Citation Nr: 0003454 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 94-19 425 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to an increased evaluation for a status post torn ligament of the right knee, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD M. L. Wright, Counsel INTRODUCTION The veteran had active service from December 1968 to December 1972, and from May 1975 to November 1988. This appeal arises from a March 1992 rating decision of the Manchester, New Hampshire, Regional Office (RO) which denied an increased evaluation for the veteran's service connected right knee disability. The RO confirmed and continued the evaluation of this disorder at 10 percent disabling. This determination was appealed by the veteran. In a rating decision of December 1996, the RO granted an increased evaluation for the right knee disorder to 20 percent disabling. The veteran continued his appeal. This case was remanded by the Board in June 1997 for development of the medical evidence. It has now returned for final appellate consideration. FINDINGS OF FACT 1. All evidence required for an equitable decision of the issue on appeal has been obtained. 2. The veteran's service-connected right knee disability is characterized by mild instability, mild quadriceps atrophy, chronic pain, weakness, fatigability, and significant limitation of motion during flare-ups without evidence of degenerative changes. CONCLUSION OF LAW An increased evaluation to 40 percent disabling, but not more, is warranted for the veteran's status post torn ligament of the right knee. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.7, 4.10, 4.14, 4.20, 4.40, 4.45, 4.68, 4.71, Code 5003, 5162, 5256, 5257, 5258, 5259, 5260, 5261, 5262, 5263 (1999). See also VAOPGCPREC 23-97. REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background. By rating decision of June 1989, the RO granted service connection for the veteran's status post torn meniscus of the right knee. This disability was evaluated under the U. S. Department of Veterans Affairs (VA) Schedule for Rating Disabilities, 38 C.F.R. Part 4, Diagnostic Code (Code) 5257 as noncompensable. The award was made effective from November 1988. In a rating decision of July 1989, the RO increased the evaluation of the veteran's right knee disability to 10 percent disabling from November 1988. This rating was confirmed and continued in a rating decision of November 1989 and a Board decision of October 1990. In December 1991, the veteran filed a claim for an increase in the evaluation of his right knee disability. VA treatment records dated from December 1988 to November 1991 were incorporated into the claims file in January 1992. These records predominately noted treatment for hearing, psychiatric, right ankle, and headache complaints. An undated prosthetic clinic record noted the veteran's complaints of instability in the right knee. He was examined and fitted for a knee brace. On examination, no ligamentous instability was found. In outpatient records of June 1990, July 1991, and October 1991, the veteran complained of right knee and ankle pain. It was noted that he continued to use a right knee brace. A private orthopedic examination of December 1991 reported the status of disorders associated with the veteran's left lower extremity. It was mentioned that the veteran had an old right knee injury. By rating decision of March 1992, the RO determined that based on the medical evidence the veteran's right knee injury was mild in nature. The 10 percent evaluation for this disorder was confirmed and continued. The veteran appealed this evaluation. At his hearing on appeal in July 1992, the veteran testified that since his retirement from the military he had been treated by the VA and by a private physician for an on-the- job injury covered under Workers' Compensation. He asserted that he had continually worn a brace on his right knee in recent years. The veteran claimed that he had started to have instability in the right knee and the VA modified his brace in order to prevent this from happening. He alleged that the nature of his right knee disorder prohibited surgical intervention to correct it. If the veteran did not use a brace on his knee, he was forced to use crutches to ambulate. The veteran contended that because he was forced to continually wear a brace on his right knee that this disorder could not be considered slight in nature. He asserted that he experienced pain and swelling in the right knee and was forced to take prescription medication to alleviate these symptoms. The veteran claimed that his right knee had a tendency to pop during flexion of the joint. He also alleged that it became weak and, at times, would feel like it was going to collapse. A VA orthopedic examination was provided to the veteran in August 1992. He complained of instability and pain in his right knee. It was noted by the examiner that the veteran used a Townsend brace on this knee to maintain stability. He asserted that there was a popping and clicking in the knee