KNEE IMPAIRMENT OF

REBECCA N. POULSON · 2025 · Case ID: A25098231

MIXED

Summary

The Veteran, an Army Veteran who served from July 2002 to October 2004, appeals a September 2024 higher-level review rating decision. The appeal concerns the Veteran's left and right knees, bilateral shin splints, right elbow, and left elbow conditions. Specifically, the Veteran sought an increased rating for his left knee, which was granted at 20 percent for strain with patellofemoral pain syndrome, meniscal tear, and shin splints, replacing a 0 percent rating under diagnostic code 5258 and a 10 percent rating under diagnostic code 5299-5262. The Board also granted a separate 10 percent rating for left knee instability and right knee instability, each under diagnostic code 5257. However, the Veteran's appeal for a higher rating for his right knee, including patellofemoral pain syndrome, ACL sprain, and shin splints, was denied. Similarly, claims for higher ratings for left knee limitation of extension and right knee limitation of extension were denied. The claim for right knee scars was also denied. Crucially, service connection for left knee radiculopathy, claimed as secondary to the service-connected left knee strain, was granted. Claims for right elbow medial epicondylitis, left elbow medial epicondylitis with degenerative arthritis and ulnar nerve entrapment, and a left elbow scar were all denied. The Board found persuasive evidence for the left knee's manifestations, including limited flexion and extension, and instability, supporting the granted ratings. However, for the right knee, the evidence preponderated against a nexus to service for the claimed conditions beyond the granted 10 percent ratings for instability. The Board also found no service connection for the elbow conditions or the right knee scars.

Rationale

Criteria for 20 percent rating met; Replaces prior 0 percent and 10 percent ratings; Based on findings of pain, limited flexion/extension, instability

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

5258

Docket No.

241016-482648

Full Decision Text

Citation Nr: A25098231
Decision Date: 11/12/25 Archive Date: 11/12/25

DOCKET NO. 241016-482648
DATE: November 12, 2025

ORDER

Entitlement to an increased rating of 20 percent, but no higher, for left knee strain with patellofemoral pain syndrome, meniscal tear, and shin splints, from July 11, 2023, under diagnostic code 5258 (in place of the Veteran's 0 percent rating under diagnostic code 5260 and 10 percent rating under diagnostic code 5299-5262) is granted.

Entitlement to a rating higher than 10 percent for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain and shin splints, from July 11, 2023, under diagnostic code 5260 (in place of the Veteran's 10 percent rating under diagnostic code 5262) is denied.

Entitlement to a rating higher than 20 percent for left knee strain with patellofemoral pain syndrome (limitation of extension) is denied.

Entitlement to a rating higher than 10 percent for right knee patellofemoral pain syndrome with ACL sprain (limitation of extension) is denied.

Entitlement to a separate disability rating of 10 percent, but no higher, for left knee strain with patellofemoral pain syndrome (instability), from July 11, 2023, is granted.

Entitlement to a separate disability rating of 10 percent, but no higher, for right knee patellofemoral pain syndrome with ACL sprain (instability), from July 11, 2023, is granted.

Entitlement to an initial compensable rating for right knee scars status post right knee arthroscopy is denied.

Entitlement to service connection for left knee radiculopathy, as secondary to the service-connected left knee strain with patellofemoral pain syndrome and meniscal tear, is granted.

Entitlement to service connection for right elbow medial epicondylitis (claimed as nerve disability) is denied.

Entitlement to service connection for left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment (claimed as nerve disability) is denied.

Entitlement to service connection for left elbow scar, post left ulnar nerve transposition, including as due to the treatment associated with left elbow medial epicondylitis with ulnar nerve entrapment (claimed as scars, extremities and trunk), is denied.

FINDINGS OF FACT

1. Since July 11, 2023, the weight of the persuasive evidence shows that the Veteran's left knee disability is manifested by meniscal tear with episodes of pain and difficulty bending of the knee, flexion limited to 80 degrees, extension limited to 15 degrees, and instability.

2. Since July 11, 2023, the weight of the persuasive evidence shows that the Veteran's right knee disability is manifested by episodes of pain and difficulty bending of the knee, flexion limited to 100 degrees, extension limited to 10 degrees, and instability.

3. Since July 11, 2023, the Veteran's bilateral shin splints do not require current treatment.

4. The Veteran's right knee scars status post right knee arthroscopy are smaller than 144 square inches (929 square centimeters); the scars are not associated with underlying soft tissue damage; the scars are not unstable or painful.

5. The most probative evidence of record indicates that the Veteran's left knee radiculopathy is caused or aggravated by the Veteran's service-connected left knee strain with patellofemoral pain syndrome and meniscal tear.

6. The weight of the persuasive evidence is against finding that the Veteran's right elbow medial epicondylitis began during his active service or is otherwise related to his active service.

7. The weight of the persuasive evidence is against finding that the Veteran's left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment, began during his active service or is otherwise related to his active service.

8. The Veteran's left elbow scar is not secondary to a service-connected disability and is not otherwise related to his active service.

CONCLUSIONS OF LAW

1. Since July 11, 2023, the criteria for a 20 percent rating, but no higher, for left knee strain with patellofemoral pain syndrome, meniscal tear and shin splints, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5258.

2. Since July 11, 2023, the
, and ulnar nerve entrapment, began during his active service or is otherwise related to his active service.

8. The Veteran's left elbow scar is not secondary to a service-connected disability and is not otherwise related to his active service.

CONCLUSIONS OF LAW

2. Since July 11, 2023, the criteria for a disability rating higher than 10 percent for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain and shin splints have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5260.

3. Since July 11, 2023, the criteria for a disability rating higher than 20 percent for left knee strain with patellofemoral pain syndrome and meniscal tear (limitation of extension) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261.

4. Since July 11, 2023, the criteria for a disability rating higher than 10 percent for right knee patellofemoral pain syndrome with ACL sprain (limitation of extension) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261.

5. Since July 11, 2023, the criteria for a separate 10 percent rating, but no higher, for left knee strain with patellofemoral pain syndrome and meniscal tear (instability) has been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5257.

6. Since July 11, 2023, the criteria for a separate 10 percent rating, but no higher, for right knee patellofemoral pain syndrome with ACL sprain (instability) has been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5257.

7. The criteria for a compensable rating for right knee scars status post right knee arthroscopy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Code 7802.

8. The criteria for service connection for left knee radiculopathy, as secondary to the service-connected left knee strain with patellofemoral pain syndrome and meniscal tear, are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

9. The criteria for service connection for right elbow medial epicondylitis are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303.

10. The criteria for service connection for left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303.

11. The criteria for service connection for left elbow scar, post left ulnar nerve transposition, associated with the treatment of left elbow medial epicondylitis with ulnar nerve entrapment, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably in the United States Army from July 2002 to October 2004. The Board of Veterans' Appeals (Board) thanks the Veteran for his service to our country.

