DEGENERATIVE ARTHRITIS

CAROLINE FLEMING · 2025 · Case ID: 25015129

MIXED

Summary

The Veteran, who served in the United States Marine Corps from August 1966 to November 1969, appeals the denial of an increased rating for left knee degenerative changes and instability. The appeal period spans from June 13, 2014, to November 7, 2021. The Veteran sought a rating higher than 20 percent for left knee degenerative changes, citing frequent episodes of locking, pain, swelling, and a history of meniscal tear and arthritis. He also contended that his left knee instability warranted a higher rating than the 20 percent assigned. The Board reviewed extensive evidence, including multiple VA examinations, treatment records, private medical opinions, and lay statements from the Veteran and his friends. Key evidence included VA examinations noting degenerative arthritis, limitation of extension to 10 degrees, and occasional instability, while lay statements consistently reported worsening pain, swelling, instability, and falls. The Board found that while VA examiners did not consistently find severe instability or effusion, the Veteran's and his friends' consistent reports, coupled with the benefit of the doubt, supported a finding of severe instability and constant swelling. Consequently, the Board granted a 10 percent rating for genu recurvatum and limitation of extension, and a 30 percent rating for severe left knee instability, while denying an increased rating beyond 20 percent for the degenerative changes with frequent locking, pain, and effusion.

Rationale

Board found Veteran's reports of constant swelling sufficient for effusion, resolving doubt in Veteran's favor.; Board found evidence persuasively weighs against finding a rating in excess of 20 percent for frequent episodes of locking, pain, and effusion under DC 5258.

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

5258

Docket No.

17-63 748

Full Decision Text

Citation Nr: 25015129
Decision Date: 12/22/25 Archive Date: 12/22/25

DOCKET NO. 17-63 748
DATE: December 22, 2025

ORDER

Entitlement to an evaluation in excess of 20 percent for left knee degenerative changes of the posterior horn of the lateral meniscus based on frequent episodes of locking, pain, and swelling of the left knee, prior to November 8, 2021, is denied.

Entitlement to a separate 10 percent rating for left knee degenerative changes of the posterior horn of the lateral meniscus based on limitation of extension, prior to November 8, 2021, is granted.

Entitlement to a separate rating of 10 percent for genu recurvatum of the left knee prior to November 8, 2021, is granted.

Entitlement to an initial rating of 30 percent for left knee instability prior to November 8, 2021, is granted.

FINDINGS OF FACT

1. From June 13, 2014, to November 7, 2021, the Veteran's degenerative changes of the posterior horn of the lateral meniscus disability manifested as frequent episodes of pain, locking and swelling in the left knee.

2. Prior to November 8, 2021, the Veteran's degenerative changes of the posterior horn of the lateral meniscus disability manifested at worst as extension limited to 10 degrees in the left knee.

3. Prior to November 8, 2021, the Veteran's left knee disability manifested as genu recurvatum (acquired, traumatic, with weakness and insecurity in weightbearing objectively demonstrated).

4. Prior to November 8, 2021, the Veteran's left knee disability manifested as severe instability in the left knee.

CONCLUSIONS OF LAW

1. From June 13, 2014, to November 7, 2021, the Veteran is in receipt of the highest available rating of 20 percent for frequent episodes of locking, pain, and swelling of the left knee. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5010-5258.

2. Prior to November 8, 2021, the criteria for entitlement to a separate 10 percent disability rating for genu recurvatum in the left knee has been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5010-5263.

3. Prior to November 8, 2021, the criteria for entitlement to a separate 10 percent disability rating based on limitation of extension of the left knee has been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5010-5261.

4. Prior to November 8, 2021, the criteria for entitlement to an initial rating of 30 percent for left knee instability were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5010-5257.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served in the United States Marine Corps from August 1966 to

November 1969.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from

an August 2014 rating decision by the Department of Veterans Affairs (VA)

Regional Office (RO), also known as the Agency of Original Jurisdiction (AOJ). In

July 2020, the Veteran testified before the undersigned Veterans Law Judge; a copy

of the transcript has been associated with the electronic claims file.

This case was first denied by the Board in a February 2022 decision. The

Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court),

which vacated the decision pursuant to a February 2023 Joint Motion for Remand. In a March 2023 decision, the Board remanded the claim for consideration of new evidence associated with the claims file, including VA treatment records and a January 202
2014 rating decision by the Department of Veterans Affairs (VA)

Regional Office (RO), also known as the Agency of Original Jurisdiction (AOJ). In

July 2020, the Veteran testified before the undersigned Veterans Law Judge; a copy

of the transcript has been associated with the electronic claims file.

