A disability rating in excess of 10 percent for left patellofemoral pain syndrome with degenerative arthritis (left knee disorder) is denied.

Citation Nr: 26001385 Decision Date: 01/30/26 Archive Date: 01/30/26 DOCKET NO. 20-02 218 DATE: January 30, 2026 ORDER A disability rating in excess of 10 percent for left patellofemoral pain syndrome with degenerative arthritis (left knee disorder) is denied. REMANDED The issue of entitlement to a total disability rating due to unemployability (TDIU) is remanded. FINDING OF FACT The Veteran's left knee has been manifested by flexion greater than 45 degrees, when considering pain and functional impairment. CONCLUSION OF LAW The criteria for a disability rating in excess of 10 percent for a left knee disorder are not met. 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.71a, Diagnostic Code (DC) 5260. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 2004 to June 2010. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in August 2023 and September 2024. In September 2024, the Board denied entitlement to a disability rating in excess of 10 percent for a left knee disorder. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (the Court). In June 2025, while the matter was pending before the Court, the Veteran's attorney and a representative of VA's Office of General Counsel filed a Joint Motion for Partial Remand. In an Order issued in July 2025, the Court vacated the Board's decision and remanded the matter for actions consistent with the Joint Motion. The Court noted that the issue of entitlement to a TDIU was not before them as it had been remanded by the Board in the September 2024 decision. Additional VA treatment records were associated with the claims file following the September 2024 Board decision. Upon review, however, these records are not relevant and are duplicative of evidence already contained in the claims file and considered by the RO. As will be discussed below, the Veteran's claim is being denied for reasons unrelated to the information contained in these records. Accordingly, the recently received records do not have any bearing on the issues decided in this decision and a waiver of regional office consideration is not necessary. Joint Motion In the Joint Motion, the parties agreed that the Board erred when it failed to provide an adequate statement of reasons or bases for the finding "that the evidence of record does not approximate the criteria for a higher rating because Appellant still maintained flexion and extension greater than required by the rating criteria for increased or separate ratings." The motion pointed to potentially favorable evidence that was not addressed in its determination of benefits. The Court stated that the Board did not address "evidence from the January 2024 VA Examination that Appellant experienced functional loss in the form of difficulty standing or walking for prolonged periods upon weight-bearing, active range of motion (ROM) and passive ROM." The Board is aware of the Court's instructions in Fletcher v. Derwinski, 1 Vet. App. 394 (1991), to the effect that a remand by the Court is not "merely for the purposes of rewriting the opinion so that it will superficially comply with the 'reasons or bases' requirement of 38 U.S.C. § 7104(d)(1). A remand is meant to entail a critical examination of the justification for the decision." The Board's analysis of the Veteran's claim has been undertaken with that obligation in mind. Disability Ratings The Veteran seeks a higher rating for his left knee disorder. He is currently assigned a 10 percent rating under DC 5003-5260, the minimum compensable rating for painful motion of the knee. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, the Veteran was compensated for limitation of flexion (DC 5260) due to degenerative arthritis (DC 5003). For the reasons set forth below, the Board concludes that the Veteran's symptoms did not cause the level of impairment required for an increased disability rating. Rating criteria Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. VA is responsible for determining whether the evidence persuasively favors the claim or is in approximate balance, with the Veteran prevailing in either event, or whether the evidence persuasively weighs against the claim, in which case the claim is denied. In other words, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (2021). 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. 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. 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."). Further, although pain may cause a functional loss, pain itself does not constitute functional loss. Under 38 C.F.R. § 4.59, at least the minimum compensable rating is warranted for actually painful, unstable, or malaligned joints. The plain language of § 4.59 indicates that it is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is being evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016) (holding that the criteria of 38 C.F.R. § 4.59 applies in foot disabilities involving pain such as Diagnostic Code 5280). The provisions of 38 C.F.R. § 4.49 relating to painful motion are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. DC 5260 provides disability ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees warrants a noncompensable rating. Flexion of the leg limited to 45 degrees warrants a 10 percent rating. Flexion of the leg limited to 30 degrees warrants a 20 percent rating. Flexion of the leg limited to 15 degrees warrants a 30 percent rating. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, DC 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). The rating criteria for the knee also contemplate limitation of extension under DC 5261. Extension of the leg limited to 5 degrees warrants a 0 percent rating. Extension of the leg limited to 10 degrees warrants a 10 percent rating. Extension of the leg limited to 15 degrees warrants a 20 percent rating. Extension of the leg limited to 20 degrees warrants a 30 percent rating. Extension of the leg limited to 30 degrees warrants a 40 percent rating. Extension of the leg limited to 45 degrees warrants a 50 percent rating. Other diagnostic codes relating to the knee are DC 5256 for ankylosis, DC 5257 for recurrent subluxation or lateral instability and patellar instability, DC 5258 and 5259 for symptomatic dislocation or removal of semilunar cartilage, DC 5262 for impairment of tibia and fibula, and DC 5263 for genu recurvatum. As these conditions or the functional equivalent of, are not shown on examination of the Veteran, or in the medical evidence of record, the Board finds that application of these diagnostic codes is not warranted. 