This case comes before the Board on appeal from a September 2024 higher-level review rating decision issued by a Department of Veteran's Affairs (VA) Regional Office.

In the October 16, 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record
5107; 38 C.F.R. § 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably in the United States Army from July 2002 to October 2004. The Board of Veterans' Appeals (Board) thanks the Veteran for his service to our country.

This case comes before the Board on appeal from a September 2024 higher-level review rating decision issued by a Department of Veteran's Affairs (VA) Regional Office.

In the October 16, 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the November 2023, April 2024, and May 2024 agency of original jurisdiction (AOJ) decision, which were subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

The October 2024 VA Form 10182 purports to appeal the following issues: the grant of service connection for chondromalacia patella, right knee, also claimed as shin splints/stress fractures with an evaluation of 10 percent effective June 17, 2010; the grant of service connection for chondromalacia patella, left knee, also claimed as shin splints/stress fractures with an evaluation of 10 percent effective June 17, 2010; and the denial of service connection for (i) a lower back condition, (ii) a right shoulder condition (dominant), (iii) residuals of left shoulder strain, (iv) residuals of traumatic brain injury, (v) migraine headaches, (vi) hip condition (bilateral), (vii) gastroesophageal reflux disease (GERD/stomach condition), (viii) arthritis condition (lower area), (ix) a mouth wound scar, (x) a narcolepsy condition, (xi) sleep apnea to include sleep disturbance, (xii) a heart condition to include heart murmurs, and (xiii) a nervous condition. The Board notes these issues were adjudicated in the May 2013 rating decision.

Issues not on appeal

The October 2024 VA Form 10182 purports to appeal the following issues: the grant of service connection for left knee limitation of flexion with an evaluation of 0 percent effective December 31, 2020; the grant of service connection for right knee limitation of flexion with an evaluation of 0 percent effective December 31, 2020; the evaluation of left knee patellofemoral pain syndrome continued as 10 percent disabling; the evaluation of right knee patellofemoral pain syndrome continued as 10 percent disabling; the denial of service connection for (i) allergies and (ii) foot pain; and the deferred issues of entitlement to compensation for (i) hearing loss, (ii) PTSD with bipolar disorder, and (iii) tendinitis. The Board notes these issues were adjudicated in the February 2021 rating decision.

The October 2024 VA Form 10182 purports to appeal the following issues: entitlement to an effective date prior to December 31, 2020, for the grant of service connection for bilateral tinnitus; service connection for depression for the purpose of establishing eligibility to treatment; and the denial of service connection for (i) posttraumatic stress disorder (PTSD), (ii) bilateral hearing loss, (iii) bipolar disorder, and (iv) major depressive disorder. The Board notes these issues were adjudicated in the March 2021 rating decision.

The October 2024 VA Form 10182 purports to appeal the following issues: the
The Board notes these issues were adjudicated in the February 2021 rating decision.

The October 2024 VA Form 10182 purports to appeal the following issues: the grant of service connection for PTSD (posttraumatic stress disorder) with an evaluation of 70 percent effective December 30, 2020; the evaluation of left knee patellofemoral pain syndrome increased to 20 percent effective December 30, 2020; the evaluation of left knee limitation of flexion increased to 10 percent effective December 30, 2020; the evaluation of right knee patellofemoral pain syndrome continued as 10 percent disabling; the evaluation of right knee limitation of flexion increased to 10 percent effective December 30, 2020; and the continued denial of service connection for (i) bipolar disorder, (ii) a lower back condition, (iii) a mouth wound scar, (iv) residuals of left shoulder strain, (v) residuals of traumatic brain injury, and (vi) a right shoulder condition (dominant). The Board notes these issues were adjudicated in the March 2022 rating decision.

The October 2024 VA Form 10182 was received more than one year after the February 2021, March 2021, and March 2022 rating decisions. As the decisions were not timely appealed, those issues will not be addressed by the Board.

Increased Ratings

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings 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 civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.

Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. When the appeal arises from an initially assigned rating, consideration must be given to whether a "staged" rating should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007).

When there is a question as to which of two evaluations will be assigned, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. Reasonable doubt regarding the degree of disability is to be resolved in favor of the claimant. 38 C.F.R. § 4.3. A claim will only be denied if the weight of the persuasive evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

Musculoskeletal Disabilities

In determining the appropriate evaluation for musculoskeletal disability, particular attention is focused on functional loss of use of the affected part(s). Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability, and actually painful joints are entitled to at least the minimum compensable rating for the joint.

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4
functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability, and actually painful joints are entitled to at least the minimum compensable rating for the joint.

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). Moreover, joint testing is to be conducted on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 170 (2016).

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 the examination.

The provisions of 38 C.F.R. §§ 4.40 and 4.45 permit consideration of ankylosis ratings if a claimant's functional loss is the functional equivalent of ankylosis. Chavis v. McDonough, 34 Vet. App. 1 (2021).

In Ingram v. Collins, 38 Vet. App. 130 (2025), the Court held that the Board is to take due consideration that the beneficial effects of medication are discounted in assessing musculoskeletal ratings as such effects are not contemplated therein and, therefore, taking medication may make a veteran appear less disabled in reality.

The Veteran's left knee patellofemoral strain with patellofemoral pain syndrome and meniscal tear is currently rated as 10 percent disabling from June 17, 2010 to December 30, 2020, and as 20 percent disabling from December 30, 2020. The Regional Office has evaluated this disability under diagnostic codes 5258 and 5261.

The Veteran's left knee strain with patellofemoral pain syndrome and meniscal tear (limitation of flexion) is currently rated as 10 percent disabling from December 30, 2020 to August 14, 2023, and as 0 percent disabling from August 14, 2023, under diagnostic code 5260.

The Veteran's left lower extremity shin splints are currently rated as 10 percent disabling from July 11, 2023, under diagnostic code 5299-5262.

The Veteran's right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain is currently rated as 10 percent disabling from June 17, 2010. The Regional Office has evaluated this disability under diagnostic codes 5257 and 5261.

The Veteran's right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain (limitation of flexion) is currently rated as 10 percent
percent disabling from August 14, 2023, under diagnostic code 5260.

The Veteran's left lower extremity shin splints are currently rated as 10 percent disabling from July 11, 2023, under diagnostic code 5299-5262.

The Veteran's right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain (limitation of flexion) is currently rated as 10 percent disabling from December 30, 2020 to August 14, 2023, and as 0 percent disabling from August 14, 2023, under diagnostic code 5260.

The Veteran's right lower extremity shin splints are currently rated as 10 percent disabling from July 11, 2023, under diagnostic code 5299-5262.

The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a.

Under Diagnostic Code (DC) 5260, flexion limited to 60 degrees warrants a 0 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260.

Under DC 5261, extension limited to 5 degrees warrants a 0 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5261.

