Entitlement to an initial 70 percent rating, but no higher, for post-traumatic stress disorder (PTSD) with major depressive disorder (MDD) is granted.

Citation Nr: A26069902 Decision Date: 07/30/26 Archive Date: 07/30/26 DOCKET NO. 240522-442187 DATE: July 30, 2026 ORDER Entitlement to an initial 70 percent rating, but no higher, for post-traumatic stress disorder (PTSD) with major depressive disorder (MDD) is granted. Entitlement to a rating higher than 10 percent for left knee degenerative joint disease, status post anterior cruciate ligament repair (hereinafter left knee disability), is denied. Entitlement to a rating higher than 10 percent for left knee disability, limitation of extension, is denied. Entitlement to a rating higher than 10 percent for left knee instability is denied. REMANDED Entitlement to a separate rating for a meniscus condition of the left knee is remanded. FINDINGS OF FACT 1. Resolving doubt in the Veteran's favor, throughout the rating period, the Veteran's PTSD with major depressive disorder is manifested by occupational and social impairment with deficiencies in most areas, but not total social and occupational impairment. 2. Throughout the rating period, the Veteran's left knee disability has been manifested by painful motion, forward flexion to 95 degrees at worst, extension limited to 10 degrees at worst, and slight instability. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating, but no higher, for PTSD with major depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a rating higher than 10 percent for left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5260. 3. The criteria for a rating higher than 10 percent for left knee disability, limitation of extension, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 4. The criteria for a rating higher than 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Air Force National Guard of West Virginia from March 1988 to November 2012, with multiple periods of service characterized as active duty, active duty training, and inactive duty training. For his meritorious service, the Veteran was awarded (among other decorations), the Air Force Commendation Medal, the Air Force Outstanding Unit Award with Valor Device with 1 oak leaf cluster, and the Southwest Asia Service Medal with 1 service star. The Board of Veterans' Appeals (Board) thanks the Veteran for his service to our country. This matter is before the Board on appeal from a January 2024 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In the May 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. In the April 2025 decision, the Board (i) denied entitlement to a disability rating higher than 10 percent for left knee degenerative joint disease, status post anterior cruciate ligament repair (hereinafter left knee disability); (ii) granted entitlement to a separate disability rating of 10 percent, but no higher, for left knee disability (limitation of extension), from August 9, 2023; (iii) denied entitlement to a disability rating higher than 10 percent for left knee instability; (iv) denied entitlement to a disability rating higher than 10 percent for lumbosacral strain; and (v) denied entitlement to an initial disability rating higher than 50 percent for PTSD with MDD. The Veteran appealed the denial of a rating higher than 10 percent for left knee degenerative joint disease, status post anterior cruciate ligament repair (left knee disability); the denial of a rating higher than 10 percent for left knee disability (limitation of extension) from August 9, 2023; the denial of a rating higher than 10 percent for left knee instability; and the denial of an initial rating higher than 50 percent for PTSD with MDD, to the United States Court of Appeals for Veterans Claims (Court). In a February 2026 Order, pursuant to a Joint Motion for Partial Remand (JMPR) filed by the parties, the Court vacated and remanded those parts of the April 2025 decision for compliance with the instructions in the JMPR. The appeal is therefore again before the Board. The Board may only consider the evidence of record at the time of the January 2024 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 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. However, because the Board is remanding the claim of entitlement to a separate rating for a meniscus condition of the left knee, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii). 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; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. 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. 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). 