DIABETES MELLITUS

Summary

The Veteran served from January 1997 to November 2000. He appeals the denial of service connection for diabetes mellitus type II, hypertension, and a back disorder, as well as increased ratings for his service-connected bilateral knee disabilities. The Veteran claimed these conditions were secondary to his service-connected knee disabilities, with obesity as an intermediate step. The Board denied service connection for diabetes, hypertension, and the back disorder, finding no causal relationship to service or to the service-connected knee disabilities, nor that obesity was a substantial factor caused by the knee conditions. The Board noted that while the Veteran's knee disabilities caused some pain and limited motion, the evidence did not support ratings higher than the 10% already awarded for each knee, as the limitations did not meet the criteria for higher ratings or separate ratings for instability. The Board found the Veteran's weight gain and subsequent obesity were primarily due to dietary factors rather than his service-connected knee conditions, and that the claimed conditions manifested years after service without continuity of symptomatology. The Board also noted that the Veteran's claims for increased ratings for his knees were not supported by evidence demonstrating functional loss beyond what was already considered for the current 10% ratings.

Rationale

No causal relationship to service or service-connected knee disabilities.; Obesity not shown to be caused or aggravated by knee disabilities.; Diabetes manifested years after service without continuity of symptomatology.

Full Decision Text

Citation Nr: A26037649
Decision Date: 04/22/26	Archive Date: 04/22/26

DOCKET NO. 210824-181826
DATE: April 22, 2026

ORDER

Service connection for diabetes mellitus, type II, is denied.

Service connection for hypertension is denied.

Service connection for back disorder is denied.

A rating in excess of 10 percent for right knee patellofemoral syndrome is denied.

A rating in excess of 10 percent for left knee patellofemoral syndrome is denied.

FINDINGS OF FACT

1. The Veteran's diabetes mellitus type II, is not shown to be causally or etiologically related to his military service, did not manifest to a compensable degree within one year from his separation from service, and was not caused or aggravated by his service-connected bilateral knee disabilities, to include with obesity as an intermediate step.

2. The Veteran's hypertension is not shown to be causally or etiologically related to his military service, did not manifest to a compensable degree within one year from his separation from service, and was not caused or aggravated by his service-connected bilateral knee disabilities, to include with obesity as an intermediate step.

3. The Veteran's back disorder, diagnosed as lumbosacral strain, is not shown to be causally or etiologically related to his military service and was not caused or aggravated by his service-connected bilateral knee disabilities, to include with obesity as an intermediate step.

4. The Veteran's bilateral knee disabilities have been manifested by pain and painful motion, with retained flexion to greater than 45 degrees and normal extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without recurrent subluxation, lateral instability, patellar instability, ankylosis or the functional equivalent thereof, dislocation or removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum.

CONCLUSIONS OF LAW

1. The criteria for service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.

3. The criteria for service connection for back disorder have not been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260.

5. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 1997 to November 2000.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2021 rating decision issued by a Department of Veterans Affairs (VA) Regional Office, as the agency of original jurisdiction (AOJ). In an August 2021 VA Form 10182, the Veteran elected the Hearing option for Board review. On April 10, 2025, his attorney withdrew the hearing request. Thus, the Board cannot, and has not, considered any evidence submitted or added to the claims file (1) during the period after the May 19, 2021, AOJ decision on appeal and prior to receipt of the withdrawal of the hearing request on April 10, 2025, or (2) more than 90 days following receipt of the withdrawal, which was by July 9, 2025. 
 decision issued by a Department of Veterans Affairs (VA) Regional Office, as the agency of original jurisdiction (AOJ). In an August 2021 VA Form 10182, the Veteran elected the Hearing option for Board review. On April 10, 2025, his attorney withdrew the hearing request. Thus, the Board cannot, and has not, considered any evidence submitted or added to the claims file (1) during the period after the May 19, 2021, AOJ decision on appeal and prior to receipt of the withdrawal of the hearing request on April 10, 2025, or (2) more than 90 days following receipt of the withdrawal, which was by July 9, 2025. 38 C.F.R. §§ 20.300, 20.302(b), 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. 

1. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected disability.