Flexion of the knee to 140 degrees is considered full, and extension to 0 degrees is considered full. 38 C.F.R. § 4.71a, Plate II.

Under DC 5258, a maximum 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258.

Separate ratings are not precluded for limitation of motion (5260 and 5261), meniscal disability (5258 and 5259) and recurrent subluxation or instability or patellar instability (5257). Lyles v. Shulkin, 29 Vet. App. 107 (2017).

Under DC 5262, a 0 percent rating is warranted for medial tibial stress syndrome (MTSS), or shin splints, with treatment less than 12 consecutive months, one or both lower extremities. A 10 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities. A 20 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity. A 30 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. 38 C.F.R. § 4.71a, DC 5262.

The assignment of a particular diagnostic code is dependent on the facts of the 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 current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which code, or codes, are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995).

Factual Background

The Veteran contends his left knee disability and right knee disability warrant higher ratings. See October 2024 VA Form 10182.

The Veteran submitted an intent to file a claim for compensation on July 11, 2023. On July 26, 2023, he submitted his completed application (VA Form 21-526EZ) seeking an increased rating for patello
, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which code, or codes, are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995).

Factual Background

The Veteran contends his left knee disability and right knee disability warrant higher ratings. See October 2024 VA Form 10182.

The Veteran submitted an intent to file a claim for compensation on July 11, 2023. On July 26, 2023, he submitted his completed application (VA Form 21-526EZ) seeking an increased rating for patellofemoral right knee, patellofemoral left knee, right knee limitation of flexion, and left knee limitation of flexion. Therefore, the relevant period for consideration is from one year prior to receipt of the intent to file a claim for compensation, from July 11, 2022.

In April 2023, the Veteran requested an appointment with a "foot doctor" and a "shoulder doctor." He reported having surgery on his left knee and needing surgery on his right knee. He stated that in October, while he was walking down a flight of stairs, his left knee buckled, and he injured his left foot and shoulder. Radiographs of the left knee were "unremarkable."

The Veteran submitted to a VA Knee and Lower Leg Conditions examination in August 2023. The Veteran underwent right knee arthroscopy in March 2021. A December 2011 MRI confirmed left knee meniscal tear. During the examination, the Veteran reported his left and right knee conditions progressed/worsened. He denied flare-ups. He reported functional loss and functional impairment described as moderate bilateral knee pain; increased pain with sitting, standing, walking, and navigating stairs; he was unable to kneel without assistance; he experienced tingling and numbness in his legs; any movement past 90 degrees was painful; and his "knees give out." He was treated with over-the-counter ibuprofen.

Initial active and passive range of motion for right knee flexion was measured from 0 to 110 degrees, and extension was limited to 10 degrees. There was evidence of pain on weight-bearing and nonweight-bearing, active and passive motion, and on rest/non-movement. There was objective evidence of crepitus. There was objective evidence of moderate pain in the right patella on palpation. The Veteran was able to perform repetitive-use testing with at least three repetitions. The examiner stated pain, fatigability, weakness, and lack of endurance significantly limits functional ability with repeated use over time. The examiner estimated range of motion after repetitive use as flexion to 110 degrees, and extension to 10 degrees. The examination was not conducted during a flare-up. Additional factors contributing to the right knee disability included interference with sitting and standing, disturbance of locomotion, and less movement than normal. There was no muscle atrophy. There was no ankylosis. There was no recurrent subluxation or persistent instability. There was no history of ligament tear (sprain). There was no recurrent patellar instability. There was no recurrent patellar dislocation or stress fractures. The examiner noted "shin splints" (medial tibial stress syndrome - MTSS) with treatment for less than 12 consecutive months. There was no meniscal condition. The examiner noted the Veteran underwent right knee arthroscopy in March 2021. The Veteran required the constant use of a brace.

The VA examiner diagnosed right knee patellofemoral pain syndrome, ACL (anterior cruciate ligament) sprain, and shin splints. The examiner remarked, "the new diagnosis of shin splints and ACL right knee sprain are new and directly due to or related to the service-connected diagnosis. The right knee limitation of flexion is a sign in the physical exam that the Veteran has been having due to these diagnoses."

Initial active and passive range of motion for left knee flexion was measured from 0 to 100 degrees, and extension was limited to 5 degrees. There was evidence of pain on weight-bearing and nonweight-bearing, active and passive motion, and on rest/non-movement. There was objective evidence of crepitus. There was objective evidence of moderate pain in the anterolateral portion of the left knee on palpation. The Veteran was able to perform repetitive-use testing with at least three repetitions. The examiner stated pain, fatigability, weakness, and lack of endurance significantly limits functional ability with repeated use over time. The examiner estimated range of motion after repetitive use as flexion to 100 degrees, and extension to 5 degrees. The examination was not conducted during a flare-up, and the Veteran denied flare-ups. Additional factors
degrees, and extension was limited to 5 degrees. There was evidence of pain on weight-bearing and nonweight-bearing, active and passive motion, and on rest/non-movement. There was objective evidence of crepitus. There was objective evidence of moderate pain in the anterolateral portion of the left knee on palpation. The Veteran was able to perform repetitive-use testing with at least three repetitions. The examiner stated pain, fatigability, weakness, and lack of endurance significantly limits functional ability with repeated use over time. The examiner estimated range of motion after repetitive use as flexion to 100 degrees, and extension to 5 degrees. The examination was not conducted during a flare-up, and the Veteran denied flare-ups. Additional factors contributing to the left knee disability included interference with sitting and standing, disturbance of locomotion, and less movement than normal. There was no muscle atrophy. There was no ankylosis. There was no recurrent subluxation or persistent instability. There was no history of ligament tear (sprain). There was no recurrent patellar instability. There was no recurrent patellar dislocation or stress fractures. The examiner noted "shin splints" (medial tibial stress syndrome - MTSS) with treatment for less than 12 consecutive months. There was meniscus (semilunar cartilage) condition. The Veteran required the constant use of a brace.

The VA examiner diagnosed left knee meniscal tear, patellofemoral pain syndrome, and shin splints. The examiner remarked, "the new diagnosis of left knee meniscal tear and shin splints are directly due to or related to the service-connected diagnosis. The left knee limitation of flexion is a sign in the physical exam that the Veteran has been having due to these diagnoses."

The Board finds that the requirements of DeLuca, Correia, and Sharp have been adequately satisfied in the VA examination. During the VA examination, the examiner measured active and passive range of motion as well as range of motion on repetitive use testing; the effect of pain on range of motion is described above. The Veteran denied experiencing flare-ups.

Regarding Ingram, the August 2023 VA examiner merely noted the Veteran reported he takes over the counter ibuprofen for pain but did not indicate that he was taking anything at the time of the actual examination. The examiner considered the Veteran's lay description of functional impairment due to pain and range of motion limitations in all worse case-scenarios. There is no indication that the examiner considered the ameliorative effects of medication and indeed, factored in the Veteran's description of when his pain is at its worst, i.e., discounted such effects.