This case was first denied by the Board in a February 2022 decision. The

Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court),

The claim was before the Board again in December 2023 when the Board denied

the claim for entitlement to a rating in excess of 10 percent for degenerative

changes of the posterior horn of the lateral meniscus of the left knee from June 13, 2014, and granted a separate rating of 10 percent for left knee instability. The Veteran appealed the Board's December 2023 decision to the Court, which in a June 2024 Order granted the parties' joint motion for remand, vacating the Board's December 2023 decision and remanding the case for compliance with the terms of the joint motion. When this matter was last before the Board in December 2024, the Board remanded the claim for an adequate retrospective VA examination.

A remand by the Board confers on the claimant a legal right to compliance with the remand order. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates another remand for corrective action. See id. However, substantial compliance with the remand order, not strict compliance, is required. See Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010), Dyment v. West, 13 Vet. App. 141, 147 (1990). In January 2025 and May 2025, retrospective VA medical opinions were uploaded into the claims file. Therefore, the Board finds that the AOJ has substantially complied with the December 2024 Board remand directives and will proceed with adjudication of the claims.

Notably, in a June 2025 rating decision, the AOJ granted an initial 20 percent rating for the Veteran's left knee instability effective June 13, 2014, to November 8, 2021.

Increased Rating

Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Individual disabilities are assigned separate diagnostic codes. Id. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7.

The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. The Board may consider whether another rating code is "more appropriate" than the one used by the AOJ. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Any change in a Diagnostic Code must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992).

Hyphenated diagnostic 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. 38 C.F.R. § 4.20.

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994
a Diagnostic Code must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992).

Hyphenated diagnostic 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. 38 C.F.R. § 4.20.

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility.

When considering whether lay evidence is competent, the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007).

VA is responsible for determining whether the evidence supports the claim or is in relative balance, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). If the evidence persuasively weighs against a claim, the claim is denied.

1. Entitlement to an increased evaluation in excess of 20 percent for degenerative changes of the posterior horn of the lateral meniscus.

The Veteran's left knee degenerative changes of the posterior horn is rated 20 percent, from October 14, 1997, to August 24, 1998, and 100 percent from August 25, 1998, to September 30, 1998. From October 1, 1998, to June 12, 2014, the disability is rated 20 percent, under DC 5258, for semilunar cartilage dislocation. On June 13, 2014, the Veteran submitted an informal claim for an increased rating. See Report of General Information. From June 13, 2014, to November 7, 2021, the disability is rated 20 percent, under DC 5258, for semilunar cartilage dislocation. See June 2025 rating decision. On November 8, 2021, the Veteran had a total arthroplasty and is rated 100 percent, under DC 5055 and 5258 from June 13, 2014, to November 7, 2021. From November 8, 2021, he is rated 30 percent under 5055 for left total knee arthroplasty. The Veteran contends that from June 13, 2014, to November 7, 2021, his left knee disability warrants a higher rating. He is not appealing his 30 percent rating from November 8, 2021, after the total arthroplasty.

In this case, the appeal period begins June 13, 2014, with the Veteran's informal claim for an increased rating plus the one-year lookback period. See 38 C.F.R. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010) (allowing for a one-year lookback to determine if there is an ascertainable date on which the Veteran's disability increased in severity in the year prior to the date VA received the increased rating claim). Because the claims file does not contain evidence of worsening prior to the June 13, 2014, informal claim, the appeal period begins on June 13, 2014, and ends November 8, 2021, when the Veteran underwent a total left knee arthroplasty.

As a preliminary matter, the Board is adding DC
. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010) (allowing for a one-year lookback to determine if there is an ascertainable date on which the Veteran's disability increased in severity in the year prior to the date VA received the increased rating claim). Because the claims file does not contain evidence of worsening prior to the June 13, 2014, informal claim, the appeal period begins on June 13, 2014, and ends November 8, 2021, when the Veteran underwent a total left knee arthroplasty.

As a preliminary matter, the Board is adding DC 5010 to better reflect the Veteran's disability. Here, the Veteran had a diagnosis of degenerative arthritis, confirmed by X-ray, throughout the appeal period. See August 2014 VA Examination; October 2014 X-ray report; October 2017 VA Examination; April 2017 X-ray report. Furthermore, the Veteran's left knee disability is a result of a fall in service. See August 2014 VA Examination. Under DC 5010, arthritis, due to trauma, substantiated by X-ray findings is rated as degenerative arthritis. 38 C.F.R. § 4.71a. DC 5010 provides that traumatic arthritis is to be evaluated as degenerative arthritis pursuant to DC 5003, which in turn directs the rater to evaluate symptoms on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. Id. Here, the record shows limitation of extension under DC 5261, as will be discussed below, as well as frequent episodes of locking, pain, and effusion into the joint under DC 5258 and genu recurvatum under DC 5263.

Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg; however, DCs 5256, 5258, 5259, 5260, 5261, 5262 and 5263 were not changed.

Diagnostic Code 5258 provides for assignment of a 20 percent rating for dislocation of the semilunar cartilage, with frequent episodes of "locking," pain and effusion into the joint. 38 C.F.R. § 4.71a.

Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated 0 percent disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. Full flexion of the leg is to 140 degrees and full extension is to 0 degrees. 38 C.F.R. § 4.71, Plate II.

Acquired traumatic genu recurvatum, with weakness and insecurity in weight-bearing objectively demonstrated, is rated at 10 percent under Diagnostic Code 5263 rating criteria.

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 flareups 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
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."

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.

A VA examination was conducted in August 2014. The Veteran reported daily pain that increases with more than one hour of weight bearing, stiffness when he sits, occasional locking, inability to kneel or squat without pain, and taking aspirin as needed but only two to three doses per week. Active range of motion (ROM) was flexion to 90 degrees, with pain beginning at 90 degrees, and extension to 10 degrees with pain beginning at 10 degrees. After three repetitions, ROM was the same as in initial testing. No additional limitation of ROM was noted, but additional functional loss was described as less movement than normal, pain on movement, deformity, and interference with sitting, standing and weightbearing. Pain significantly limited functional ability during flareups and when the joint was used repeatedly over time. The examiner found tenderness or pain to palpation for joint line or soft tissues, described as mild with patellar pressure. Muscle strength and joint stability testing were normal, and no patellar subluxation/dislocation was noted. The examiner found no "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment, but a history of meniscal (semilunar cartilage) tear with subsequent meniscectomy in 2008 was noted. The Veteran reported residual pain from the meniscectomy, and the examiner noted a mild overall and varus deformity of the left knee. The Veteran did not use any assistive devices, and functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Functional impairment was described as inability to lift more than 40 pounds or carry more than 20 pounds; inability to walk for more than one and a half hours or sit for more than one hour.

September and October 2014 Sandusky VAMC treatment notes show the Veteran had a long history of left knee pain, underwent left knee arthroscopy about seven to eight years ago for meniscal debridement; he tried braces, injections, physical therapy and medications, which did not work; and X-ray of the left knee now shows severe degenerative arthritis. Examination showed joint line tenderness to touch, was negative for patellar grinding, and showed a correctable varus, with ROM 10-100 degrees and normal strength.

In his November 2014 NOD, the Veteran reported that over the past few years his left has knee symptoms have continued to worsen, including worsening pain and having to treat the pain with over-the-counter pain medication. He also reported constant swelling to the left knee, a grinding noise and that it occasionally gives out.

The Veteran submitted a July 2017 private medical opinion from A.P.S., PA-C, stating that the Veteran had severe degenerative arthritis of the left knee.

Another VA examination was conducted in October 2017. The Veteran reported daily knee pain that increases with prolonged periods of weight bearing and ambulation, swelling with increased use; the left knee will give out and sometimes locks up on him; and he uses over-the-counter medications about two times a week. He denied flareups, and any functional loss or functional impairment of the joint or extremity. Active ROM was flexion to 100, extension to 0. ROM did not contribute to functional loss and pain was noted on examination but did not result in or cause functional loss. Pain was exhibited in flexion. The examiner found objective evidence of localized pain to medial and lateral joint lines on palpation of the joint or associated soft tissue. Objective evidence of crepitus was noted. On repetitive use testing, the examiner found no additional functional loss or range of motion after three repetitions and pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. The Veteran was being examined immediately after repetitive use over time but pain, weakness, fatigability or incoordination did not significantly limit functional ability. The examiner noted no flareups occurred. Additional factors contributing to disability were described as less movement than normal, disturbance of locomotion, and interference with standing. Muscle strength testing was normal, with no muscle atrophy or ankylosis. The examiner noted no history of recurrent subluxation or lateral instability. Joint stability testing was negative and no history of or current recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment was noted. The examiner noted a history of left meniscal tear and arthroscopic debridement with residual chronic pain and decreased ROM. The examiner found that there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The examiner noted the Veteran used a brace regularly and functional impact was noted as impairment of the Veteran's ability for physical work requiring any prolonged periods of standing, walking, climbing or repetitive bending.

In November 2017, the Veteran submitted an Appeal to Board of Veterans' Appeals (VA Form 9) in which he asserted that the October 2017 VA examination was inadequate because the examiner did not perform X-rays; his ROM was not measured properly; he has had more stiffness in his left knee and has had to begin taking over-the-counter medications more often.