1. Increased rating for PTSD with MDD. The JMPR found that the Board provided an inadequate statement of reasons or bases when it failed to adequately address several pieces of relevant evidence, which the Board has discussed below. The Veteran's PTSD with major depressive disorder is currently rated as 50 percent disabling from August 9, 2023, under Diagnostic Code 9411. Psychiatric impairment is rated under the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptom driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas," i.e., "the regulation . . . requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130. VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disorder; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 12 (2017). Factual Background The Veteran contends his PTSD with major depressive disorder warrants a higher rating. On August 9, 2023, VA received an intent to file a claim for compensation. On August 14, 2023, the Veteran submitted a fully developed claim (VA Form 21-526EZ) seeking service connection for PTSD. Therefore, the relevant period for consideration is from August 9, 2023. In a September 11, 2023, domiciliary consult note, the Licensed Clinical Social Worker (LCSW) stated, "met with patient today for his PCT intake. Additionally, since patient will be joining the CPT group next week, which will be entering the second session, writer conducted session 1 of CPT with patient today, following the intake. See the PTSD Clinical Team Note this date for details." In the September 11, 2023, PTSD clinical team assessment note, the Veteran was diagnosed with PTSD, chronic. The Veteran stated, "I feel like I'm living in a hole, everything's negative, nothing's positive. The future looks bleak. I can't stop watching the news; I literally watch the news for hours and hours a day; I'm hooked." He was currently working full-time at this VA as an emergency room (ER) nurse. He reported being married with three adult children. He was currently living with his wife and all three adult children. Social support: Wife, to some degree. The LCSW noted the Veteran's mental health history included a history of diagnosis including PTSD, chronic; "unsocialized conduct disorder, aggressive, severe"; insomnia; depression; and generalized anxiety disorder (GAD). He was currently taking duloxetine. The LCSW noted the diagnostic impressions: Veteran's chief complaint is intrusive memories. He was oriented to person, place, time, and situation. He appeared to have no audio or visual hallucinations. He did not appear to be responding to internal stimuli. He denied any suicidal ideation/homicidal ideation. He was well-groomed and dressed appropriately for the weather. On mental status exam his appearance was good. His motor activity was good. His interpersonal was good. His behavioral presentation was good. His speech was normal. His affect was good. He was oriented to person, place, time, and situation. His intellectual ability was good. His thought processes were clear. His insight and judgment were fair. In the September 11, 2023, social work note, Patient Health (Depression) Questionnaire (PHQ-9) screen was completed, and the Veteran's score of 24 was consistent with a major depressive episode. He reported being bothered by the following over the last two weeks: little interest or pleasure; feeling down, depressed or hopeless; trouble sleeping; tired, low energy; poor appetite, over-eating; feelings of failure, guilt; trouble concentrating; and motor retardation, agitation. He stated that "he sometimes wonders what it would be like to not be here, and he sometimes just plain gets tired of everyday living. However, he stated that he would never do that to his wife or kids." He stated, "the depressive symptoms make it extremely difficult to work, take care of things at home, or get along with others." A PTSD Checklist for DSM-5 (PCL-5) screen was completed, and the Veteran's score of 65 indicated a very high level of PTSD symptoms. He reported being bothered by the following over the past month: disturbing memories, disturbing dreams, re-experiencing events, cued distress, cued physical symptoms, avoiding internal reminders, avoiding external reminders, negative beliefs, blaming self/others, negative feelings, loss of interest, feeling distant from others, feeling numb, feeling irritable, being "super-alert", feeling easily startled, difficulty concentrating, and trouble sleeping. In a September 11, 2023, mental health diagnostic study note, a Columbia Suicide Severity Rating Scale (C-SSRS) screen was completed. The Veteran did not endorse suicidal ideation in the past month; no past suicidal behavior reported. In a September 25, 2023, VA mental health note, the examining physician noted the Veteran's past medical history of PTSD, depression and alcohol use disorder. On mental status exam his appearance and attitude were good. His eye contact was fair. His motor function was grossly intact. He was alert and oriented to person, place, time, and situation. His speech was normal rate, rhythm and tone. His mood was euthymic and his affect was congruent with mood. His thought processes were logical and goal directed. He denied suicidal ideation/homicidal ideation. His insight and judgment were good. The examining physician assessed "patient with alcohol use disorder, stable, on Vivitrol." In a October 11, 2023, VA psychiatry note, the Veteran stated, "everything seems to be decent." The examining physician noted the Veteran's history of PTSD, depression, and anxiety. The Veteran reported doing well, although he had not been too consistent with taking his medications. He continued to work night shifts as an ER nurse. He denied new stressors. He noted that his mood was "decent." He denied any sustained