The Board finds the August 2023 VA examination adequate for adjudication purposes. The examiner interviewed the Veteran, reviewed the claims file, and reported all signs and symptoms necessary to evaluate the disability under the rating criteria. The Veteran has not argued otherwise.

For these reasons, the Board gives the examination great probative weight.

The Veteran submitted to a VA Knee and Lower Leg Conditions examination to evaluate the nature of his claimed left leg condition in January 2024. During the examination, the Veteran reported left knee flare-ups, occurring multiple times per week, which he described as severe. The flare-ups were precipitated by walking, sitting, standing and weather changes, and alleviated by "nothing." He reported functional loss and functional impairment described as constant throbbing, swelling, tingling up and down his leg. He was treated with over-the-counter ibuprofen as needed. The VA examiner diagnosed left knee strain, meniscal tear, and patellofemoral pain syndrome.

Initial active and passive range of motion for left knee flexion was measured from 0 to 90 degrees, and extension was limited to 10 degrees. There was evidence of pain on weight-bearing and nonweight-bearing, active and passive motion, and on rest/non-movement. There was objective evidence of crepitus. There was objective evidence of severe pain on palpation of the left patellar ligament. The Veteran was able to perform repetitive-use testing with at least three repetitions. The examiner stated pain, weakness, and lack of endurance significantly limits functional ability with flare-ups. The examiner estimated range of motion during a flare-ups as flexion to 80 degrees, and extension to 15 degrees. Additional factors contributing to the left knee disability included interference with sitting and standing, disturbance of locomotion, swelling, and left knee radiculopathy. There was no muscle atrophy. There was no ankylosis. There was no recurrent subluxation or persistent instability. There was no history of ligament tear (sprain). There was no recurrent patellar instability. There was no recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or any other tibial or fibular impairment. There was meniscus
endurance significantly limits functional ability with flare-ups. The examiner estimated range of motion during a flare-ups as flexion to 80 degrees, and extension to 15 degrees. Additional factors contributing to the left knee disability included interference with sitting and standing, disturbance of locomotion, swelling, and left knee radiculopathy. There was no muscle atrophy. There was no ankylosis. There was no recurrent subluxation or persistent instability. There was no history of ligament tear (sprain). There was no recurrent patellar instability. There was no recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or any other tibial or fibular impairment. There was meniscus (semilunar cartilage) condition. The Veteran required the use of a brace.

Regarding Ingram, the January 2024 VA examiner merely noted the Veteran reported he takes over the counter ibuprofen for pain but did not indicate that he was taking anything at the time of the actual examination. The examiner considered the Veteran's lay description of functional impairment due to pain and range of motion limitations in all worse case-scenarios. Further, the Veteran stated that nothing alleviates his flare-ups. There is no indication that the examiner considered the ameliorative effects of medication and indeed, factored in the Veteran's description of when his pain is at its worse, i.e., discounted such effects.

The Board finds the January 2024 VA examination adequate for adjudication purposes. The examiner interviewed the Veteran, reviewed the claims file, and reported all signs and symptoms necessary to evaluate the disability under the rating criteria. The Veteran has not argued otherwise.

For these reasons, the Board gives the examination great probative weight.

1. Entitlement to an increased rating of 20 percent, but no higher, for left knee strain with patellofemoral pain syndrome, meniscal tear, and shin splints, from July 11, 2023, is granted.

For this issue, the Board may only consider the evidence of record at the time of the April 2024 rating decision on appeal.

In determining whether a separate rating is warranted under diagnostic code 5258, the Board must decide whether separate and distinct symptoms exist or whether there is overlapping symptomatology such that only a single rating is appropriate. The critical element in permitting the assignment of more than one evaluation under different diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping of the symptomatology of another condition. See 38 C.F.R. § 4.14; see also Lyles, 29 Vet. App. 107.

Given the totality of the evidence, the Board finds the assignment of a 20 percent rating, but no higher, is warranted for left knee strain with patellofemoral pain syndrome and meniscal tear from July 11, 2023. In reviewing the evidence, the Veteran was shown to have a meniscal tear of the left knee, and he has continued to experience severe joint pain, crepitus, swelling, fatigability, weakness, lack of endurance, and difficulty in bending of the left knee (limitation of flexion).

In this case, the Veteran's 10 percent rating under diagnostic code 5262 was awarded based on painful motion, and his 0 percent rating under diagnostic code 5260 was awarded based on "a diagnosed disability with no compensable symptoms."

The rules against pyramiding do not allow the Veteran to be compensated for the same symptom twice. To provide the Veteran with the highest possible disability rating for his left knee disability, the Board is granting a 20 percent rating under diagnostic code 5258; and discontinuing the 10 percent rating under diagnostic code 5262 and the 0 percent rating under diagnostic code 5260. Assigning separate ratings under diagnostic codes 5250, 5262, and 5258 would constitute pyramiding because the diagnostic codes overlap in symptoms or findings of pain and limitation of motion, including limitation of motion due to pain. Moreover, this change in diagnostic code does not amount to a reduction, rather it provides the appropriate rating and a more favorable outcome. Tedeschi, 7 Vet. App. 411, 414.

The Board finds the Veteran is not entitled to a rating higher than 20 percent at any time during the appeal period for limitation of motion under diagnostic code 5260. Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by his statements would not result in
ing separate ratings under diagnostic codes 5250, 5262, and 5258 would constitute pyramiding because the diagnostic codes overlap in symptoms or findings of pain and limitation of motion, including limitation of motion due to pain. Moreover, this change in diagnostic code does not amount to a reduction, rather it provides the appropriate rating and a more favorable outcome. Tedeschi, 7 Vet. App. 411, 414.

The Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.49, and the holdings in DeLuca and Mitchell. However, an increased evaluation for the Veteran's left knee disability is not warranted on the basis of functional loss due to pain, fatigability, weakness, lack of endurance, interference with sitting and standing, disturbance of locomotion, or less movement than normal, as his symptoms are supported by pathology which do not indicate that a rating higher than 20 percent is warranted. Although the Veteran's painful motion is significant, there is no indication that it has resulted in further limitation of motion than what was shown on examination, and without clinical medical evidence indicating further functional limitation, the Board is unable to find that the Veteran's pain is so disabling to actually, or effectively, limit flexion of the left knee to such an extent as to warrant assignment of a higher rating.

The Board finds that a separate and/or higher rating is not warranted pursuant to diagnostic code 5262. There is no evidence of malunion of the tibia and fibula at any point during the period on appeal. In addition, while the August 2023 examiner noted "shin splints," the shin splints did not require current treatment.

Based on the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds a 20 percent rating, but no higher, is warranted for left knee strain with patellofemoral pain syndrome, meniscal tear and shin splints, under diagnostic code 5258. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.71a; Lynch, 21 F.4th 776.

