Citation Nr: 24005697 Decision Date: 02/02/24 Archive Date: 02/02/24 DOCKET NO. 17-55 932 DATE: February 2, 2024 ORDER From May 10, 2016, to August 8, 2016; entitlement to a 10 percent rating, and not higher, for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint is granted. From August 9, 2016, a rating in excess of 10 percent for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint is denied. Prior to August 16, 2022, a 10 percent rating, and not higher, for instability is granted. Entitlement to a separate 20 percent rating for left knee meniscal dislocation with frequent episodes of "locking," pain, and effusion into the joint is granted. Entitlement to an initial compensable rating for surgical scar of the left knee is denied. FINDINGS OF FACT 1. From May 10, 2016, the Veteran's left knee joint was diagnosed by X-ray with arthritis and manifest with painful motion. 2. From August 9, 2016, the Veteran's left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint is manifested by painful flexion to, at worst 50 degrees and painful extension to zero degrees, with no evidence of ankylosis, tibia or fibula impairment, or genu recurvatum. 3. Resolving reasonable doubt in favor of the Veteran, slight instability was present in the left knee prior to August 16, 2022. 4. The Veteran's left knee was found to have meniscal dislocation with frequent episodes of "locking," pain, and effusion into the joint. 5. The Veteran's surgical scar of the left knee is not manifest by any disabling effects not considered under Diagnostic Codes 7800-04. His surgical scar of the left knee measures 4.0 cm by 0.4 cm. CONCLUSIONS OF LAW 1. From May 10, 2016, to August 8, 2016, the criteria for a 10 percent rating, and not higher, for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5260-5024. 2. From August 9, 2016, the criteria for a rating in excess of 10 percent for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5260-5024. 3. Prior to August 16, 2022, the criteria for a separate 10 percent rating for left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 4. The criteria for a separate 20 percent rating for left knee meniscal dislocation with frequent episodes of "locking," pain, and effusion into the joint have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 5. The criteria for an initial compensable rating for surgical scar of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1968 to April 1988 in the U.S. Army and is a recipient of a Bronze Star. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran withdrew his request for a Board hearing by way of a November 2021 correspondence. A March 2022 Board decision remanded the issues on appeal for further development. The remand directed that the RO obtain the Veteran's VA treatment records for the period from March 2019 to the present. Those records were obtained. The RO was also directed to ask the Veteran to complete a VA Form 21-4142, general release for medical provider information, for treatment from any private medical providers. The VA Form 21-4142 was provided to the Veteran in April 2022. The Veteran returned the release form but only identified VA treatment. The remand also directed that the Veteran be afforded new VA examinations for his left knee and his left knee surgical scar, in order to determine the present nature and severity of his disabilities. The Veteran was afforded new VA examinations in August 2022 , both of which were adequate. Therefore, there was substantial compliance with the remand directives. There was no new, non-duplicative, VA generated evidence relevant to the issues decided in this appeal that was submitted after the most recent September 2022 supplement statement of the case (SSOC). Therefore, waiver for RO review is not warranted. This case has been advanced on the docket pursuant to 38 C.F.R. § 20.800(c). Increased Ratings Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, an appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Where an increase in the level of a disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. From May 10, 2016 to August 8, 2016; entitlement to a 10 percent rating, and not higher, for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint is granted. 2. From August 9, 2016, a rating in excess of 10 percent for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint is denied. 3. Entitlement to a separate 20 percent rating for left knee meniscal dislocation with frequent episodes of "locking," pain, and effusion into the joint. 4. Prior to August 16, 2022, a 10 percent rating, and not higher, for instability is granted. The Veteran contends that he is entitled to a higher rating for his service-connected left knee tendonitis/tendonosis post reconstruction of the left knee due to dislocation (left knee disability) based upon increased symptomology. The November 2016 rating decision on appeal assigned a 10 percent rating for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint under 38 C.F.R. § 4.71a, DC 5260-5024. A prior noncompensable rating under DC 5299-5259 for the left knee reconstruction due to dislocation stopped effective August 9, 2016. The 10 percent rating was based on upon objective evidence of tenosynovitis along with any limitation of motion of the joint. The November 2016 rating decision also assigned a noncompensable rating based upon limitation of flexion of 46 to 60 degrees under 38 C.F.R. § 4.71a, DC 5024-5260. Hyphenated codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The Veteran's claim for an increased rating was filed August 9, 2016. Thus, the review period begins on August 9, 2015. See Gaston v. Shinseki, 605 F.3d 979, 980 (Fed. Cir. 2010). A review of the evidence reflects that the Veteran's left knee disability has manifested as tendonitis/tendinosis and been rated based on noncompensable limitation of motion, and that the disability has not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the relevant rating period. Under Diagnostic Code 5024, tenosynovitis, including tendonitis and tendinosis, are evaluated as degenerative arthritis under Diagnostic Code 5003, based on limitation of motion of affected parts. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings will be 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 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a 10 percent disability rating is assigned when extension is limited to 10 degrees, and a 20 percent disability rating is assigned when extension is limited to 15 degrees. A 30 percent disability rating is assigned when extension is limited to 20 degrees, and a 40 percent disability rating is assigned when extension is limited to 30 degrees. Finally, a 50 percent disability rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a , Diagnostic Code 5261. 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; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was afforded two VA examinations during the review period. On VA examination in August 2016, the Veteran was newly diagnosed with left knee tendonitis/tenodonosis, which was found to be a progression of his already service-connected history of left knee reconstructive surgery due to dislocation. The Veteran reported that his left knee condition has worsened, with pain on a daily basis. He noted that at times it feels like his left knee locks and he has to work to get it moving again. He experiences edema to the left knee several times a week. The Veteran reported left knee flareups that lead to increased pain and decreased movement resulting in issues with walking, standing, and bending. The Veteran reported functional loss as decreased range of motion in his left knee causing issues with walking, standing, and bending. The August 2016 examination report shows initial range of left knee motion was from zero to 90 degrees. Pain was noted on exam on rest/non-movement, as well as with weight bearing. There was objective evidence of crepitus. There was additional loss of range of motion after three repetitions measured as zero to 70 degrees, with pain noted to cause functional loss. The Veteran was not examined immediately after repetitive use over time, but the examiner indicated that the examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Weakness was noted to limit functional ability estimated in terms of range of motion as zero to 70 degrees. The Veteran was not examined during a flare-up, but the examiner indicated that the examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-up. Pain, weakness, and lack of endurance were noted to limit functional ability estimated in terms of range of motion as zero to 50 degrees. Muscle strength testing was 4/5 and there was no muscle atrophy. There was no ankylosis. There was no history of recurrent subluxation or lateral instability. The report shows a history of recurrent effusion, noted as swelling several times a week, that has never required fluid to be drawn off. The Veteran had no tibial or fibular impairments and no meniscal condition. Regular use of a left knee brace to provide stability and support when walking, standing, and weight bearing was noted. On VA examination in August 2022, the Veteran reported his left knee functional loss as difficulty with sleeping, sitting with knee bent, walking, standing, bearing weight working, going up and down stairs, difficulty getting up and down from a sitting or lying position, walking inclines and being unable to squat or kneel down. The Veteran reported moderate left knee flareups that occur daily and last days to weeks, precipitated by movement, standing, bearing weight, and walking, and alleviated by rest, and pain medication. The Veteran also reported a history of instability with his knee giving out on him which has resulted in falls. He also reported that his left knee swells up and hurts. The August 2022 examination report shows initial range of left knee motion was from zero to 90 degrees for both active and passive motion with pain noted on flexion and extension for both active and passive motion. Pain was also noted with weight bearing, nonweight bearing, and on rest/non-movement which causes the limitation in range of motion. There was objective evidence of crepitus and of localized tenderness or pain on palpitation. There was no additional loss of range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time, but the Veteran's statements describing functional loss with repetitive use over time suggested that pain and weakness limited functional ability estimated in terms of range of motion as zero to 90 degrees. The Veteran also was not examined during a flare-up, but the Veteran's statements describing functional loss during a flare-up suggested that pain, weakness, fatigability, incoordination, and lack of endurance were noted to limit functional ability estimated in terms of range of motion as zero to 50 degrees. There was no muscle atrophy or ankylosis. There was no recurrent patellar instability, however, recurrent subluxation or persistent instability was indicated, found to be an unrepaired incomplete/partial ligament tear requiring a prescription a walker and brace to aid in ambulation. There were no tibial or fibular impairments. A currently