38 C.F.R. § 4.71a. The rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including DC 5257 and 5262, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board considered the old version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board considered both the old and amended version (amended code) of the diagnostic code and rated based on whichever was most favorable to the Veteran. However, there is no objective or subjective evidence to support application of these diagnostic codes. English v. Wilkie, 30 Vet. App. 347, 352 (2018). Rating Upon examination in August 2018, the Veteran reported flare-ups when climbing. Active range of motion testing revealed normal motion (0 to 140 degrees from extension to flexion). The Veteran was able to perform repetitive use testing with at least three repetitions without any additional functional loss. The examiner reported that pain, weakness, fatiguability, or incoordination would not significantly limit functional ability after repeated use or during flare-ups. The examination was negative for ankylosis, recurrent subluxation or lateral instability, symptomatic dislocation or removal of semilunar cartilage, impairment of tibia and fibula, and genu recurvatum. Muscle strength was normal on flexion and extension, and joint stability test results were normal in all respects. In February 2019, the Veteran stated that his left knee would swell with prolonged standing or during activity and his pain would increase to 8 or 9 (out of 10) during flare ups. In December 2023, the Veteran reported that his left knee would swell up and did not "move well" after prolonged walking. Upon examination in January 2024, the Veteran reported flare-ups in his left knee lasting one to seven days, described as pressure pain, precipitated by running, hiking, walking, and standing, which was alleviated with rest. The Veteran reported that he had difficulty walking and standing for prolonged periods, which the examiner evidenced as pain on weight-bearing activity, as well as active and passive motion. Active and passive range of motion testing revealed pain on flexion to 125 degrees and extension to zero degrees. The Veteran was able to perform repetitive use testing with at least three repetitions without additional loss in range of motion. The examiner estimated range of motion would be 120 at flexion and zero degrees at extension during flare-ups. The Board finds that a disability rating in excess of 10 percent is not warranted for the left knee. Range of motion testing was normal for extension and at worst 120 degrees to flexion. Upon examination, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed by the examiners, to include testing for pain and testing to reveal any additional functional limitations in certain circumstances, such as after repetitive use. The Veteran reported pain when climbing and difficulty walking and standing after prolonged periods. While given the opportunity to describe functional limitation related to the disability, the Veteran's statements do not show the requisite limitation of motion necessary for a higher or separate rating. The Board recognizes that the August 2018 examiner stated that pain would not significantly limit functional ability but did not provide an estimated range of motion in degrees for the joint during a flare-up. However, in January 2024, the Veteran reported flare-ups that were more painful and more frequent then his earlier 2018 reports, thereby indicating a worsening. The January 2024 examiner considered the Veteran's reports and conducted relevant physical examination and observation and determined that estimated range of motion during flare-up would be at worst 120 degrees of flexion with no change in extension. Thus, the Board finds that the range of motion findings on the January 2024 examination report depicts the estimated range of motion during a flare-up and after repeated use. Treatment records do not show greater limitation of motion than the examination findings. In March 2023, the Veteran reported that he continued to enjoy climbing and sky diving and in July 2024, the Veteran reported that his knee pain was stable. As shown, a higher or separate rating is not warranted based on limitation of motion. 38 C.F.R. § 4.71a, DCs 5260, 5261. The evidence does not demonstrate left knee flexion limited to 45 degrees or extension limited to 10 degrees, which is the level of impairment necessary for a compensable rating under DC 5260 or DC 5261 based on limitation of motion. When the limitation of motion under the appropriate diagnostic codes for the specific join or joints involved is noncompensable under the appropriate diagnostic codes, as is the case here, a rating of 10 percent is for application. 38 C.F.R. § 4.71a, DC 5003. The Board has considered whether a separate rating may be assigned under other DCs pertaining to the knee. The relevant DCs are DC 5256 for ankylosis of the knee, DC 5257 recurrent subluxation or instability and patellar instability, DC 5258 for dislocation of the semilunar cartilage (meniscus), DC 5259 symptomatic removal of the semilunar cartilage, DC 5261 for limitation of extension of the leg, DC 5262 for impairment of the tibia and fibula, and DC 5263 genu recurvatum. There is no evidence of record (either objective findings or subjective reports) suggesting these impairments, or the functional equivalents thereof. Thus, separate ratings under DC 5256, 5257, 5258, 5259, 5261, 5262, and 5263 may not be assigned. As discussed above, the Board made the same finding in September 2024. The joint motion stated that the Board failed to provide an adequate statement of reasons or bases for this finding. The parties noted that the Board reasoned that the evidence did not approximate the criteria for a higher rating because the Veteran still maintained flexion and extension greater than required by the criteria for an increased or separate rating. The parties agreed that the Board failed to address favorable evidence from the January 2024 VA examination that the Veteran experienced functional loss in the form of difficulty standing or walking for prolonged periods upon weight bearing, and active and passive range of motion. As noted in the September 2024 Board decision and above, the Board recognizes the Veteran's assertions regarding his functional loss. With