entitlement to an evaluation in excess of 10 percent for service-connected left knee strain, and to an evaluation in excess of 10 percent for service-connected left knee instability are denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the positive and negative evidence is not in approximate balance, the doctrine is not for application. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307, at *10 (Fed. Cir. Dec. 17, 2021). KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rogos 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.