joint during ambulation. The veteran denied any problems with prolonged standing or sitting, but did complain of pain when arising or walking upstairs. On examination, the veteran walked with a slight limp on the right side. There was no evidence of swelling, erythema, or warmth. His right thigh measured 16 1/2 inches and his left measured 17 inches. His right calf measured 13 3/4 inches and his left was 14 inches. Leg lengths were equal and the examiner commented that there was no obvious deformity with the right leg. There was no tenderness about the right knee joint and all testing of this joint was negative. The right knee was noted to be stable to varus/valgus stress and anterior-posterior drawer testing. An X-ray of the right knee noted no joint space narrowing on non-weight bearing. The radiological study failed to reveal any evidence of joint swelling. The assessment was internal derangement of the right knee status post medial collateral tear. In his substantive appeal (VA Form 9) submitted in May 1993, the veteran complained that the VA examination of August 1992 had been inadequate. He asserted that this examination had been cursory and lasted only five minutes. The veteran also reported that the examiner had failed to get up-to-date X- rays of his right knee joint. A letter was received from the veteran in July 1993. He reported that his VA health providers had recently issued him a wheelchair to enhance his mobility. The veteran again contended that the VA examination of August 1992 had not been thorough in evaluating his right knee disability. At his Board hearing in March 1994, the veteran testified that he used a Townsend brace with a kneecap modification, Canadian crutches, and a wheelchair to facilitate his problems with prolonged walking. If he did not use his right knee brace, the joint would have severe swelling and instability. It was asserted by the veteran that the swelling in his right knee had increased in recent years. The veteran alleged that his right knee would become swollen at the end of each day and he self-treated it with a Jacuzzi and applied heat. He claimed that the military had determined that his right knee disorder was such that it was inoperable and he had never had surgery performed on this joint. The pain level in his right knee varied from day to day and depended on his level of activity. He asserted that the use of his knee brace lessened his knee pain. It was acknowledged by the veteran that his physicians had wanted him to go for periods of time without the use of the brace, but he did not do so because he wanted to have the functional use of his knee as long as possible. He claimed that he could only walk from five to ten feet without using the knee brace. It was acknowledged by the veteran that since leaving the military the only treatment he had received for his right knee disability had been from the VA. The veteran testified that he worked as a teacher and that his right knee disability caused him to lose approximately one day a week of work. He reported that he worked two to three days a week as a teacher in addition to attending his vocational rehabilitation courses. A VA orthopedic examination was afforded the veteran in March 1996. It was noted that the veteran wore a brace on his right knee. He claimed that when he did not wear a brace his right knee would swell and become irritated. The veteran denied any actual buckling or locking, but did complain of some unsteadiness. Range of motion studies revealed that the right knee had full extension to 125 degrees of flexion. There was no joint effusion or neurovascular deficit. However, the examiner did report mild anterior laxity in the right knee and quadriceps atrophy. The right knee X-ray noted medial distal femur epicondylitis which the radiologists opined did not usually cause knee instability. It was determined that there was no evidence of a right knee joint abnormality. The diagnosis was chronic instability of the right knee. A private orthopedic examination was obtained by the VA in August 1996. It was noted that the veteran used a brace on his right knee. He complained of persistent pain in his right knee that was aggravated by any standing or walking. The veteran denied any weakness or numbness in his legs. On examination, the veteran's leg lengths were equal with good pedal pulses. Range of motion in the right knee was from zero degree extension to 40 degrees flexion. There was no instability or swelling in the right knee. However, there was some tenderness over the medial knee and the right thigh measured 1/2 inch less then the left. A radiological study of the right knee revealed a calcified area at the adductor tubercle, but otherwise the joint was found to be unremarkable. The diagnoses included arthralgias of the right knee of undetermined cause. In December 1996, the RO issued a supplemental statement of the case (SSOC) that informed the veteran that an increased evaluation for his right knee disability had been granted to 20 percent disabling. The