respect to the Veteran's left knee disorder, in September 2024, the Board mentioned the Veteran's assertions that he has difficulty and pain associated with "walking" four times and "standing" three. In September 2024, the Board also stated "[i]n a January 2024 VA examination, the Veteran reported flare ups occurring three times weekly lasting 1-7 days resulting in pressure pain of 9 on a scale of 10, caused by running, hiking, walking, or standing. He had functional loss resulting in difficulty walking and standing for prolonged periods." In the sentence prior to the finding that the Veteran "still maintained flexion and extension greater than required by the rating criteria for increased or separate ratings" the Board wrote: "even taking into account the Veteran's reports, repetitive use, and flare-ups, the evidence does not show that he more nearly approximates the criteria for higher ratings." Emphasis added. When the paragraph is read as a whole, it appears that an implicit finding that the Veteran's statements, to include those made at examination, were considered. In any event, to avoid further misunderstanding, as stated above, the Board finds the January 2024 examiner's estimated loss in range of motion to be an accurate depiction of the estimated range of motion during a flare-up and after repeated use. Notably, treatment records demonstrate the Veteran subsequently reported that his knee pain was stable and he continued to participate in physical activity (such as climbing and sky diving). To the extent the Veteran's attorney argues that the examination is inadequate because the examiner failed "to cite and discuss the evidence used to reach" their conclusions, the Board finds no merit in this argument. There is no reasons or bases requirement imposed on examiners Acevedo v. Shinseki, 25 Vet. App. 286 (2010). Examiner reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion; Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). The Board finds that the January 2024 examiner fully documented the Veteran's description of his flare-ups and functional impairments, performed appropriate testing, and reported their observations and made findings accordingly. To the extent the Veteran, through his attorney, asserted that the examination is internally inconsistent, the Board disagrees. It appears the attorney found section 2C and 3C to be the same question, which they are not. Section 2C asks if the Veteran reports having any functional loss or functional impairment of the joint being evaluated, including, but not limited to, after repeated use over time. The examiner responded in the affirmative to this question and documented the Veteran's description of functional loss and functional impairment (in his own words) as "difficulty walking and standing for prolonged periods." Section 3C asks if the Veteran is being examined after repeated use over time and whether the procured evidence (statements from the Veteran) "suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time." The examiner responded in the negative to both questions in section 3C. The Board does not find the 2C and 3C responses contradictory. Section 2C requests information regarding the Veteran's report of functional impairment, including after repeated use over time. A positive response in section 2C does not require a positive response in 3C, as suggested by the Veteran's argument. Rather, section 2C is a general question about all functional impairment, to include but not limited to repeated use over time. A positive response in section 2C does not dictate a positive finding in 3C. Section 2C is a broad question, and section 3C is a narrower question related to repeated use. Thus, the Board does not find the examination internally inconsistent. A consistent reading of the responses is that the Veteran's functional limitation included difficulty walking and standing, but that repeated use over time did not significantly limit functional ability beyond the impairment reported by the Veteran in section 2C. In sum, the Veteran does not present with sufficient limitation of flexion or extension to warrant a compensable rating based on range of motion. However, as there was evidence of painful motion resulting in some limitation of motion, the Board finds that a 10 percent rating is warranted. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Because his reported pain is already contemplated under DC 5260, entitlement to a separate rating for painful motion under DC 5261 is not warranted. Accordingly, entitlement to a disability rating in excess of 10 percent for a left knee patellofemoral pain syndrome with degenerative arthritis is denied. In denying the claim, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND In September 2024, the Board directed the Agency of Original Jurisdiction (AOJ) to, after development of the Veteran's claims for entitlement to service connection for bilateral wrist disorders, readjudicate the issue of entitlement to a TDIU, finding that the issues were inextricably intertwine. In March 2025, a supplemental statement of the case for TDIU was issued. However, the issue of entitlement to service connection for bilateral wrist disorders was still being developed. Notably, VA opinions were obtained in July 2025. As noted in a subsequent March 2025 Board decision, the issue of TDIU had not been re-certified to the Board. In this instance, the AOJ did not follow the September 2024 Board directive and adjudicated the issue of TDIU before the development of the wrist claims were complete, and evidence was added to the claims file. As evidence was associated with the file prior to certification of the appeal to the Board, the issue must be remanded for the issuance of a Supplemental Statement of the Case (SSOC). 38 C.F.R. § 19.31(b)(1). In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. The matter is REMANDED for the following action: 1. Readjudicate the claim on appeal upon consideration of the additional evidence associated with the Veteran's claims file after the March 2025 Supplemental Statement of the Case (SSOC). (continued on the next page) ? Send the Veteran and his representative an SSOC that addresses the issue on appeal. The Veteran and his representative should be given an appropriate time to respond before the appeal is returned to the Board for further appellate consideration. Thomas L. English Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Palatt, E V. 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.