2. Entitlement to a rating higher than 10 percent for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain and shin splints (limitation of flexion with painful motion) from July 11, 2023, is denied.

For this issue, the Board may only consider the evidence of record at the time of the November 2023 rating decision on appeal.

Given the totality of evidence when considering the Veteran's competent and credible reports of right knee pain and functional loss or functional impairment, the Board finds a 10 percent rating under diagnostic code 5260, but no higher, is warranted from July 11, 2023. There is no evidence showing that the Veteran's right knee disability manifested in limitation of motion meeting the criteria for any increased rating on the basis of limited flexion. However, the Veteran has painful limitation of motion, and a 10 percent rating under diagnostic code 5260 is the minimal compensable rating for limitation of motion of the joint in accordance with the provisions of 38 C.F.R. § 4.59.

To provide the Veteran with the appropriate rating for his right knee disability, the Board is changing the diagnostic code from 5262 (shin splints) at 10 percent and the diagnostic code from 5260 at 0 percent (limitation of flexion), to diagnostic code 5260 at 10 percent. The assignment of a particular diagnostic code to rate a disability is "completely dependent of the facts of a particular case." See Butts, 5 Vet. App. at 538. The Veteran's painful motion will now be compensated under diagnostic code 5260. Changing the diagnostic code in this instance does not prejudice the Veteran, rather it allows for the appropriate rating to be awarded.

The Board finds that the rating currently assigned considered the pain on movement that the Veteran experiences in his right knee that affects his functional ability, to include any increased functional impairment following repeated use over time. The Board has considered the criteria for a higher rating, however,
0 percent (limitation of flexion), to diagnostic code 5260 at 10 percent. The assignment of a particular diagnostic code to rate a disability is "completely dependent of the facts of a particular case." See Butts, 5 Vet. App. at 538. The Veteran's painful motion will now be compensated under diagnostic code 5260. Changing the diagnostic code in this instance does not prejudice the Veteran, rather it allows for the appropriate rating to be awarded.

Therefore, as there is no indication that the Veteran's right knee range of motion for flexion is limited to 30 degrees, the Board must find that the criteria for a rating higher than 10 percent is not met, and an increased rating is not warranted under diagnostic code 5260.

The Board acknowledges the Veteran's statements that his right knee disability is more severe than evaluated but finds that neither the Veteran's statements nor the medical evidence demonstrates that the criteria for a higher rating have been met. The Veteran has reported that he experiences chronic daily pain and limitation of motion, fatigability, weakness, lack of endurance, interference with sitting and standing, disturbance of locomotion, and less movement than normal of his right knee. While the Veteran is competent to observe his right knee symptoms, he does not have the training or credentials to determine the current nature and severity of those symptoms in conjunction with the applicable diagnostic criteria. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

Accordingly, the Board assigns greater probative weight to the objective findings in the August 2023 VA examination report, as those findings represent objectively documented range of motion testing. This evidence does not reflect limited motion, even following repetitive movement and with repeated use over time, to warrant a rating greater than 10 percent for the Veteran's right knee disability. Indeed, the next higher rating requires limited range of motion for flexion to 30 degrees or less. Additionally, a separate compensable evaluation for shin splints requires treatment for no less than 12 consecutive months, and shin splints unresponsive to either shoe orthotics or other conservative treatment.

In sum, the weight of the persuasive evidence is against the assignment of a disability rating higher than 10 percent for the service-connected right knee patellofemoral pain syndrome with ACL sprain with shin splints (limitation of flexion with painful motion).

Therefore, given the record before it, the Board finds that the persuasive weight of the evidence is against a rating higher than 10 percent for the service-connected right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain with shin splints (limitation of flexion with painful motion). Thus, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F.4th 776. Therefore, the appeal for an increased rating from July 11, 2023, is denied.

3. Entitlement to a rating higher than 20 percent for left knee strain with patellofemoral pain syndrome (limitation of extension) from July 11, 2023, is denied.

4. Entitlement to a rating higher than 10 percent for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain (limitation of extension) from July 11, 2023, is denied.

For the issue of entitlement to a rating higher than 20 percent for left knee strain with patellofemoral pain syndrome (limitation of extension), the Board may only consider the evidence of record at the time of the April 2024 rating decision on appeal.

For the issue of entitlement to a rating higher than 10 percent for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain, the Board may only consider the evidence of record at the time of the November 2023 rating decision on appeal.

In considering the evidence of record under the laws and regulations as set forth above, the
) sprain (limitation of extension) from July 11, 2023, is denied.

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to an increased evaluation for his left knee disability (limitation of extension). In this regard, the Veteran has not demonstrated extension limited to 20 degrees from July 11, 2023. 38 C.F.R. § 4.71a, DC 5261.

In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to an increased evaluation for his right knee disability (limitation of extension). In this regard, the Veteran has not demonstrated extension limited to 15 degrees from July 11, 2023. 38 C.F.R. § 4.71a, DC 5261.

The Board finds that the rating currently assigned considered the pain on movement that the Veteran experiences in his left and right knee that affects his functional ability, to include any increased functional impairment during left knee flare-ups or following repeated use over time.

The Board has considered the criteria for a higher rating, however, a close review of the lay and medical evidence of record reveals that the Veteran's left knee disability, at worst, was limited to 15 degrees of extension. Therefore, as there is no indication that the Veteran's left knee range of motion for extension is limited to 20 degrees, the Board must find that the criteria for a rating higher than 20 percent is not warranted under DC 5261.

The Board has considered the criteria for a higher rating, however, a close review of the lay and medical evidence of record reveals that the Veteran's right knee disability, at worst, was limited to 10 degrees of extension. Therefore, as there is no indication that the Veteran's right knee range of motion for extension is limited to 15 degrees, the Board must find that the criteria for a rating higher than 20 percent is not warranted under DC 5261.

The Board acknowledges the Veteran's statements that his left knee and right knee disability are more severe than evaluated but finds that neither the Veteran's statements nor the medical evidence demonstrates that the criteria for a higher rating have been met. The Veteran has reported that he experiences chronic daily pain and limitation of motion, fatigability, weakness, lack of endurance, interference with sitting and standing, disturbance of locomotion, and less movement than normal of his left knee and right knee. While the Veteran is competent to observe his left and right knee symptoms, he does not have the training or credentials to determine the current nature and severity of those symptoms in conjunction with the applicable diagnostic criteria. Jandreau, 492 F.3d 1372.

Accordingly, the Board assigns greater probative weight to the objective findings in the August 2023 and January 2024 VA examination reports, as those findings represent objectively documented range of motion testing. This evidence does not reflect limited motion, even following repetitive movement and with flare-ups, to warrant a rating greater than 20 percent for the Veteran's left knee disability. Indeed, the next higher rating requires limited range of motion for extension to 20 degrees or less.

In sum, the weight of the persuasive evidence is against the assignment of a disability rating higher than 20 percent for the service-connected left knee strain with patellofemoral pain syndrome (limitation of extension).