diagnosed meniscus (semilunar cartilage) condition was identified with symptoms of frequent episodes of joint pain, meniscal dislocation, frequent episodes of joint "locking" and frequent episodes of joint effusion. Based on the evidentiary record, the Board finds that a 10 percent rating, and not higher, is warranted from May 10, 2016, to August 8, 2016, for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint. In the year prior to the August 9, 2016, claim, VA treatment records from May 10, 2016, show that X-rays of the left knee revealed the presence of forms of arthritis and indicate that the Veteran reported chronic pain of his left knee. These are the earliest records in the year prior to the August 9, 2016 increased rating claim which show left knee arthritis and painful motion. The Board notes that 38 C.F.R. § 4.59 provides for at least the minimum compensable rating for a joint that experiences painful motion, with the "intention to recognize actually painful... joints, due to healed injury." See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran's painful motion of his left knee, due to residuals of his healed 1979 left knee reconstructive surgery, and caused at least in part by his newly diagnosed arthritis, is therefore entitled to the minimum 10 percent rating for limitation of motion of the knee, from earliest date as of which it is factually ascertainable that an increase in disability had occurred, here the date of the May 10, 2016, VA treatment record. For these reasons, the 10 percent rating for left knee tendonitis/tendonosis status post reconstruction left knee due to dislocation is granted from May 10, 2016. Gaston. Based on the evidentiary record, the Board finds that a rating in excess of 10 percent is not warranted during the entire appeal period for left knee tendonitis/tendonitis post reconstruction of the left knee due to dislocation based on objective evidence of tenosynovitis along with limitation of motion of the joint. The Board acknowledges the Veteran's lay report of symptoms and that the examination noted functional loss due to pain, weakness, fatigability, incoordination, and lack of endurance, including during repetitive use over time and during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, including estimated loss of range of motion due to flare-ups, the degree of additional limitation reflected by the Veteran's statements would not result in limitation of motion more nearly approximating flexion limited to 30 degrees or extension limited to 15 degrees. Thus, a higher rating is not warranted for limitation of flexion or extension under Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a. Therefore, the criteria for the next higher rating have not been met for limitation of motion under these Diagnostic Codes. The Board has also considered the other diagnostic codes pertaining to the knee and leg under both the prior and current diagnostic codes. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Diagnostic Code 5256 is not applicable because the record does not reflect ankylosis or symptoms more closely approximating ankylosis. The record also fails to demonstrate impairment of the tibia and fibula and/or genu recurvatum. Therefore, Diagnostic Codes 5262 and 5263 are not applicable. The August 2022 VA examination report shows that a currently diagnosed meniscus (semilunar cartilage) condition was identified, noted as meniscal dislocation, with symptoms of frequent episodes of joint pain, frequent episodes of joint "locking" and frequent episodes of joint effusion. Therefore, Diagnostic Codes 5258, cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint, is applicable. As the Veteran was noted to have all of the symptoms listed in Diagnostic Code 5258, the Board finds that the Veteran is entitled to a separate 20 percent rating under this Diagnostic Code (the highest and only rating under Diagnostic Code 5258). Diagnostic Code 5259, cartilage, semilunar, removal of, symptomatic, is not for application as the record does not show that the Veteran had his semilunar cartilage removed. Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability; a 20 percent rating when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating when there is severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. The Board notes that regulations regarding the musculoskeletal system changed effective February 7, 2021. While DCs 5260 and 5261 remained the same, DC 5257 changed. The new criteria state that for recurrent subluxation or instability, unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation warrants a 30 percent rating. A 20 percent rating is warranted for (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or, (b) 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. A 10 percent rating is warranted 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 (e.g., cane(s), crutch(es), walker) or bracing for ambulation. 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 and either a cane or a walker warranted a 30 percent rating. 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: 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. Note (1) states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states that 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). 