2. Entitlement to service connection for hypertension, to include as secondary to service-connected disability.

3. Entitlement to service connection for back disorder, to include as secondary to service-connected disability.

The Veteran seeks service connection for his current diabetes mellitus, type II, hypertension, and lumbosacral strain (low back disability) as secondary to his service-connected bilateral knee disabilities. He asserts that he became obese due to being sedentary as a result of knee pain and that his obesity resulted in his claimed conditions (obesity as an intermediate step). 

In the decision on appeal, the AOJ made favorable findings of a current disability of diabetes mellitus, type II, hypertension, and lumbosacral strain, all as noted in May 2021 VA examinations, and that the claimed primary knee disabilities were service-connected. The AOJ denied the claims due to no secondary nexus to the knee disabilities, as well as finding no in-service or nexus elements for a direct theory.

The Board will first address secondary service connection, as it is the primary asserted theory, followed by inferred theories of direct service connection.

Secondary Service Connection

Service connection may be granted on a secondary basis for a nonservice-connected disability that is caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995); Ward v. Wilkie, 31 Vet. App. 233 (2019) (holding that secondary aggravation need not be permanent); Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the "proximate cause" requirement and applying a "but for" requirement for secondary causation; and holding that secondary service connection applies to any worsening of functionality, whether through an inability to treat or a more direct cause).

Obesity may qualify as an "intermediate step" between a service-connected disability and a claimed disability on a secondary basis. See VA Off. Gen. Counsel Prec. Op. 1-2017; Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). The evidence must show that (1) the service-connected disability caused or aggravated the Veteran's obesity; (2) such obesity, or aggravation of obesity, was a substantial factor in causing the current claimed disability; and (3) the current disability would not have occurred but for the obesity being caused or aggravated by the service-connected disability. Id. If all of these conditions are satisfied, then service connection for the claimed disability may be established on a secondary basis.

For all pertinent matters, reasonable doubt will be resolved in favor of the claimant when there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

In this case, a May 2021 VA examiner opined that the Veteran's diabetes mellitus, type II, hypertension, and low back disability (lumbosacral or lumbar strain) were less likely than not caused by his bilateral knee disabilities (patellofemoral syndrome, or PFS), with discussions of the potential etiology and role of his obesity. The opinions are adequate and highly probative because they reflect application of medical expertise to the accurate facts, including notations in treatment
 matters, reasonable doubt will be resolved in favor of the claimant when there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

In this case, a May 2021 VA examiner opined that the Veteran's diabetes mellitus, type II, hypertension, and low back disability (lumbosacral or lumbar strain) were less likely than not caused by his bilateral knee disabilities (patellofemoral syndrome, or PFS), with discussions of the potential etiology and role of his obesity. The opinions are adequate and highly probative because they reflect application of medical expertise to the accurate facts, including notations in treatment records, and they are supported by well-reasoned rationale with relevant medical literature. 

Although the VA examiner did not expressly address whether the service-connected knee disabilities aggravated the Veteran's obesity, the opinion rationale does not suggest any potential for aggravation. Medical notations in VA treatment records are consistent with the examiner's opinion rationale, and they also do not suggest any aggravation such that the claimed disabilities would not have occurred "but for" the obesity being caused or aggravated by the knee disabilities. 

Furthermore, neither the Veteran nor his attorney has submitted a contrary medical opinion. In May 2025, the attorney submitted medical articles concerning a relationship between obesity and diabetes and obesity and hypertension. These are consistent with the VA examiner's rationale and treatment records. In addition, the articles do not suggest an underlying relationship between the Veteran's knee disabilities and obesity. The Veteran and his attorney are not competent to identify an etiology for his obesity or the claimed disabilities. These questions require medical expertise to interpret his history and relevant tests due to the complex nature of the multiple involved body systems. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

Accordingly, the Board finds that a remand for another medical opinion would have no reasonable possibility of assisting in substantiating any claim on appeal, and no further assistance is required in this regard. See 38 C.F.R. § 3.159(c).

Concerning the Veteran's diabetes mellitus, type II, and his knee disabilities, the May 2021 VA examiner stated that "the only conceivable mechanism connecting the two conditions would be massive weight gain as a result of reduced activity due to the PFS." The examiner noted that the Veteran had gained 180 pounds (from 254 pounds to 421 pounds) between 2003 (three years after service) and 2018. The examiner acknowledged that obesity is a known risk factor for diabetes mellitus type II, but "it would defy logic to assume that his [knee disabilities] could be etiologic in such massive weight gain." The examiner noted that the knee disabilities were each rated only 10 percent disabling. The examiner also observed, "Weight gain after separation from active duty is common in veterans without any service-connected disabilities, and [it] is generally felt to be the result of a continued high level of caloric intake out of proportion to the level of reduced activity in civilian life, given the absence of rigorous physical training." 