Board remanded this case in June 1997 for development of the medical evidence. By letter of June 1997, the RO requested that the veteran inform it of the names and addresses of the healthcare providers that had treated his right knee disability in recent years. He was notified that his failure to submit this type of evidence could have an adverse effect on his claim for an increased evaluation. In September 1997, the veteran provided this information to the RO. A VA orthopedic examination was given to the veteran in September 1997. The veteran complained of chronic pain in his right knee. It was noted that the veteran was employed on a full-time basis. On examination, range of motion in the right knee was from 20 degrees from full extension to 90 degrees flexion. It was reported by the examiner that the veteran experienced pain on the extremes of motion with crepitation noted during motion. There was 1 1/2 inch of atrophy in the right quadriceps. There was no joint effusion, neurovascular deficit, or instability found on examination. The diagnosis was chronic degenerative joint disease in the right knee. It was opined by the examiner that: The claimant does demonstrate painful motion with some weakness and fatigability of the right knee joint. These [findings] are supported by objective evidence and are consistent with the history and pathology of the disability. These do limit functional ability during flare-ups and when the joint is used repeatedly over a period of time by 20 %. In October 1997, the RO requested that the U. S. Air Force facilities identified by the veteran forward copies of his medical records. A response was received in November 1997 from the U. S. Air Force that these records were no longer in its possession and were believed to be in the possession of the veteran. VA medical records dated from March 1989 to August 1994 were associated with the claims file in November 1997. These records noted treatment for headaches, psychiatric problems, dental complaints, a hearing disorder, and various orthopedic complaints. The veteran received an orthopedic consultation in August 1993. It was noted that the veteran wore a Townsend brace on his right knee and occasionally walked with the use of Australian walkers. He complained that his right knee was very unstable. On examination, range of motion in the right knee was from zero to 100 degrees. There was no valgus or varus instability. However, Lachman, McMurray, patellar grind, and anterior drawer testing were all positive. There was no swelling or effusion in the right knee joint, but the examiner did find joint line tenderness. The assessment was right knee ACL, medial, and lateral meniscal tears. In January 1998, the veteran's private medical records dated from November 1994 to September 1996 were received by the RO. These records predominately noted treatment of the veteran's left lower extremity and low back complaints. An outpatient record of November 1994 noted that the veteran had a right knee disability that was nicely controlled by a specialized brace. It was noted that the veteran worked as a teacher and spent a significant amount of time teaching from a wheelchair. On examination, it was reported that "there are no obvious palpable abnormalities of the lower extremities." The assessment was chronic orthopedic injuries and disabilities that were stable and well-controlled. A letter from a private physician dated in February 1995 noted that the veteran's primary complaints were pain and stiffness in his back and lower left extremity. Physical examination revealed that the right knee had relatively good movement with no effusion. The impression was post-traumatic degenerative arthritis, but the examiner failed to identify which joints were involved in this finding. The RO contacted the veteran by letter in January 1998 and informed him that it had been unable to get his post-service medical records from the U. S. Air Force. It requested that the veteran directly obtain these records and submit them to the VA. He was informed that his failure to comply with this request could have an adverse effect on his claim. Another VA orthopedic examination was provided to the veteran in May 1999. The veteran acknowledged that he was able to work, but asserted that his right knee problems limited his activity. He complained of continual pain in his right knee that was worse when he was fatigued. The veteran asserted that he had some weakness, stiffness, swelling, heat, and redness in the right knee. It was alleged by the veteran that his right knee experienced occasional locking, fatigability, and lack of endurance. He claimed that his right knee would give way every two to three months. The veteran also complained of flare-ups of severe pain that occurred once a month and lasted two to three days. These flare-ups were precipitated by cold weather and activity. He reported that his right knee disorder was treated by a brace, prescribed medication, whirlpool bath, and, at times, the use of a cane. The veteran