A February 2018 Cleveland VAMC primary care note show reports of left knee sharp, aching pain, current severity of 3/10 pain and that the Veteran takes 800 mg of ibuprofen. The clinician noted an X-ray shows degenerative joint disease but the knee has no laxity, discoloration, significant edema or effusion.

An April 2018 left knee X-ray showed ongoing degenerative changes with positional varus orientation.

Another VA examination was conducted in September 2018. The Veteran reported that his left knee is painful and swelled daily with increased use and he takes Ibuprofen about twice a week. ROM was flexion to 100 and extension to 0 degrees and did not contribute to functional loss. Pain was noted on examination but did not result in or cause functional loss. There was no evidence of pain on passive ROM or on non-weight bearing, but evidence of pain on weight bearing, objective evidence of pain to palpation of medial and lateral joint lines, and objective evidence of crepitus were found. Flareups were not noted. The Veteran was examined after repeated use over time, but the examiner found no additional functional loss or range of motion after three repetitions. After repetitive use over time, the examiner noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability. Additional contributing factors of disability were noted as less movement than normal, disturbance of locomotion, and interference with standing. Muscle strength testing was normal; no muscle atrophy or ankylosis were noted. The Veteran did not now have or had ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or
. Flareups were not noted. The Veteran was examined after repeated use over time, but the examiner found no additional functional loss or range of motion after three repetitions. After repetitive use over time, the examiner noted that pain, weakness, fatigability or incoordination did not significantly limit functional ability. Additional contributing factors of disability were noted as less movement than normal, disturbance of locomotion, and interference with standing. Muscle strength testing was normal; no muscle atrophy or ankylosis were noted. The Veteran did not now have or had ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The examiner noted a history of a meniscal tear that was treated with arthroscopic surgery, with residual decreased range of motion and chronic pain remaining. The Veteran reported using braces regularly. There was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The Veteran's left knee disability was noted to impact his ability to perform occupational tasks, described as altered mechanical gait.

In a December 2018 Appellate Brief, the Veteran argued that the September 2018 examination was inadequate because the examiner did not perform any X-rays to determine the severity of the Veteran's degenerative arthritis and failed to stop flexing his knee when he began experiencing severe pain during ROM measurement. The Veteran also reported that the examiner failed to note his reports that he experienced consistent and chronic pain that is worsened when he remains seated for an extended time, stands up, and while walking or climbing; and he wears braces at all times and takes over-the-counter pain medications daily.

April 2019 Cleveland VAMC treatment notes show the Veteran reported increased pain and that his primary care provider requested new x-rays.

A September 2019 orthopedic consultation showed the Veteran reported left knee pain with walking, squatting, climbing stairs, and getting up from a seated position; the pain improves with rest, but it negatively impacts his quality of life. He reported conservative management of his pain with CBD oil.

During a July 2020 Board hearing, the Veteran reported that his left knee had worsened since the October 2017 VA examination. He asserted that it swells to about the size of a grapefruit, stays constantly swollen, constantly aches, has no flexibility and his doctor has told him that he needs a knee replacement.

Another VA examination was conducted in August 2020. The Veteran reported chronic mild "nagging" left knee pain, and moderate to severe flareups with certain activities. Flareups are characterized by pain, with no weakness, fatigue or functional loss, and pain, weakness, fatigability or incoordination did not significantly limit functional ability with flareups, were precipitated by prolonged standing, walking, kneeling and squatting, and alleviated fairly by rest, position change and medications, including Aleve. Pain severity with flareups range from 3/10 to 6-7/10. Repetitive use testing revealed ROM remained the same. There was pain on active, passive, and non-weight bearing motion. Pain was also noted on weight bearing but there was no physiological way that ROM could be tested in weight bearing. Active ROM was flexion to 100 degrees and extension to 0 degrees and ROM itself did not contribute to functional loss. Pain noted on examination caused functional loss in flexion and extension. The examiner found that there was objective evidence of localized pain to palpation of medial and lateral joint lines and crepitus. On repetitive use testing, there was no additional functional loss or range of motion after three repetitions, and the Veteran was not examined after repetitive use testing, but procured evidence revealed that pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Additional factors contributing to disability were described as less movement than normal, deformity, disturbance of locomotion, and interference with standing. Muscle strength was normal with no atrophy or ankylosis. No history of recurrent subluxation, effusion or recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment were noted. A history of meniscal tear with frequent episodes of joint pain was noted and was repaired with arthroscopic meniscectomy in 1998. However, residual pain with decreased ROM still existed. The examiner noted occasional use of a brace and that there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The examiner also noted
no atrophy or ankylosis. No history of recurrent subluxation, effusion or recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment were noted. A history of meniscal tear with frequent episodes of joint pain was noted and was repaired with arthroscopic meniscectomy in 1998. However, residual pain with decreased ROM still existed. The examiner noted occasional use of a brace and that there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. The examiner also noted that September 2019 X-rays results showed severe degenerative change involving the medial joint spaces and moderate degenerative change of patellofemoral joints. Functional impairment was noted as employment requiring prolonged standing or walking would not be recommended.