In sum, the weight of the persuasive evidence is against the assignment of a disability rating higher than 10 percent for right knee patellofemoral pain syndrome with ACL sprain (limitation of extension).

Therefore, given the record before it, the Board finds that the persuasive weight of the evidence is against a rating higher than 20 percent for left knee strain with patellofemoral pain syndrome (limitation of extension) and against a rating higher than 10 percent for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain (limitation of extension). Thus, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F.4th 776. Therefore, the appeal for increased ratings from July 11, 2023, is denied.

5. Entitlement to a separate disability rating of 10 percent, but no higher, for left knee strain with patellofemoral pain syndrome (instability), from July 11, 2023, is granted.

6. Entitlement to a separate disability rating of 10 percent, but no higher, for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain (instability), from July 11, 2023, is granted.

For the issue of entitlement to a separate disability rating of 10 percent, but no higher, for left knee strain with patellofemoral pain syndrome (instability), the Board may only consider the evidence of record at the time of the April 2024 rating decision on appeal.

For the issue of entitlement to a separate disability rating of 10 percent, but no higher, for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain (instability), the Board may only consider the evidence of record at the time of the November 2023 rating decision on appeal.

Diagnostic Code 5257 provides separate criteria for ratings based on recurrent subluxation or lateral instability or patellar instability.

For recurrent subluxation or lateral instability, a 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired), or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted 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. A 30 percent rating is warranted 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. 38 C.F.R. § 4.71a, DC 5257.

For patellar instability, a 10 percent rating is warranted 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 warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id.

Analysis

Based on the above, the Board is granting herein a separate 10 percent rating for left knee patellofemoral pain syndrome with instability from July 11, 2023; and a separate 10 percent rating for right knee patellofemoral pain syndrome with instability from July 11, 2023.

In April 2023, the Veteran reported having surgery on his left knee and needing surgery on his right knee. He stated that in October, while he was walking
, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id.

Analysis

In April 2023, the Veteran reported having surgery on his left knee and needing surgery on his right knee. He stated that in October, while he was walking down a flight of stairs, his left knee buckled and injured his left foot and shoulder.

During the August 2023 VA Knee and Lower Leg Conditions examination, he reported worsening of symptoms over time. He reported functional loss and functional impairment described as moderate bilateral knee pain; increased pain with sitting, standing, walking, and navigating stairs; and that his "knees give out." The Veteran required the constant use of knee braces for his left knee meniscal tear and bilateral patellofemoral pain syndrome.

The VA examinations and treatment records do not contain objective medical evidence of left knee and right knee instability, but the Veteran reported his right and left knee were unstable, he has a sensation of his knees giving out on him, and he requires knee braces for ambulation. He is competent to describe symptoms associated with his left knee disability and right knee disability, and the Board finds him credible. See English v. Wilkie, 30 Vet. App. 347, 349 (2018).

The Board does not, however, find that a rating higher than 10 percent is warranted for the left knee or right knee disability at any time during the appeal from July 11, 2023. In this regard, there is no evidence of patellar instability after surgical repair, nor a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, or unrepaired or failed repair of complete ligament tear causing persistent instability.

Based on the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds a 10 percent rating, but no higher, is warranted for left knee strain with patellofemoral pain syndrome (instability) and a 10 percent rating, but no higher is warranted for right knee patellofemoral pain syndrome with anterior cruciate ligament (ACL) sprain (instability), under diagnostic code 5257, from July 11, 2023. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.71a; Lynch, 21 F.4th 776.

Finally, the Veteran is not entitled to a higher or separate rating for his left knee disability or right knee disability under diagnostic codes 5256, 5259, or 5263. There is no indication of ankylosis or functional equivalent thereof, removal of semilunar cartilage, or genu recurvatum. The Veteran is not entitled to a higher or separate rating for his right knee disability under diagnostic code 5258. There is no indication of dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint.

7. Increased rating for right knee scars status post right knee arthroscopy.

For this issue, the Board may only consider the evidence of record at the time of the November 2023 rating decision on appeal.

The Veteran contends his right knee scars warrant a higher rating. See October 2024 VA Form 10182.

This is an initial rating claim. The period on appeal begins July 11, 2023, when VA received an intent to file a claim for compensation. On July 26, 2023, the Veteran submitted his completed application (VA Form 21-526EZ) seeking entitlement to an increased evaluation for his service-connected right knee disability. This claim raised the issue of entitlement to service connection for right knee scars.

The Veteran's right knee scars status post right knee arthroscopy are currently rated as 0 (zero) percent disabling from July 11, 2023 under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7802.

"Scars," in general are evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7804, and 7805.

DC 7800 provides ratings for burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement
right knee scars.

The Veteran's right knee scars status post right knee arthroscopy are currently rated as 0 (zero) percent disabling from July 11, 2023 under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7802.

"Scars," in general are evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.118, Diagnostic Codes 7800, 7801, 7802, 7804, and 7805.

DC 7800 provides ratings for burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, DC 7800. As the Veteran's service-connected scar is located on his right lower extremity, a compensable rating is not warranted under DC 7800.

DC 7801 provides ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. Scars involving an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) are assigned a 10 percent rating. Scars involving an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) are assigned a 20 percent rating. Scars involving an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) are assigned a 30 percent rating. Scars involving an area or areas of 144 square inches (929 sq. cm.) or greater are assigned a 40 percent rating. 38 C.F.R. § 4.118, DC 7801.

DC 7802 provides ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. Scars involving an area or areas of 144 square inches (929 sq. cm.) or greater are assigned a 10 percent rating. 38 C.F.R. § 4.118, DC 7802.

Note (1): For the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2): A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Combine the separate evaluations under § 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this diagnostic code. Id.

DC 7804 provides ratings for scar(s) that are unstable or painful. One or two scars that are unstable or painful are assigned a 10 percent rating. Three or four scars that are unstable or painful are assigned a 20 percent rating. Five or more scars that are unstable or painful are assigned a 30 percent rating. 38 C.F.R. § 4.118, DC 7804.

Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3): Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code when applicable. Id.

DC 7805 provides that scars, others; and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805.

In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31.

Factual Background and Analysis

During the August 2023 VA Knee and Lower Leg Conditions examination, the examiner noted the Veteran underwent right knee arthroscopy in March 2021. The examiner indicated residuals of surgery included two right
7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805.

Factual Background and Analysis

During the August 2023 VA Knee and Lower Leg Conditions examination, the examiner noted the Veteran underwent right knee arthroscopy in March 2021. The examiner indicated residuals of surgery included two right knee scars, described as (1) a linear anterior patella scar measured 1.5 by 0.2 mm and (2) a small anteriomedial scar measured 0.5 by 0.3 mm. There was no limitation of function.

In considering the evidence of record under the laws and regulations as set forth above, the Board finds a compensable rating for the Veteran's right knee scars is not warranted.