denied any history of dislocation, subluxation, or definite inflammatory arthritis. On examination, the veteran's gait was antalgic. When he walked with the use of a knee brace, the veteran listed to the right side with each step and experienced some pain in the right knee. There was 1/2 inch atrophy in the right thigh. No lateral or posterior instability was found in the right knee. Range of motion in the right knee was flexion to 120 degrees with pain starting at 110 degrees. Regarding extension of the right knee, the examiner noted that this joint was fixed at 15 degrees flexion. It was opined by the examiner that there was definite weakness of flexion and extension in the right knee. Deep tendon reflexes were equal and active. The diagnosis was medial epicondylitis of the right knee with limitation of motion, painful motion, and weakness. Attached to this examination report was a radiological study taken of the right knee in November 1998. This X-ray noted medial epicondylitis. It was opined by the examiner that: Ordinary activity such as doing his work is possible as long as he wears his right knee brace. The disability impairs the functioning in that he is unable to walk a considerable distance or do sports. Also, there is some limitation of mobility of the right knee. As described, the right knee exhibits weakened movement and excessive fatigability but no incoordination. An estimate of the additional range of motion lost is approximately 20 percent. There is limitation of flexion and the right knee is fixed in flexion at 15 degrees. The above findings could significantly limit functional ability during flare ups or when the right knee is used repeatedly over a period of time, this would be an estimate only and would be approximately 20 %. The RO issued a SSOC in May 1999 that informed the veteran that his right knee disability did not warrant an evaluation in excess of 20 percent disabling based on the schedular criteria. In a brief submitted directly to the Board in September 1999, the veteran's representative argued that the veteran was entitled to separate evaluations for his right knee disability based on the VA's General Counsel opinion, VAOPGCPREC 23-97. II. Applicable Criteria. Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1999). Separate diagnostic codes identify the various disabilities. The VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. §§ 4.1 and 4.2 (1999). Also, 38 C.F.R. § 4.10 (1999) provides that, in cases of functional impairment, evaluations must be based upon lack of usefulness of the affected part or systems, and medical examiners must furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon the person's ordinary activity. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet. App. at 594. In addition, 38 C.F.R. § 4.40 (1999) requires consideration of functional disability due to pain and weakness. As regards the joints, 38 C.F.R. § 4.45 (1999) notes that the factors of disability reside in reductions of their normal excursion of movements in different planes. The considerations include more or less movement than normal, weakened movement, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, swelling, deformity or atrophy of disuse, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. With any form of arthritis, painful motion is an important factor of the rated disability and should be carefully noted. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or mal-aligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. 38 C.F.R. § 4.59 (1999). The evaluation of the same disability or manifestations under different diagnoses is to be avoided. 38 C.F.R. § 4.14 (1999). Rather, the veteran's disability will be rated under the diagnostic code which allows the highest possible evaluation for the clinical findings shown on objective examination. However, 38 C.F.R. § 4.14 does not prevent separate evaluations for the same anatomic area under different diagnostic codes that evaluate different symptomatology. Estaban v. Brown, 6 Vet. App. 259 (1994). Based upon the principle set forth in Estaban, the VA General Counsel (GC) held that a knee disability may receive separate ratings under diagnostic codes evaluating instability (Code 5257, 5262, and 5263) and those evaluating range of motion (Codes 5003, 5256, 5260, and 5261). See VAOPGCPREC 23-97. The applicable schedular criteria are as follows: Code 5003. Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X- ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: >With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations; rate as 20 percent disabling. >With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups; rate as 10 percent disabling. * Note (1): The percentage ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Code 5256. Knee, ankylosis of: >Favorable angle in full extension, or in slight flexion between 0° and 10°; rate as 30 percent disabling. Code 5257. Knee, other impairment of: >Recurrent subluxation or lateral instability: Severe; rate as 30 percent disabling. Moderate; rate as 20 percent disabling. Slight; rate as 10 percent disabling. Code 5258. Cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint; rate as 20 percent disabling. Code 5259. Cartilage, semilunar, removal of, symptomatic; rate as 10 percent disabling. Code 5260. Leg, limitation of flexion of: >Flexion limited to 15°; rate as 30 percent disabling. >Flexion limited to 30°; rate as 20 percent disabling. >Flexion limited to 45°; rate as 10 percent disabling. >Flexion limited to 60°; rate as noncompensable. Code 5261. Leg, limitation of extension of: >Extension limited to 45°; rate as 50 percent disabling. >Extension limited to 30°; rate as 40 percent disabling. >Extension limited to 20°; rate as 30 percent disabling. >Extension limited to 15°; rate as 20 percent disabling. >Extension limited to 10°; rate as 10 percent disabling. >Extension limited to 5°; rate as noncompensable. Code 5262. Tibia and fibula, impairment of: >Nonunion of, with loose motion, requiring brace; rate as 40 percent disabling. >Malunion of: With marked knee or ankle disability; rate as 30 percent disabling. Code 5263. Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) rate as 10 percent disabling. 38 C.F.R. Part 4 (1999). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). The combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68 (1999). Normal range of motion in a knee joint is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (1999). III. Analysis. The first responsibility of a claimant is to present a well- grounded claim. 38 U.S.C.A. § 5107(a) (West 1991). A claim for an increased evaluation is well-grounded if the claimant asserts that a disorder for which service connection has been granted has worsened. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). In this case, the veteran asserted that his right knee disability is worse than evaluated, and he has thus stated a well-grounded claim. In addition, the undersigned finds that the VA has conducted all development required in this case to comport with the requirements of 38 U.S.C.A. § 5107(a). The Board's remand of June 1997 required that the RO request information from the veteran on his healthcare providers and conduct a thorough compensation examination based on the veteran's entire medical history. These actions were carried out by the RO and do not require any further development. See Stegall v. West, 11 Vet. App. 268 (1998). While the veteran identified specific U. S. Air Force hospitals as providing treatment for his right knee complaints, the only response received from these hospitals noted that the treatment records were in the veteran's possession. By letter of January 1998, the RO informed the veteran of this response and requested that he submit this evidence. There was no response to this request. The undersigned finds that the RO has fully complied with any duty to assist under 38 U.S.C.A. § 5107(a) regarding the recovery of these U. S. Air Force medical records. It is also found that the veteran has been adequately informed of the requirements for increased evaluation of his right knee disability in the statement of the case and SSOC's of recent years and the Board's remand of June 1997. As the veteran has been provided with the opportunity to present evidence and arguments on his behalf and availed himself of those opportunities, appellate review is appropriate at this time. See Robinette v. Brown, 8 Vet. App. 65 (1995); Bernard v. Brown, 4 Vet. App. 384 (1993). In accordance with the GC's opinion noted above, a veteran who evidences symptoms of restricted range of motion and instability in a knee joint with a service-connected disability can receive separate evaluations on the same joint. In order to received an additional evaluation for limitation of motion in a service-connected knee disorder, there must be objective evidence of arthritis or degenerative changes in the joint. See VAOPGCPREC 23-97. The medical evidence in the current case has been inconsistent regarding degenerative changes in the right knee joint. The private examiner of February 1995 diagnosed traumatic degenerative arthritis, but failed to identify which joints were involved. An examiner of September 1997 diagnosed degenerative joint disease in the right knee, but there are no radiological studies of record that have specifically identified degenerative joint disease in this joint. In fact, many of the right knee X-rays have found the joint space normal. However, X-rays of March 1996 and November 1998 noted epicondylitis (inflammation of adjoining tissues) on the rounded projection of the femur bone. Based on these radiological studies, there is no objective evidence that the veteran currently suffers with degenerative changes in his knee joint at the current time. Based on this objective evidence, the GC's opinion in VAOPGCPREC 23-97 would not be applicable to the current appeal and the residuals of the veteran's status post torn ligament must be evaluated under the single diagnostic code that provides the highest