During a July 2021 VA examination, the Veteran reported constant swelling to the left knee, constant aching pain severity of 3-5/10, pain with walking, going up and down stairs, stiffness and limited range of motion and an unsteady gait due to pain. Flareups were described as sharp pain, severity of 5/10, three times a week, with overuse, alleviated by rest and stretching. Functional loss was described as pain with walking and going up and down stairs, any movement involving range of motion and an inability to walk longer than two blocks before having to stop and rest. Active ROM was flexion to 100 degrees and extension to 0 degrees. ROM did not contribute to functional loss but pain was exhibited on flexion. Passive ROM was the same as active ROM with pain exhibited on flexion. There was also evidence of pain on weightbearing, active, and passive ROM that did not result in or cause functional loss. There was no objective evidence of crepitus, but objective evidence of localized moderate pain on palpation was noted. On observed repetitive use testing, pain was noted but no additional loss of function or range of motion after three repetitions was noted. The Veteran was not tested immediately after repeated use over time or during a flareup, but procured evidence suggested pain, fatigability, and lack of endurance significantly limited functional ability with repeated use over time and during flareups. Estimated ROM after repeated use over time and during flareups was flexion to 95 degrees and extension to 0 degrees. Additional contributing factors to disability were described as swelling, less movement than normal, and instability of station. No muscle weakness, atrophy or ankylosis were noted. History of recurrent subluxation or persistent instability was noted, but no current ligament tear, and the Veteran required use of a brace. The examiner noted no recurrent patellar instability, recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment. A history of a meniscal (semilunar cartilage) condition was noted with tear with episodes of frequent joint locking, pain, and effusion, which was repaired in 1998 with a meniscectomy, but residual pain still existed. No history or current chronic exertional compartment syndrome of the lower extremities was noted. An additional pertinent finding was that the Veteran walks with a hobbling gait. The Veteran used a brace occasionally, and there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis. Functional impairment was pain with walking, going up/downstairs and with any range of motion.

An August 2021 Cleveland VAMC orthopedic note shows the Veteran reported chronic left knee pain with walking, squatting, navigating stairs, and getting up from seated a position, relieved only with rest.

The Veteran submitted a September 2021 statement from J.T., his longtime friend. J.T. asserted that the Veteran has been unable to go stream fishing lately and has not been able to play golf recently either. J.T. also stated that he recalls two times in the past year when the Veteran had fallen and struggled to get up; he has noticed that the Veteran's knee turns outward; and he now walks in a bow legged fashion.

The Veteran also submitted a September 2021 statement from his friend of two years, L.G.S. She asserted that in the past two years, she has observed the Veteran's inability to take walks, and if he attempts to, he stumbles and almost falls on numerous occasions; he cannot go fishing by himself (as he might fall and no one would be there to help him up); his knee buckles causing him to grab hold of anything to stop his fall; he has difficulty getting in his car; and his knee is always swollen and hurting
times in the past year when the Veteran had fallen and struggled to get up; he has noticed that the Veteran's knee turns outward; and he now walks in a bow legged fashion.

The Veteran also submitted a September 2021 statement from his friend of two years, L.G.S. She asserted that in the past two years, she has observed the Veteran's inability to take walks, and if he attempts to, he stumbles and almost falls on numerous occasions; he cannot go fishing by himself (as he might fall and no one would be there to help him up); his knee buckles causing him to grab hold of anything to stop his fall; he has difficulty getting in his car; and his knee is always swollen and hurting all the way down to his ankles. L.G.S. also asserted that the Veteran's gait is abnormal; when he dresses in the morning, his pants, socks and shoes are a real chore; and he is unable to bend like a normal person to put these items on.

The Veteran submitted another September 2021 private medical opinion from A.S., PA-C, an orthopedic physician assistant and friend. A.S. asserted that the Veteran can no longer perform many activities of daily living due to his severe arthritis and has developed a moderately severe genu varum (bow leggedness). A.S. stated that the Veteran had difficulty getting in and out of cars, trouble going up and down stairs, and he can no longer play golf. He has decent ROM but has significant impairment of the knee and is scheduled to have a left knee replacement in the next few months.

In a September 2021 statement, the Veteran asserted that the July 2021 VA examination was inadequate because the examiner failed to obtain X-rays during the examination to determine the severity of his disability and he believes that ROM measurements of his knee was not properly performed. He reported constant left knee pain, swelling, effusion, buckling, as well as a bow leg, and stated that he has been advised to wear a knee brace and has been scheduled for left a knee replacement.