For a low back disability, the examiner stated that the Veteran's lumbar strain was most likely the result of his massive weight gain, but it was also less likely than not that his knee disabilities were etiologic in that weight gain for the same reasons.

For hypertension, the examiner acknowledged that obesity is a known risk factor, but this Veteran's hypertension was diagnosed in 2003 when his weight was 180 pounds, less than the maximum weight noted in 2018. Thus, the examiner opined that his "weight gain played no role in the development of his hypertension," nor did his knee disabilities. The Veteran reported at the May 2021 VA examination that he had been diagnosed with hypertension in 2003, although VA treatment records noted hypertension with treatment by medication in 2015. 

Historically, a November 2002 VA general medical examination recorded that the Veteran weighed 230 pounds and had no gait or posture abnormality. This reflects that he had lost about 20 pounds since service despite his knee disabilities, as an October 2000 examination for separation recorded his weight as 249 pounds. 

A July 2003 VA treatment record for knee pain reflects his weight as 254 pounds. A September 2006 record characterized the Veteran as obese, with a similar weight of 260 pounds and a body mass index (BMI) of 37.4. An October 2003 record noted improved knee pain and that maintaining an acceptable body weight, as well as exercises for flexibility and strengthening, were key to managing his knee pain.
 a November 2002 VA general medical examination recorded that the Veteran weighed 230 pounds and had no gait or posture abnormality. This reflects that he had lost about 20 pounds since service despite his knee disabilities, as an October 2000 examination for separation recorded his weight as 249 pounds. 

A July 2003 VA treatment record for knee pain reflects his weight as 254 pounds. A September 2006 record characterized the Veteran as obese, with a similar weight of 260 pounds and a body mass index (BMI) of 37.4. An October 2003 record noted improved knee pain and that maintaining an acceptable body weight, as well as exercises for flexibility and strengthening, were key to managing his knee pain. 

An August 2012 VA record noted "no hypertension to report"; the Veteran had gained 45 pounds and had a BMI of 41.4. In May 2015, the Veteran denied taking blood pressure medications and had a blood pressure reading of 168/98; he weighed 358 pounds and was prescribed HCTZ for hypertension. The provider discussed the importance of being physically active and eating wisely for better health, but the Veteran was not interested in discussing ways to do so. 

In February 2018, a VA treatment record noted elevated blood pressure, and the provider suspected that the Veteran's obstructive sleep apnea was undertreated. He reported CPAP compliance, but he had gained more than 100 pounds since his last sleep study and titration. He could not tolerate HCTZ due to side effects. 

An October 2018 treatment record noted essential hypertension and prescribed Toprol, and the Veteran was also diagnosed with diabetes mellitus, type II, with an A1c level of 6.5 percent, which was noted as borderline. He planned to try lifestyle changes before starting medication. In February 2019, the Veteran started on amlodipine for hypertension and metformin for diabetes, although his A1c level was still 6.5 percent and was noted as stable. His weight was 403 pounds with a BMI of 57.95, and the provider stated that he would likely benefit from weight management. The Veteran had made no dietary changes, but he had increased his physical activity to walking 1/2 mile when he was able, which he described as limited due to knee pain. Significantly, this provider noted nutrition diagnoses of obesity related to excessive energy intake (or calories) as evidenced by the Veteran's BMI of 57.95, excessive intake of carbohydrates as evidenced by his A1c level of 6.5 percent, and excessive fat intake as evidence by his LDL level (for cholesterol). The Veteran was provided handouts on diet and nutrition. 

An August 2020 record noted that the Veteran had stopped taking metformin and amlodipine, and he did not want to start any medications. Similar to February 2019, the medical history noted "morbid (severe) obesity due to excess calories," benign essential hypertension, and "Type 2 diabetes mellitus in obese."

In summary, the medical evidence reflects that while the Veteran had some limitation of physical activity due to his service-connected knee disabilities, his obesity and progressive weight gain (or aggravation of obesity) were repeatedly attributed to his diet, specified as excessive intake of calories, fat, and cholesterol. The evidence is not in at least relative equipoise; thus, there is no reasonable doubt to resolve in the Veteran's favor. The criteria for obesity as an intermediate step to secondary service connection have not been met, and there is no other raised secondary theory.