evaluation. Thus, there was no requirement for the RO to evaluate this claim under VAOPGCPREC 23-97 and a remand for such consideration is not appropriate at this time. Concerning the evaluation of instability in the veteran's right knee, he is currently evaluated as 20 percent disabled for his right knee instability under Code 5257. Any evaluation under Code 5262 requires malunion or nonunion of the tibia and fibula. There is no evidence of record that the veteran's service-connected knee disability has resulted in such a problem and, thus, an evaluation under Code 5262 is not warranted. It is noted that the veteran's right knee has never been found to evidence genu recurvatum and therefore is not entitled to an evaluation under Code 5263. Evaluating the instability in the veteran's right knee, the medical evidence is inconsistent on the very existence of such instability. While the veteran has consistently claimed to have instability in his right knee when not using a brace, examiners in August 1992, August 1996, September 1997, and May 1999 have not found evidence of such instability. However, objective examination in March 1996 and August 1993 did note positive findings for instability. The March 1996 examiner defined this instability as mild in nature. Reviewing this evidence in a light most favorable to the veteran, there is objective evidence that he currently has mild instability in his right knee. While the veteran has claimed that his knee disorders interfered with his employment, he acknowledged in April 1999 that he was currently employed. He also reported that he is forced to use, on occasion, crutches and even a wheelchair. However, the objective evidence indicates that the use of these appliances is more the result of his multiple nonservice- connected orthopedic disorders rather than due to his right knee. In fact, the veteran has acknowledged at his hearings in July 1992 and March 1994 that his right knee was stable while using his knee brace. This evidence indicates that an increased evaluation for the instability in his knee is not warranted under Code 5257, as the evaluation of moderate instability appears more than appropriate. While the examiners of September 1997 and May 1999 opined that flare- ups of the veteran's right knee disorder would result in a 20 percent increase in symptomatology, these findings do not appear to be associated with any instability in the right knee. This is apparent based on the fact that both examiners failed to find any instability in this joint during examination and appear to be referring to loss of motion in the joint. Under these circumstances, an increased evaluation for instability in the right knee is not warranted. Turning to the veteran's restricted motion in his right knee, as there are no degenerative changes in the right knee, a compensable evaluation is not warranted under Code 5003. As the evidence of record does not indicate dislocation or removal of knee cartilage, a compensable evaluation under Codes 5258 and 5259 is also not warranted. The veteran has claimed that any type of strenuous activity will exacerbate his pain resulting in difficulties with everyday activities. He has never claimed that this pain has resulted in fixation or ankylosis of his knee joint. The range of motion in the right knee was measured at its worst on the examination of September 1997. This examination found right knee motion from 20 degrees to 90 degrees with a 20 percent loss during flare-ups of symptomatology. It appears that any limitation of motion due to pain, fatigability, or weakness was included in this estimate. Therefore, the objective medical opinion indicates that range of motion would be limited to approximately 30 degrees extension to 80 degrees flexion. This estimate is consistent with the May 1999 examiner's range of motion findings of extension limited to 15 degrees and flexion limited to 110 degrees with a 20 percent decrease during flare-ups. Under Code 5260, limitation of flexion at 80 degrees would not entitle the veteran to a compensable evaluation. However, limitation of extension at 30 degrees would entitle the veteran to an evaluation of 40 percent disabling under Code 5261. Based on the above analysis, the veteran's right knee disability is characterized by mild instability, mild quadricep atrophy, chronic pain, weakness, fatigability, and significant limitation of motion during flare-ups without evidence of degenerative changes. Resolving reasonable doubt in the veteran's favor, this degree of symptomatology more nearly approximates the criteria for a 40 percent evaluation under Code 5261. 38 C.F.R. § 4.7 (1999). Therefore, the evidence supports the grant of an increased evaluation for the veteran's service-connected right knee disability. ORDER An increased evaluation to 40 percent disabling, but not more, for status post torn ligament of the right knee is granted; subject to the applicable criteria pertaining to the payment of veterans' benefits. D. C. Spickler Member, Board of Veterans' Appeals