low mood, anhedonia or hopelessness. He continued his sobriety with alcohol and was still taking Vivitrol injection. On mental status exam, he was casually dressed, in no apparent distress, with good eye contact. His affect was euthymic, full range, stable, congruent with reported mood. His speech was regular rate, normal rhythm, normal volume. His thought process was linear, logical and goal directed. His thought content: no suicidal ideations, intent or plan; no homicidal ideations; no delusions evident or elicited. His perceptions: no auditory, visual or tactile hallucinations; not responding to internal stimuli. He was alert, oriented; no overt deficits in attention, memory or concentration. His insight and judgment were intact. There were no overt deficits in attention, memory or concentration. The examining physician diagnosed major depressive disorder (MDD), recurrent, moderate; chronic PTSD; generalized anxiety disorder; and alcohol use disorder, moderate in full sustained remission since February 2022. The Veteran was continued on Bupropion and Duloxetine. On October 25, 2023, the Veteran presented to the VAMC for bridge therapy. He reported ongoing lack of motivation. He just finished a week vacation without accomplishing much on his to-do list. He had a good weekend with his sons. He was back working the night shift. He remained sober. On mental status exam, he was casually dressed. He was pleasant with good sense of humor. His speech was normal tone and rate. His mood was "good." No suicidal ideation/homicidal ideation, no hopelessness or helplessness noted. His thought process was rational, linear. His thought content was normal. His insight was good. His judgment appeared good. The LCSW remarked, "patient is making progress toward goals. Continues sobriety and behavioral motivation - exercise." The LCSW noted diagnosis: PTSD, alcohol use, and depressive disorder. The Veteran submitted to a VA Initial Post Traumatic Stress Disorder (PTSD) examination in December 2023. The VA examiner diagnosed (i) PTSD and added the following comments: difficulty remaining asleep. Will use alcohol to help sleep. Frequent upsetting dreams and nightmares. Frequent intrusive thoughts. Will get worked up, sweating, heart racing. "I always think the worst." Don't like crowds. Don't go out anymore. Some avoidance behaviors. Hypervigilance. Exaggerated startle response. Acute anxiety episodes, sometimes at work. "Short fuse." Will lose his temper at times. Forgetfulness. (ii) Major depressive disorder, recurrent, moderate, and added the following comments: feels sad or down "all the time." Loss of interest in many activities (comic books). Decreased motivation for daily tasks. Social withdrawal. Tearfulness. Denies suicidal ideation. (iii) Alcohol use disorder. During the examination, the Veteran reported being married and having three adult children. He described his marital relationship as "strained." He described challenges in the relationship as his accountability and follow-through, and trust issues regarding his drinking. He did not get out socially. He described himself as "a couch surfer." He was currently employed as a nurse. He described significant interpersonal conflicts with one of his recent bosses. He was currently engaged in mental health treatment through the VA beginning in at least 2013. He was currently prescribed Wellbutrin, Trazodone, and Hydroxyzine; he was receiving Vivitrol shots. The VA examiner noted the Veteran's symptoms included depressed mood, anxiety, panic attacks, chronic sleep impairment (sleep disturbance), mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, persistent negative emotional state, markedly diminished interest or participation in significant activities, irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects, hyper-vigilance, and exaggerated startle response. The examiner observed the Veteran arrived promptly for his scheduled appointment. He presented casually dressed and appropriately groomed. He was alert and fully oriented. His speech was logical and coherent with no evidence of thought disorganization. He presented in no acute emotional distress. The examiner ultimately opined the Veteran's psychiatric impairment resulted in occupational and social impairment with reduced reliability and productivity. Analysis The Board has considered the Veteran's statements, the relevant treatment records, and the VA examination. After engaging in a "holistic analysis" that assesses the severity, frequency, and duration of the signs and symptoms of the Veteran's PTSD with major depressive disorder, the Board finds that his psychiatric disorder more closely approximates occupational and social impairment with deficiencies in most areas. See Vazquez-Claudio, 713 F.3d at 117; Mauerhan, 16 Vet. App. at 442. Therefore, an initial rating of 70 percent, but no higher, is warranted. As an initial matter, the Board presumes all psychiatric symptoms to be due to his service-connected PTSD with major depressive disorder. See Mittleider v. West, 11 Vet. App. 181 (1998). The Veteran's PTSD with major depressive disorder has been productive of such symptoms as depressed mood, anxiety, panic attacks, chronic sleep