Direct Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred in or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 

A nexus to service will be presumed for certain "chronic" diseases, including diabetes mellitus, type II, and hypertension, if the disease was noted or diagnosed as chronic in service; or if it manifested to a compensable degree within one year after at least 90 continuous days of active duty; or if there is continuity of symptomatology since service with no intervening cause. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303(b), 3.307,
 service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 

A nexus to service will be presumed for certain "chronic" diseases, including diabetes mellitus, type II, and hypertension, if the disease was noted or diagnosed as chronic in service; or if it manifested to a compensable degree within one year after at least 90 continuous days of active duty; or if there is continuity of symptomatology since service with no intervening cause. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a)(3); see also Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015). 

In this regard, the Veteran has not described any potentially relevant injury, event, or disease for diabetes mellitus, type II, hypertension, or a low back disability during his service from January 1997 to November 2000. Service records also do not suggest any relevant symptoms or diagnosis, to include in Reports of Medical Assessment, History, and Examination from April 2000 to October 2000 for separation and Physical Evaluation Board. Although other symptoms and conditions were reflected in those reports, the Veteran denied sugar or albumin in his urine, high blood pressure, and recurrent back pain or any back injury, and his blood pressure was 117/73. He was medically discharged due to his bilateral knee disabilities. 

The Veteran also has not reported persistent or recurring symptoms of the claimed conditions since service, and no medical records or VA opinions suggest a nexus. For example, a November 2002 VA general medical examination summarized that the Veteran seemed to be in good health other than his knee pain. He had a blood pressure of 125/85, normal range of motion and strength except for the knees, no disc disease, an endocrine system within normal limits, and normal laboratory results. 

As noted in May 2021 VA examinations and reflected in VA treatment records, the Veteran's diabetes was diagnosed in 2018, and he reported a diagnosis of hypertension in 2003 but medication a diagnosis and medication were noted in 2015. The VA examiner diagnosed lumbosacral strain based on the Veteran's reported onset of low back pain in 2016 when he slept "wrong," pain or flares after prolonged standing or walking, and that his condition had been worsening. VA treatment records since 2002 do not reflect back or spine complaints or diagnoses. 

Contemporary medical evidence is not required to show a disability or incurrence of injury or aggravation in service. However, the lack of treatment or corroborating medical evidence for many years may be considered as one of several factors in determining whether a disability was incurred during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009). 

In this case, there are not only a lack of treatment or documented complaints since service, but affirmative statements by the Veteran of an onset more than 10 years after service (for the back), denial of any prior history more than 10 years after service (for hypertension), and previously normal objective tests (for diabetes). Thus, the probative evidence is against an onset or diagnosis in or near service.

Similarly, the chronic disease presumption does not establish a nexus for diabetes mellitus, type II, or hypertension, as they did not manifest within one year of separation from service and were not diagnosed until several years after service. See 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). 

No VA medical opinion is required for direct service connection. Although there are current diagnoses for diabetes mellitus, type II, hypertension, and lumbosacral strain, there was no in-service injury, disease, or event, and there is no competent evidence indicating that a current disability may be related to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As noted above, there is no such argument. 

In summary, the evidence is not in at least relative equipoise for a nexus to service based on a direct or legal presumption. Thus, there is no reasonable doubt to resolve in the Veteran's favor. The appeals
3.307(a)(3), 3.309(a). 

No VA medical opinion is required for direct service connection. Although there are current diagnoses for diabetes mellitus, type II, hypertension, and lumbosacral strain, there was no in-service injury, disease, or event, and there is no competent evidence indicating that a current disability may be related to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As noted above, there is no such argument. 

In summary, the evidence is not in at least relative equipoise for a nexus to service based on a direct or legal presumption. Thus, there is no reasonable doubt to resolve in the Veteran's favor. The appeals are denied.

Increased Ratings

4. Entitlement to a rating in excess of 10 percent for right knee patellofemoral syndrome.

5. Entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome.

The Veteran generally seeks increased ratings for his bilateral knee disabilities based on pain and painful or limited motion with resulting functional impairment. 

The period on appeal stems from receipt of the Veteran's VA 21-526EZ, Fully Develop Claim on March 18, 2021.