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 DC 5257 to warrant a separate rating for arthritis based on x-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero percent rating. A separate rating for arthritis could 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). The General Counsel further held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004 ; 69 Fed. Reg. 59,990 (2004). In VAOPGCPREC 9-98, VA's General Counsel reiterated that, if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. The Board has further determined that assigning separate ratings under Diagnostic Codes 5257 and 5258 does not constitute "pyramiding" under 38 C.F.R. § 4.14. In this regard, the Board notes that every symptom contemplated by DC 5258 (dislocated semilunar cartilage, episodes of locking, and effusion in the joint) is distinct and separate from the current percent ratings assigned under DC 5257, which contemplate instability of the knee. Separate ratings under DCs 5257 and 5258 are therefore permissible in this instance and do not amount to impermissible pyramiding. 38 C.F.R. § 4.14 ; Esteban v. Brown, 6 Vet. App. 259, 262 (1964); VAOPGCPREC 9-2004. Based on the evidence, and resolving reasonable doubt in the Veteran's favor, a 10 percent rating is assigned prior to August 16, 2022, for slight knee instability under the rating criteria in effect prior to February 7, 2021. In this respect, VA treatment records show the Veteran reported use of an over the counter sleeve to wear on his knee for support in May 2016. At the VA examination in August 2016, the examiner noted that there was regular use of a left knee brace to provide stability and support when walking, standing, and weight bearing At the August 2022 examination, the Veteran reported a 'history' of instability with his knee giving out on him which has resulted in falls. According to MERRIAM WEBSTER, "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under DC 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Because the Veteran reported use of a knee sleeve/brace for stability and support, the Board finds a separate 10 percent rating for slight left knee instability is warranted. However, during the clinical examination at the August 2016 VA examination, no objective clinical evidence of instability was present. The examiner indicated that there was no history of recurrent subluxation or lateral instability. The Board has not found any other clinical evidence of instability in the VA medical records prior to August 2022, and the Veteran did not address instability in his notice of disagreement or substantive appeal. As the evidence does not reflect a more serious level of impairment in the form of instability, a rating higher than 10 percent is not warranted for the left knee instability prior to August 16, 2022. The Veteran has already been awarded a 20 percent rating for left knee recurrent subluxation or persistent instability, under the revised criteria for DC 5257 effective from August 16, 2022. Objective evidence of instability was identified on the August 2022 VA examination report, found to be an unrepaired incomplete/partial ligament tear requiring a prescription by a medical provider for a walker and brace to aid in ambulation. The September 2022 rating decision assigned the Veteran a separate 20 percent rating under Diagnostic Code 5257 for left knee sprain, incomplete ligament tear, causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, effective August 16, 2022, the date of the most recent VA examination. The Veteran could not receive the higher 30 percent rating under this Diagnostic Code as he has not been found to have a complete ligament tear. There are no other Diagnostic Codes under which the Veteran could receive compensation for his left knee disability. 5. Entitlement to an initial compensable rating for surgical scar of the left knee. The Veteran was assigned an initial noncompensable rating for his left knee surgical scar, effective August 9, 2016, by way of a November 2016 rating decision. He contends that he is entitled to an initial compensable rating. For the reasons that follow, an initial compensable rating is denied. The Veteran's left knee surgical scar is rated under Diagnostic Code 7805 for other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 be evaluated under an appropriate Diagnostic Code. VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7805 was not changed by the August 13, 2018, amendments. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran's left knee surgical scar is not of the head, face, or neck, and there is no evidence that it is deep or nonlinear, or associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does not cover an area or areas of 144 square inches or greater. Moreover, the Veteran's left knee surgical scar is not unstable or painful. Therefore, Diagnostic Codes 7800, 7801, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. The August 2022 VA scars/disfigurement examination report shows a left knee surgical scar that is not painful or unstable. The total area of the scar was not greater than 6 square inches. His scar was measured 4.0 cm by 0.4 cm wide. The Board finds that the evidence of record persuasively weighs against the assignment of a compensable rating for the Veteran's left knee surgical scar under Diagnostic Code 7805 as there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. However, he does not assert, and medical records do not show, that the Veteran's left knee surgical scar is manifest by any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04. In light of the foregoing, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a compensable rating for left knee surgical scar. As the evidence of record persuasively weighs against a compensable rating, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Caban, 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.