impairment (sleep disturbance), mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, obsessional rituals which interfere with routine activities, passive suicidal ideation, intrusive memories, persistent negative emotional state, markedly diminished interest or participation in significant activities, irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects, hyper-vigilance, and exaggerated startle response. The Board observes the Veteran has not endorsed all the symptoms typically associated with a 70 percent evaluation. There was no evidence showing, for example, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; and neglect of personal appearance and hygiene. Nevertheless, in assigning an evaluation, the Board is not required "to find the presence of all, most, or even some, of the enumerated symptoms." Mauerhan, 16 Vet. App. 436. However, the Board finds that the record does not support a rating higher than 70 percent for the Veteran's PTSD with major depressive disorder. The Veteran has not consistently shown any of the symptoms listed in the rating criteria for 100 percent. He has worked throughout the rating period, indicating that he does not have total occupational impairment. He also does not have total social impairment. The Veteran lives with his wife and adult children. While at one point he described the relationship with his wife as strained, he also indicated that she is a source of support. Although he does not socialize much outside the home, it appears that he spends time with his children. The Board notes that it must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead, 29 Vet. App. at 22; 38 C.F.R. § 4.130. The Board finds that the severity, frequency, and duration of the Veteran's symptoms have not risen to the level contemplated by the 100 percent disability rating. Considering the above, and given the holding in Mauerhan, the Board has resolved reasonable doubt in favor of the Veteran to conclude the service-connected post-traumatic stress disorder (PTSD) with major depressive disorder is manifested by occupational and social impairment with deficiencies in most areas. Thus, a 70 percent rating, but no higher, is warranted. 38 C.F.R. §§ 3.102, 4.130; Lynch, 21 F.4th 776. 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. § 4.40 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. 2. Increased rating for left knee disability. 3. Increased rating for left knee disability, limitation of extension. 4. Increased rating for left knee instability. The JMPR found that the Board provided an inadequate statement of reasons or bases for its determination that the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5258 or 5259. Specifically, the parties agreed that the Board failed to address the evidence documenting the Veteran's multiple partial meniscectomies and his reports of left knee symptoms following those surgeries. The Veteran's left knee degenerative joint disease, status post anterior cruciate ligament repair, is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5003-5260. The Veteran's left knee disability, limitation of extension, is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5261. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional code to identify the basis for the evaluation assigned. In this case, the hyphenated code indicates that the Veteran's left knee disability is evaluated as degenerative arthritis (other than post-traumatic) under diagnostic code 5003, and limitation of flexion under diagnostic code 5260. The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a. Under 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. Separate ratings are not precluded for limitation of motion (5003, 5260 and 5261), meniscal disability (5258 and 5259) and instability (5257). Lyles v. Shulkin, 29 Vet. App. 107 (2017). Factual Background The Veteran contends his left knee disability warrants a higher rating. On August 9, 2023, VA received an intent to file a claim for compensation. On August 14, 2023, the Veteran submitted a fully developed claim (VA Form 21-526EZ) seeking an increased rating for his service-connected left knee disability. Therefore, the relevant period for consideration is from one year prior to receipt of the intent to file a claim for compensation, from August 9, 2022. The Veteran submitted to a VA Knee and Lower Leg examination in December 2023. During the examination he reported worsening of symptoms over time. He reported pain and swelling daily. He reported crepitus and that his knee feels unstable. He reported the use of a left knee brace on and off. He denied recent evaluations. He denied flare-ups. He reported functional impairment described as increased pain with working out/sports, squatting, cutting movements, and awkward movements. He was treated with over-the-counter ibuprofen. Initial active and passive range of motion testing for left knee flexion was measured from 0 to 105 degrees, and extension was normal to 0 degrees. There was evidence of pain on active and passive motion. There was objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions. The examiner stated pain significantly limits functional ability with repeated use over time. The