The Veteran submitted another September 2021 lay statement from a friend, W.R. The friend reported that the Veteran's mobility has been severely affected by his knee disability; he experiences significant pain even during a short walk; his flexibility is very limited; his routine activities such as putting on socks or getting in/out of vehicles are challenging; and he can only stand for short durations.

November 2021 VA treatment notes show the Veteran underwent a total knee replacement on November 8, 2021.

A VA examination was conducted in January 2023; however, that examination does not contain retrospective evidence from prior to November 8, 2021. Therefore, it will not be discussed here.

In July 2023, the Veteran submitted a statement regarding his left knee symptoms beginning in 2014. He asserted that he has had swelling, crepitus and severe pain since he applied for an increased rating in 2014.

The Veteran also submitted a July 2024 statement asserting that his left knee disability has affected his quality of life for the past 27 years, his overall coordination performing simple tasks, inability to distribute his weight so it prevents him from recovery when he trips, continuous knee swelling in both knees, and an adverse change in his gait. He also asserted falling numerous times.

In the January and May 2025 VA retrospective examinations, the examiner noted that since an April 2018 X-ray showed endstage osteoarthritic changes, additional X-rays would not have been warranted or beneficial as they would not have provided additional information. The examiner noted that based on the imaging between 2010-2019, the Veteran's X-rays exhibited an increase in degenerative changes. Since October 2014, the Veteran has had ongoing degenerative changes with positional varus orientation with no acute findings, including fracture. Regarding effusion, the examiner noted that the record does not contain any evidence of effusion, and the Veteran denied that he was diagnosed with effusion of the left knee, but he continues to report constant swelling throughout the appeal period.

The Board assigns significant weight to the August 2014, October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners' findings, when combined, as they were written by clinicians who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007).

Similarly, the Board assigns great probative weight to the Veteran and his friends' consistent reports about his symptoms throughout the record because lay evidence is competent if it is provided by a person who has knowledge of facts or
The Board assigns significant weight to the August 2014, October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners' findings, when combined, as they were written by clinicians who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007).

Similarly, the Board assigns great probative weight to the Veteran and his friends' consistent reports about his symptoms throughout the record because lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed by a lay person, to include observable symptoms. See 38 C.F.R. § 3.159 (a)(2); Jandreau, 492 F.3d 1372.

Notably, throughout the record, the Veteran has asserted that VA examinations were inadequate because the examiners failed to obtain X-rays and failed to properly measure his ROM during the various examinations to address the severity of his disability. In this case, although the Veteran is competent to report signs and symptoms of his disability and medical history, he is not qualified to make medical determinations such as the propriety of diagnostic tests for evaluation of his knee disability or the accuracy of ROM measurements, as he has not been shown to be a medical professional. See Jandreau, 492 F.3d 1372; Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991).

Throughout the record and for the entire appeal period, the Veteran has reported frequent joint locking, joint pain, and constant swelling, sufficient to establish a rating under Diagnostic Code 5258, the highest schedular rating available. The Board acknowledges that the October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners did not find the Veteran had effusion into the joint. However, the Board finds that resolving reasonable doubt in the Veteran's favor, his and his friends' consistent reports of constant swelling of the left knee is sufficient evidence of effusion into the joint.

Additionally, the August 2014 VA examiner found that the Veteran's ROM was extension to 10 degrees, with pain beginning at 10 degrees, consistent with a 10 percent rating, under DC 5261, for limitation of extension. The Board has extended this finding to the entire appeal period as the record shows consistent reports of symptomatology of the Veteran's disability throughout the appeal period.

Further, the Veteran has repeatedly asserted that he experienced a bow leg deformity; the September 2021 private medical opinion from A.S., PA-C, noted a moderately severe genu varum (bow leggedness); and the August 2014 VA examination found a mild overall and varus deformity of the left knee. Finally, an April 2018 left knee X-ray also showed positional varus orientation.

Therefore, the Board finds that a separate rating of 10 percent, the highest schedular rating available, is warranted under DC 5263.

The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. 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.

Under Diagnostic Code 5259, removal of semilunar cartilage that is symptomatic warrants a 10 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Here, the record does not contain evidence of removal of semilunar cartilage with symptoms.

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. Here, the August 2014, October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners all found the Veteran's flexion was not limited to 60 degrees to warrant a compensable rating under DC 5260. Therefore, DC 5260 does not apply, and no separate rating is warranted under that Diagnostic Code.

Diagnostic Code 5262 does not apply as the evidence does not demonstrate impairment of the tibia or fibula, specifically malunion or nonunion. Here, the August
ion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Here, the August 2014, October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners all found the Veteran's flexion was not limited to 60 degrees to warrant a compensable rating under DC 5260. Therefore, DC 5260 does not apply, and no separate rating is warranted under that Diagnostic Code.