VA evaluates disabilities by applying a schedule of ratings that is based on average impairment of earning capacity, with separate diagnostic codes (DCs) identifying the various disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part 4. A disability is viewed in relation to its history, with emphasis on resulting limitation of activities; and the basis of a disability rating is the ability to function under the conditions of ordinary daily life, including employment. See 38 C.F.R. §§ 4.1, 4.10.

Where the evidence is in relative equipoise as to any material matter, all reasonable doubt will be resolved in the claimant's favor. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. Where there is a question as to which of two ratings applies, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7.

Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Higher or lower ratings may be assigned for separate periods where factual findings show distinct periods where the disability symptoms warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). 

A separate or higher rating may be assigned based only on non-overlapping conditions and symptoms, if the compensable criteria under applicable diagnostic codes are met, including with consideration of additional functional loss after repetitive use or flareups for musculoskeletal conditions based on range of motion. See 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.71a; Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009); Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016). Pain itself does not constitute functional loss, and painful motion must result in functional loss to constitute limited motion for a rating under diagnostic codes based on limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011).

Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. Although the law generally prevents considering the same symptoms under various diagnoses to support separate ratings (pyramiding), some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, and recurrent subluxation or instability of the knee. A rating may also be assigned for meniscal impairment if there are non-overlapping symptoms. The Board will explore all possibilities in this case.

Normal knee range of motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate I. 

Under DC 5260, limitation of flexion of the leg is assigned a rating of 0 percent for flexion to 60 degrees; 10 percent for flexion to 45 degrees; 20 percent for flexion to 30 degrees; or 30 percent for flexion to 15
 of flexion of the knee, limitation of extension of the knee, and recurrent subluxation or instability of the knee. A rating may also be assigned for meniscal impairment if there are non-overlapping symptoms. The Board will explore all possibilities in this case.

Normal knee range of motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate I. 

Under DC 5260, limitation of flexion of the leg is assigned a rating of 0 percent for flexion to 60 degrees; 10 percent for flexion to 45 degrees; 20 percent for flexion to 30 degrees; or 30 percent for flexion to 15 degrees. Id. Under DC 5261, limitation of extension is assigned a rating of 10 percent for extension to 10 degrees; 20 percent for extension to 15 degrees; 30 percent for extension to 20 degrees; 40 percent for extension to 30 degrees; or 50 percent for extension to 45 degrees. Id. Where there is painful or limited motion with both flexion and extension, but the compensable criteria are not met for either plane, one minimum rating of 10 percent should be assigned. Additionally, separate ratings may not be assigned for compensable limitation under one code and noncompensable limitation under another code using section 4.59. Mitchell, supra. 

As explained below, the Veteran's knee disabilities have been manifested by pain and painful motion at times, with retained flexion to greater than 45 degrees and extension to greater than 10 degrees despite increased pain or other contributing factors; with no recurrent subluxation, instability, meniscal impairment, or other abnormality. Thus, a higher or separate rating is not warranted for either knee.

In a May 2025 brief, the Veteran's attorney summarized notations of pain and range of motion findings from a May 2021 VA examination and asserted that the full history of the conditions should be considered, pointing to notations of crepitus and limited flexion from July 2003. Considering his full history, the evidence generally reflects normal knee X-rays with crepitus, pain, and painful or limited motion at times. Findings from 2003 have little to no probative value for the current level of disability because they were well before the current claim in 2021. 

The May 2021 VA examination reflects bilateral knee pain for which the Veteran took over-the-counter NSAIDs as needed. For both knees, he described flareups of moderate severity with increased pain, which occurred three to four times per week for two hours at a time. They were precipitated by prolonged walking or standing and were alleviated by rest and NSAIDS. Functional impairment or loss, including after repeated use over time, involved difficulty or inability to walk more than 100 yards (a football field), sit, squat, or work in a kneeling or squatting position. There was no history of instability, subluxation, or effusion. The Veteran used a brace on each knee constantly to reduce pain and crutches occasionally during flareups. 