examiner estimated range of motion after repeated use as flexion to 95 degrees, and extension to 10 degrees. The examination was not conducted during a flare-up. There was no muscle atrophy. There was no ankylosis. There was no recurrent subluxation or persistent instability. There was no 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 no meniscus (semilunar cartilage) condition. The Veteran required occasional use of a brace due to left knee instability. Regarding functional impact, the examiner stated the Veteran's left knee disability impacted his ability to perform occupational tasks. Lastly, the examiner remarked, joint stability testing was performed for the left knee. Anterior instability, posterior instability, medial instability, and lateral instability testing were all normal. 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 range of motion, passive range of motion, as well as range of motion on repetitive use testing. The examiner provided an estimated range of motion after repetitive use. The Veteran denied experiencing flare-ups. Regarding Ingram, the December 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 worst 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. For these reasons, the Board gives the examination great probative weight. Analysis: Left Knee Disability: Diagnostic Code 5260 The Veteran's left knee degenerative joint disease, status post anterior cruciate ligament repair, is currently rated as 10 percent disabling under diagnostic codes 5003-5260. Given the totality of the evidence when considering the Veteran's competent and credible report of left knee pain and functional loss or functional impairment, the Board finds the Veteran is not entitled to a rating higher than 10 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 limitation of motion more nearly approximating flexion limited to 30 degrees. The Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, 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, less movement than normal, or interference with sitting, standing, and weight-bearing. The Veteran's left knee flexion has been limited to, at worst, 95 degrees after repeated use. Additionally, the Veteran's left knee extension has been limited to, at worst, 10 degrees after repeated use. There is no indication that the Veteran has functional loss greater than that contemplated by the 10 percent rating assigned with repeated use over time, during a flare-up, or due to pain. In reaching its conclusion, the Board acknowledges the Veteran's belief that his left knee disability is more severe than the current rating reflects. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. Therefore, given the record before it, the Board finds the most probative evidence of record persuasively weighs against the assignment of a disability rating higher than 10 percent for the service-connected left knee degenerative joint disease, status post anterior cruciate ligament repair. The benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. Analysis: Left Knee Disability: Diagnostic Code 5261: Limitation of Extension The Veteran's left knee disability, limitation of extension, is currently rated as 10 percent disabling under diagnostic code 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 rating higher than 10 percent at any time during the appeal period for left knee disability, limitation of extension, under diagnostic code 5261. 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 limitation of motion more nearly approximating extension limited to 15 degrees. 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 10 degrees of extension. In reaching its conclusion, the Board acknowledges the Veteran's belief that his left knee disability, limitation of extension, is more severe than the current rating reflects. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, 21 Vet. App. 456. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. Therefore, given the record before it, the Board finds the most probative evidence of record persuasively weighs against the assignment of a disability rating higher than 10 percent for the service-connected left knee disability, limitation of extension, for the period on appeal from August 9, 2023. The benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. Analysis: Left Knee Disability: Diagnostic Code 5257: Instability The Veteran's left knee instability is currently rated as 10 percent disabling under Diagnostic Code (DC) 5257. DC 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. § 4.71, 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 Given the totality of the evidence when considering the Veteran's competent and credible reports of left knee instability, the Board finds the Veteran is not entitled to a rating higher than 10 percent at any time during the appeal period for instability under DC 5257. During the December 2023 VA examination, the Veteran reported that his knee feels unstable. On examination, there was no recurrent subluxation or persistent instability. There was no ligament tear (sprain). There was no recurrent patellar instability. There was no recurrent patellar dislocation. He required occasional use of a brace due to