Diagnostic Code 5262 does not apply as the evidence does not demonstrate impairment of the tibia or fibula, specifically malunion or nonunion. Here, the August 2014, October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners all found the Veteran did not now have or had not ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment, nor is such reflected in other evidence of record.

Similarly, as there is no lay or medical evidence of ankylosis, the Board finds that Diagnostic Code 5256 does not apply as well, and thus, cannot provide for a higher rating. Specifically, the August 2014, October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners all found the Veteran had no ankylosis. Further, ankylosis is not indicated in the other evidence of record.

The Veteran has been granted a separate disability rating under Diagnostic Code 5257, recurrent subluxation or lateral instability, as discussed in the decision below.

The Veteran has consistently reported receiving injections and taking over-the-counter medications to treat his left knee disability, and these reports are corroborated by his VA treatment records. In Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), the Court held that, when assigning a disability rating, the Board may not consider the ameliorative effects of medication where those effects are not explicitly contemplated by the rating criteria. "Thus, if [the applicable diagnostic code] does not specifically contemplate the effects of medication, the Board is required, pursuant to Jones, to discount the ameliorative effects of medication when evaluating [the disability]. Conversely, if [the applicable diagnostic code] does specifically contemplate the effects of medication, then Jones is inapplicable." McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (en banc). In this case, because the criteria for Diagnostic Code 5258 and 5263 do not address the effects of medication, the Board must not consider the ameliorative effects of the Veteran's medications used to alleviate his left knee pain. Here, the Veteran has reported that only rest and stretching alleviated his pain. Given the Veteran's report of constant left knee pain experienced during his examinations, there is no basis for discounting the ameliorative effects of medications. In other words, ameliorative effects of medications or pain management were not reported, nor suggested with the frequency of the Veteran's pain complaints. Ingram, supra. Thus, the evidence of record weighs against finding medication obscures loss of function beyond that which was observed and reported. Id.

In conclusion, the Board finds that the evidence of record persuasively weighs in favor of finding that separate ratings of 10 percent are warranted for the Veteran's knee disability based on both genu recurvatum under DC 5263 and DC 5261 for limitation of extension. The Board also finds that the evidence of record persuasively weighs against finding a rating in excess of 20 percent for the Veteran's left knee disability based on frequent episodes of locking, pain, and effusion of the left knee, under DC 5258, from June 13, 2014 to November 7, 2021, as this is the highest schedular rating available for that disability under the Diagnostic Code. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; See Lynch, 999 F.3d 1391; Ortiz, 274 F.3d 1361.

2. Entitlement to a rating of 30 percent for left knee instability from June 13, 2014, to November 7, 2021.

The Veteran's left knee instability is rated 20 percent, from June 13, 2014, to November 7, 2021, under DC 5257. As noted above, his left knee disability
, as this is the highest schedular rating available for that disability under the Diagnostic Code. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; See Lynch, 999 F.3d 1391; Ortiz, 274 F.3d 1361.

2. Entitlement to a rating of 30 percent for left knee instability from June 13, 2014, to November 7, 2021.

The Veteran's left knee instability is rated 20 percent, from June 13, 2014, to November 7, 2021, under DC 5257. As noted above, his left knee disability is rated pursuant to his total arthroplasty from November 8, 2021. He contends that his instability warranted a higher rating from June 13, 2014, to November 8, 2021. The Veteran is not asserting post-arthroplasty instability from November 8, 2021.

For the reasons discussed below, the Board finds that a rating of 30 percent is warranted, but no higher, from June 13, 2014, to November 7, 2021, for the Veteran's left instability, pursuant to Diagnostic Code 5257.

Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. Prior to February 7, 2021, Diagnostic Code 5257 provided recurrent subluxation or lateral instability of the knee was evaluated as follows: severe (30 percent); moderate (20 percent); and slight (10 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2019).

The amended Diagnostic Code 5257 provides a 10 percent rating 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. Additionally, a 20 percent rating is assigned for 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 (e.g., cane(s), crutch(es), walker) for ambulation; (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. Finally, a 30 percent rating is assigned for 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. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021).

The amended criteria for Diagnostic Code 5257 also include ratings for patellar instability. Specifically, 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. The maximum 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. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021).

Note 1 under Diagnostic Code 5257 defines "patellofemoral components" as "quadriceps tendon, the patella, and the patellar tendon." Note 2 under Diagnostic Code 5257 defines "surgical procedure" as requiring "repair of one or more patellofemoral components that contribute to the underlying instability" and specifically excludes "arthroscopy to remove loose bodies and joint aspiration."