In this regard, a compensable rating under DC 7802 is available based on a scar involving an area or areas of 144 square inches (929 sq. cm.) or greater. The August 2023 examiner found the right lower extremity scars measured 1.5 by 0.2mm, and 0.5 by 0.3 mm. Therefore, the criteria for a compensable rating under this DC are not warranted.

The Board has also considered the applicability of diagnostic codes 7800, 7801, and 7804. However, the scars are not of the head, face, or neck, are not shown to be associated with underlying soft tissue damage and are not shown to be unstable or painful. Therefore, diagnostic codes 7800, 7801, and 7804 are inapplicable. Lastly, diagnostic code 7805 is not for application as there are no other effects of the scars that require the evaluation of any disabling effect(s) not considered in the rating provided.

Neither the Veteran nor his representative have provided any basis for a higher rating.

In sum, the weight of the persuasive evidence is against the assignment of a compensable rating (a rating higher than 0 percent) for the service-connected right knee scars status post right knee arthroscopy. Thus, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F.4th 776. Therefore, the appeal for an increased rating is denied.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Generally, to prevail on the issue of service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection under 38 U.S.C. § 1110 may be awarded on a secondary basis if a claimant suffers a disability that is "proximately due to or the result of a service-connected disease or injury." See 38 C.F.R. § 3.310(a); but see Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023). For "aggravation of nonservice-connected disabilities" it is enough to show that a nonservice-connected disability would have been less severe but-for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the nonservice-connected disability. Id.

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 evidence favorable to the claimant.

8. Entitlement to service connection for left knee radiculopathy, as secondary to the service-connected left knee strain with patellofemoral pain syndrome and meniscal tear, is granted.

The
a nonservice-connected disability would have been less severe but-for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the nonservice-connected disability. Id.

8. Entitlement to service connection for left knee radiculopathy, as secondary to the service-connected left knee strain with patellofemoral pain syndrome and meniscal tear, is granted.

The Veteran has not specifically claimed entitlement to service connection for left knee radiculopathy. However, the Board notes VA's duty to maximize benefits requires it to "exhaust all schedular alternatives for rating a disability before the extraschedular analysis is triggered," and stated that secondary service connection is one of these schedular alternatives. See Morgan v. Wilkie, 31 Vet. App. 162, 164 (2019). Further, "VA is obligated to develop and adjudicate claims for secondary service connection that are reasonably raised during the processing of a properly initiated claim as to the primary service-connected disability's evaluation level." Bailey v. Wilkie, 33 Vet. App. 188, 201 (2021).

The issue of entitlement to secondary service connection is raised by the August 2023 VA Knee and Lower Leg Conditions examination. During the examination, the Veteran reported current symptoms of a "tingling sensation and numbness" in his left leg. During the January 2024 VA examination, the Veteran reported constant throbbing, swelling, and tingling up and down his leg, left leg numbness when sitting, and sharp shooting pain from his left foot to his groin. The examiner diagnosed left knee strain, left knee meniscal tear, and left knee patellofemoral pain syndrome. Additional factors contributing to the disability included left knee radiculopathy.

The evidence of record reflects the Veteran has left knee radiculopathy. Also, the Veteran has been awarded service connection for left knee strain with patellofemoral pain syndrome and meniscal tear.

The Board finds the January 2024 knee and lower leg conditions examination report highly probative on the question of whether the Veteran's left knee radiculopathy is caused or aggravated by his service-connected left knee disability.

Accordingly, service connection for left knee radiculopathy is granted.

9. Entitlement to service connection for right elbow medial epicondylitis is denied.

10. Entitlement to service connection for left elbow medial epicondylitis with degenerative arthritis, other than post-traumatic, and ulnar nerve entrapment, is denied.

For these issues, the Board may only consider the evidence of record at the time of the May 2024 rating decision on appeal.

The Veteran asserts his right elbow disability and left elbow disability had their onset during military service.

The evidence of record reflects the Veteran has been diagnosed with (i) right elbow medial epicondylitis and (ii) left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment. See May 2020 VA Elbow and Forearm Conditions examination report.

Regarding an in-service incurrence, the Veteran asserts his right and left elbow disability are due to in-service Army Airborne parachute jumps. His DD Form 214, Certificate of Release or Discharge from Active Duty, confirms he was awarded the Parachutist Badge for successful completion of Airborne training.

The Veteran's service treatment records (STRs) are associated with the claims file. In December 2002, the Veteran was placed on temporary physical profile due to shoulder or arm injury. A December 2003 medical record notes the Veteran's "medical records are lost. New medical records started December 19, 2003."

Clinical evaluation of the musculoskeletal system was "normal" on his Report of Medical Examination form completed for the purpose of Medical Board in June 2004. He denied experiencing swollen or painful joints, broken bones, bone, joint or other deformity, or arthritis, rheumatism, or bursitis, on his Report of Medical History.

The Veteran was referred for Medical Evaluation Board in July 2004. The examining physician diagnosed narcolepsy and retropatellar pain and remarked "from a physical standpoint, the soldier has no real limitation. He has chronic knee pain, but this does not interfere with his ability to do most duties of his MOS and is not a boardable condition."

The first mention of any right elbow/nerve disability in the post-service treatment records is an April 2011 San Juan VAMC emergency department progress note.
Medical Board in June 2004. He denied experiencing swollen or painful joints, broken bones, bone, joint or other deformity, or arthritis, rheumatism, or bursitis, on his Report of Medical History.

The first mention of any right elbow/nerve disability in the post-service treatment records is an April 2011 San Juan VAMC emergency department progress note. The Veteran reported a right shoulder condition; had trauma yesterday (his son climbed on top of his arm) and now has shoulder and elbow pain and difficulty extending his arm. X-rays showed no evidence of acute bony injury. The examiner's diagnostic impression was right elbow pain.

The first mention of any left elbow/nerve disability in the post-service treatment records is an August 2018 Las Vegas VAMC emergency department note. The Veteran reported re-aggravation of a left elbow injury from six weeks ago. He reported working as a heavy equipment mechanic and recalled about six weeks ago "bumping his left elbow" and then re-aggravating it earlier today. Left elbow x-rays showed: "there is no evidence of fracture or dislocation. No abnormal fat pad sign is seen. The joint spaces are well maintained, and the joint surfaces are smooth. The bony architecture is normal. There is an enthesophyte on the olecranon." He was assessed with left elbow pain.

The Veteran was provided a VA Elbow and Forearm Conditions examination in May 2024. He stated his right and left elbow conditions had their onset in 2002 during "jump school." His right and left elbow conditions had worsened since onset. The examiner noted the April 2011 right elbow x-ray, the February 2020 left elbow x-ray, and the November 2023 left ulnar surgery (left cubital tunnel decompression with subcutaneous ulnar nerve transposition).