The examiner measured range of motion as limited right knee flexion to 95 degrees with pain at 70 degrees, and left knee flexion to 90 degrees with pain at 65 degrees, but full extension to 0 degrees bilaterally. There was pain with weightbearing, active motion, and passive motion, but no change after repetitive use testing. The Veteran had moderate subpatellar tenderness to palpation bilaterally in the area of his patellofemoral pain syndrome. The examiner estimated additional loss due to pain or other factors during flareups or after repeated use over time as right knee flexion to 70 degrees, left knee flexion to 65 degrees, and still full extension. Although these estimates were the same as the levels at which pain began during the examination, there is no suggestion of significantly more limitation at those times. 

Notably, neither the Veteran nor his attorney has asserted that the examination was inadequate. The Board finds that the report and estimates are adequate and generally consistent with the other evidence of record, to include VA treatment records, which reflect knee braces and pain with intermittently limited motion. 

For example, a December 2019 record noted that VA provided replacement knee braces. An August 2020 record noted chronic knee pain or chondromalacia for which the Veteran took taking naproxen (which is an over-the-counter NSAID) as needed; he declined new X-rays or an orthopedic referral. A February 2021 record noted chronic aching knee pain that the Veteran rated as a 5 out of 10, which had been present for more than three months and had not changed. Examination of the extremities (e.g., legs or knees) showed full range of motion and
 the other evidence of record, to include VA treatment records, which reflect knee braces and pain with intermittently limited motion. 

For example, a December 2019 record noted that VA provided replacement knee braces. An August 2020 record noted chronic knee pain or chondromalacia for which the Veteran took taking naproxen (which is an over-the-counter NSAID) as needed; he declined new X-rays or an orthopedic referral. A February 2021 record noted chronic aching knee pain that the Veteran rated as a 5 out of 10, which had been present for more than three months and had not changed. Examination of the extremities (e.g., legs or knees) showed full range of motion and no pain. 

Discounting the alleviating effects of medication would not result in a higher severity to approximate a higher rating for either knee. As noted above, the Veteran's measured and estimated limitations of flexion were higher than even the 60-degree level that would be assigned a 0 percent rating, and he had full extension. Thus, the Veteran is in receipt of a 10 percent rating for each knee due to painful but noncompensable motion (primarily with flexion), applying 38 C.F.R. § 4.59 in conjunction with DC 5260. There is no lay or medical suggestion that high levels of pain or other factors without medication would result in functional loss of flexion to 45 degrees or below, or extension limited by at least 10 degrees, as required for a 10 percent rating under DC 5260 or 5261. 38 C.F.R. § 4.71a.

Although DC 5257 for instability contemplates use of a brace or other assistive device, to include crutches, the evidence of record does not support a separate rating on this basis for either knee. Under this code, a 10 percent rating may be assigned for recurrent subluxation or instability where there is persistent instability due to a sprain, incomplete ligament tear, or complete ligament tear. Id. In this case, there is no argument or medical suggestion of a ligament sprain or tear.

Alternatively, a rating may be assigned under DC 5257 for patellar instability when there is a diagnosed condition involving the patellofemoral complex with recurrent patellar instability. A 10 percent rating applies where the condition does not require a medically prescribed brace, cane, or walker; and higher ratings are available where the condition is present after surgical repair and does require a medically prescribed brace or cane or walker (20 percent), or a brace and either a cane or a walker (30 percent). Id. In this case, although the Veteran's diagnosed patellofemoral syndrome (and chondromalacia noted at times) involve the patellofemoral complex, the weight of the evidence does not support recurrent instability of either knee, or that he used a brace or crutches for this reason. 

Rather, the Veteran reported for VA treatment and at the May 2021 VA examination that he used knee braces and crutches at times due to knee pain. Moreover, he has not described a sensation of instability, such as giving way or buckling of either knee, and his attorney has not asserted that a rating is warranted for instability. Similarly, VA examinations reflect no history or current episodes of recurrent subluxation or instability (patellar or otherwise), and there are no medical findings or suggestions of instability or laxity for treatment or compensation examinations. 

Finally, there is no argument or medical suggestion of a meniscal condition or surgery (DCs 5258 and 5259); ankylosis (actual or functional equivalent, DC 5256); tibia or fibula impairment (DC 5262); or genu recurvatum (DC 5263). 

In summary, the evidence is not in at least relative equipoise for increased ratings. Although the Veteran's symptoms have varied to some extent, they have not more nearly approximated the level of a higher or separate rating at any point. Thus, there is no reasonable doubt to resolve in his favor, and the appeals are denied.

 

M. M. Celli

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Christa Wheatley

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.