Generally, the Board applies new rating criteria from the date it becomes effective, if the new criteria are more beneficial to the Veteran than the prior version of the regulation. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (regulations may not have retroactive effect unless their language specifies so). In this case, given the greater specificity of the amended criteria, the Board finds the older criteria to be
tendon." Note 2 under Diagnostic Code 5257 defines "surgical procedure" as requiring "repair of one or more patellofemoral components that contribute to the underlying instability" and specifically excludes "arthroscopy to remove loose bodies and joint aspiration."

Generally, the Board applies new rating criteria from the date it becomes effective, if the new criteria are more beneficial to the Veteran than the prior version of the regulation. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (regulations may not have retroactive effect unless their language specifies so). In this case, given the greater specificity of the amended criteria, the Board finds the older criteria to be more beneficial and will apply the pre-amended criteria for the entire period on appeal.

During an August 2014 VA examination, the Veteran reported that his knee will give out. Joint stability testing was normal.

In his November 2014 NOD, the Veteran reported that his knee occasionally gives out.

During the October 2017 VA Examination, the Veteran reported that the left knee will give out and sometimes locks up on him; he stated that he used a brace regularly. The examiner noted no history of recurrent subluxation or lateral instability, and joint stability testing was negative with no history of or current recurrent patellar dislocation.

During the September 2018 Examination, he reported that the left knee will give out and sometimes locks up on him, but joint stability testing was normal. The Veteran required use of a brace, but the examiner noted no recurrent patellar instability.

During the July 2020 Board hearing, the Veteran reported that his knee gives out completely while walking, is very unstable, locks at times; he has no balance, cannot walk on uneven surfaces and he has fallen in the past.

During the August 2020 VA Examination, the examiner found no history of recurrent subluxation or effusion and joint stability testing was normal.

During a July 2021 VA examination, the Veteran reported his left knee has "given out" and he has fallen increasingly over the past few years, at least four to five times, or nearly fallen multiple times and that he walks with an unsteady gait due to pain. History of slight recurrent subluxation was noted but joint stability testing was negative.

An August 2021 Cleveland VAMC orthopedic note shows the Veteran reported his knee will buckle when climbing stairs.

The Veteran submitted a September 2021 statement from J.T., his friend since high school. J.T. asserted that the Veteran has fallen two times and has struggled to get up in the past year; and he has noticed that the Veteran's knee actually turns outward; and he now walks in a bowlegged fashion.

In a September 2021 statement, the Veteran reported constant buckling, bow leggedness, and he has been advised to wear a knee brace and has been scheduled for a left knee replacement.

November 2021 VA treatment notes show the Veteran underwent a total knee replacement on November 8, 2021.

A VA examination was conducted in January 2023; however, that examination does not contain retrospective evidence from prior to November 8, 2021. Therefore, it will not be discussed here.

In July 2023, the Veteran submitted a statement regarding his left knee symptoms beginning in 2014. He asserted that he has had more than a dozen falls since he applied for an increased rating in 2014.

The Veteran also submitted a July 2024 statement asserting that his left knee disability has affected his quality of life for the past 27 years with overall incoordination performing simple tasks, inability to distribute his weight, so it prevents him from recovery when he trips, continuous knee swelling in both knees and an adverse change in his gait. He also asserted falling numerous times.

In the January and May 2025 retrospective examinations, the examiners noted that the Veteran reported increased left knee instability since 2010 and several falls.

In assessing the evidence of record, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his left knee instability disability. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Board assigns significant weight to the Veteran's reports of instability
the past 27 years with overall incoordination performing simple tasks, inability to distribute his weight, so it prevents him from recovery when he trips, continuous knee swelling in both knees and an adverse change in his gait. He also asserted falling numerous times.

In the January and May 2025 retrospective examinations, the examiners noted that the Veteran reported increased left knee instability since 2010 and several falls.

In assessing the evidence of record, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his left knee instability disability. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Board assigns significant weight to the Veteran's reports of instability throughout the record, including repeated falls and having to use a brace constantly to stabilize the left knee. Based on this, the Board finds that his left knee instability was severe, consistent with a 30 percent rating, under DC 5257, throughout the period on appeal.

The Board acknowledges that the October 2017, September 2018, August 2020, July 2021, January 2025, and May 2025 VA examiners did not find severe instability. However, the Board disagrees with the VA examiners' findings and ultimately concludes that resolving reasonable doubt in the Veteran's favor, from June 13, 2014 to November 7, 2021, his left knee symptoms resulted in severe instability. Therefore, a rating of 30 percent, the maximum schedular rating available, is warranted for the Veteran's left knee instability.

Caroline B. Fleming

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Michel-Rossi, Mayerline

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.

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