The examiner reviewed the claims file and opined the Veteran's right elbow medial epicondylitis was less likely than not incurred in or caused by the claimed in-service injury, event or illness. As rationale the examiner stated:

Veteran has no diagnosis in the electronic (claims) file related to right elbow either during active duty service or after service. Upon examination medial epicondylitis on right elbow is noted. Veteran reports pain in elbow began in jump 2002. The electronic file shows no reports of elbow injury in service and no chronicity of care from active duty service until first x-ray that was WNL (within normal limits) in 2011 after injury to right elbow as reported by VA ER (emergency room). No chronicity of care is present in the electronic file. Therefore, no nexus can be made between Veteran's right elbow nerve pain and an in-service injury, event, or illness.

The examiner reviewed the claims file and opined the Veteran's left elbow medial epicondylitis with degenerative arthritis, other than post-traumatic, and ulnar nerve entrapment was less likely than not incurred in or caused by the claimed in-service injury, event or illness. As rationale the examiner stated:

Veteran has diagnosis of left ulnar nerve entrapment as well as degenerative arthritis and upon examination also has medical epicondylitis on left elbow. Veteran reports pain in elbow began with jump in 2002. The electronic (claims) file shows no reports of elbow injury in service and no chronicity of care from active duty service until first x-ray in 2020 showing mild degenerative changes and persistent dorsal enthesophytes at the left olecranon process. No chronicity of care is present from x-ray in 2020 and surgery in 20203. Therefore, no nexus can be made between Veteran's left elbow condition and nerve pain and an in-service injury, event, or illness.

The Board finds the May 2024 VA opinions probative on the question of whether the Veteran's (i) right elbow medial epicondylitis disability and/or (ii) left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment disability, were incurred in or related to his military service. The opinions are based on the Veteran's lay statements, a thorough review of his service and post-service medical history and supported by sound rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning).

In support of his appeal
The Board finds the May 2024 VA opinions probative on the question of whether the Veteran's (i) right elbow medial epicondylitis disability and/or (ii) left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment disability, were incurred in or related to his military service. The opinions are based on the Veteran's lay statements, a thorough review of his service and post-service medical history and supported by sound rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning).

In support of his appeal, the Veteran submitted an October 2024 medical opinion. Dr. S.D., stated, "based on my evaluation and treatment of Veteran, it is my professional opinion that his cubital nerve syndrome and nerve damage on his elbows are likely related to his service in the military." Dr. S.D. explained, "it is well-documented that repetitive tasks, trauma, and physical strain experienced during military service can contribute to the development of musculoskeletal injuries and nerve compression syndromes. In Veteran's case, his symptoms and medical history are consistent with these types of injuries commonly seen in service members." Dr. S.D. concluded, "I believe that his conditions have a nexus to his time in service and may be contributing to his current symptoms and limitations."

The Board finds the October 2024 opinion inadequate because the opinion is expressed in language that is equivocal or speculative in nature. The examiner's use of "are likely," "can contribute," and "may be contributing," renders the opinion speculative. Such language does not provide the degree of certainty for a medical nexus opinion. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006). Medical examinations are inadequate when the examiner's conclusions include equivocal language such as "could" or "might," with no other rationale or supporting data. See Hood v. Shinseki, 23 Vet. App. 295 (2009); see also Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009); Bloom v. West, 12 Vet. App. 185 (1999) (holding that the "use of 'could,' without supporting clinical data or other rationale," lacks the "degree of certainty required for medical nexus evidence").

After reviewing the lay and medical evidence of record, the Board finds that the weight of the persuasive evidence is against finding that a medical nexus exists between the Veteran's (i) right elbow medial epicondylitis disability and (ii) left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment disability, and an in-service injury, event, or disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. There is no adequate medical opinion of record which weighs in favor of the claim.

The Board has also considered the Veteran's lay opinion that his right elbow disability and left elbow disability are related to service. In this case, the Board considers the potential relationship between the Veteran's (i) right elbow medial epicondylitis disability and (ii) left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment disability, and their connection to service, to be complex in nature. Therefore, while the Veteran is competent to describe his symptoms, he does not have the medical expertise that would render him competent to provide nexus opinions. The Board finds the opinions of the May 2024 examiner to be more probative in this regard.

As noted above, in the December 2002 STR, the Veteran was placed on temporary physical profile due to shoulder or arm injury. The Veteran's STRs do not note further treatment of complaints of a right elbow disability or left elbow disability. Critically no right elbow disability was noted until the April 2011 San Juan VAMC emergency department report; no left elbow disability was noted until the August 2018 Las Vegas VAMC emergency department report. Therefore, the Board finds no continuity of symptomatology since service.

In this case, the most probative evidence of record does not show that the Veteran's right elbow medial epicondylitis disability and left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment disability, are due to service.

As the weight of the probative evidence is against the claim, the benefit of the doubt doctrine is not for application to the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch
emergency department report; no left elbow disability was noted until the August 2018 Las Vegas VAMC emergency department report. Therefore, the Board finds no continuity of symptomatology since service.

As the weight of the probative evidence is against the claim, the benefit of the doubt doctrine is not for application to the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 21 F.4th 776. For these reasons, the claim for service connection for (i) right elbow medial epicondylitis disability and (ii) left elbow medial epicondylitis with degenerative arthritis, other than post traumatic, and ulnar nerve entrapment disability, are denied.

11. Entitlement to service connection for left elbow scar, post left ulnar nerve transposition, associated with the treatment of left elbow medial epicondylitis with ulnar entrapment, is denied.

For this issue, the Board may only consider the evidence of record at the time of the May 2024 rating decision on appeal.

The Veteran seeks service connection for a left elbow scar associated with the treatment of left elbow medial epicondylitis with ulnar nerve entrapment. The Veteran underwent left cubital tunnel decompression with subcutaneous ulnar nerve transposition in November 2023. See Las Vegas VAMC records; see also May 2024 VA Elbow and Forearm Conditions examination report.

While the May 2024 rating decision made a favorable finding that the Veteran has a left elbow scar associated with the left cubital tunnel decompression with subcutaneous ulnar nerve transposition surgery, the Veteran's primary disability, left elbow medial epicondylitis with ulnar nerve entrapment, has not been service connected. Accordingly, entitlement to service connection for a left elbow scar cannot be granted secondary to the Veteran's nonservice connected left elbow medial epicondylitis with ulnar nerve entrapment. 38 C.F.R. § 3.310.

Additionally, the Veteran does not contend, and the evidence does not suggest that his left elbow scar is otherwise directly related to service. In fact, the record indicates the Veteran's scar is from his left cubital tunnel decompression with subcutaneous ulnar nerve transposition surgery. There is no evidence indicating a relationship between the Veteran's left elbow scar and service or any service-connected condition. Accordingly, the criteria for service connection for a left elbow scar have not been met, and the appeal is denied.

Rebecca N. Poulson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Grace A. Johnk, 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.

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