left knee instability. Regarding functional impact, the examiner stated the Veteran's left knee disability impacted his ability to perform occupational tasks. Lastly, the examiner remarked, joint stability testing was performed for the left knee. Anterior instability, posterior instability, medial instability, and lateral instability testing were all normal. The VA examination and treatment records do not contain objective medical evidence of instability, but the Veteran reported that his left knee was unstable, and he required a knee brace for ambulation. He is competent to describe symptoms associated with his left knee disability, such as instability, and the Board finds him credible. However, the Board finds an increased evaluation for the Veteran's left knee instability is not warranted. There is no evidence of patellar instability, nor a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, or unrepaired or failed repair of complete ligament tear. In reaching its conclusion, the Board acknowledges the Veteran's belief that his left knee disability, instability, is more severe than the current rating reflects. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, 21 Vet. App. 456. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. Therefore, given the record before it, the Board finds the most probative evidence of record persuasively weighs against the assignment of a disability rating higher than 10 percent for the service-connected left knee disability, instability. The benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. Finally, the Veteran is not entitled to a higher or separate rating under diagnostic codes 5256, 5262, or 5263. There is no indication of ankylosis or functional equivalent thereof, impairment of tibia and fibula, or genu recurvatum. REASONS FOR REMAND Although further delay is regrettable, this claim is remanded to correct duty to assist errors that occurred prior to the January 2024 rating decision on appeal. 38 C.F.R. §§ 3.159, 20.802. 1. Entitlement to a separate rating for a meniscus condition of the left knee is remanded. As discussed above, the Veteran submitted to a VA Knee and Lower Leg examination in December 2023. During the examination he reported worsening of symptoms over time. He reported pain and swelling daily. On examination, the VA examiner noted the Veteran did not currently have, and the Veteran had not been diagnosed with, a meniscus (semilunar cartilage) condition. See Section VIII - Meniscal Conditions. The examiner noted the Veteran had not undergone any surgical procedures. See Section IX - Surgical Procedures. The Board finds the December 2023 VA examination to be inadequate because it is based on inaccurate facts. In May 1991 the Veteran underwent diagnostic arthroscopy of the left knee. In September 1994 he underwent (1) arthroscopic partial lateral meniscectomy with debridement of medial femoral condyle articular defect and (2) open anterior cruciate ligament reconstruction utilizing autogenous bone, patellar tendon-bone graft. In February 2008 he underwent (1) diagnostic and operative arthroscopy with partial medial meniscectomy and (2) partial lateral meniscectomy. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Once VA undertakes the effort to provide an examination or medical opinion when developing a service connection claim, it must provide an adequate one or, at the minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303 (2007). The failure to obtain an adequate examination is a pre-decisional duty to assist error. Thus, a remand is necessary to fulfill VA's duty to assist. 38 C.F.R. § 5103A; Barr, 21 Vet. App. 303. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician, preferably with a clinician who has not previously examined the Veteran, to obtain a retrospective opinion addressing any (i) meniscus (semilunar cartilage) condition and (ii) residual signs of symptoms due to meniscectomy, arthroscopic ligament repair or other knee surgery. The remand body above and the claims file should be provided, and the examination report must reflect that the claims file was reviewed. (a) The examiner should specifically identify/discuss any surgical procedures that the Veteran has had performed to remove the left knee meniscus cartilage. The Board notes that in May 1991 the Veteran underwent diagnostic arthroscopy of the left knee. In September 1994 he underwent (1) arthroscopic partial lateral meniscectomy with debridement of medial femoral condyle articular defect and (2) open anterior cruciate ligament reconstruction utilizing autogenous bone, patellar tendon-bone graft. In February 2008 he underwent (1) diagnostic and operative arthroscopy with partial medial meniscectomy and (2) partial lateral meniscectomy. (b) The examiner should specifically identify/discuss whether the Veteran has had a left knee meniscus (semilunar cartilage) condition at any point during the period on appeal (from August 9, 2022). (c) The examiner should specifically identify/discuss whether the Veteran has had frequent episodes of left knee locking, pain, and effusion at any point during the period on appeal (from August 9, 2022)?. 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.