Citation Nr: 0006018 Decision Date: 03/07/00 Archive Date: 03/14/00 DOCKET NO. 96-42 011 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES Entitlement to an increased evaluation for retropatellar arthralgia and ligament laxity of the right knee, currently evaluated as 20 percent disabling. Entitlement to a rating in excess of 20 percent for retropatellar arthralgia and ligament laxity of the left knee. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Marisa Kim, Associate Counsel INTRODUCTION The veteran had active military service from June 1991 to March 1994. This appeal is before the Board of Veterans' Appeals (Board) from rating decisions from the Oakland, California, Department of Veterans Affairs (VA) Regional Office (RO). The April 1996 rating decision continued the 10 percent rating for retropatellar arthralgia and ligament laxity of the right knee and granted service connection for retropatellar arthralgia and ligament laxity of the left knee as 10 percent disabling. The Board remanded this case in December 1997 to obtain additional medical and vocational rehabilitation records and an additional VA examination. The November 1999 rating decision increased the rating for retropatellar arthralgia and ligament laxity of the right knee from 10 percent to 20 percent and the rating for retropatellar arthralgia and ligament laxity of the left knee from 10 percent to 20 percent. This matter is now before the Board for final appellate review. FINDINGS OF FACT 1. The medical evidence with respect to the bilateral knees shows moderately lateral instability; functional loss and pain; crepitation; swelling; diminishment of strength, speed, and coordination; disturbance of locomotion; and interference with sitting, standing, and weight-bearing. 2. The veteran's knee disabilities preclude him from working in occupations that require squatting, heavy lifting, repetitive climbing, standing and walking for extended periods, operation of heavy equipment, and utilization of clutch vehicles for extended periods. 3. The veteran is able to flex his right knee to about 104 degrees and extend his right knee to about 12 degrees. 4. The veteran is able to flex his left knee to about 85 degrees and extend his left knee to about 24 degrees. CONCLUSIONS OF LAW 1. The criteria are not met for an increased rating for retropatellar arthralgia and ligament laxity of the right knee, currently evaluated as 20 percent disabling. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes 5257, 5258, 5259, 5260, and 5261 (1999). 2. The criteria are met for a rating of 30 percent for retropatellar arthralgia and ligament laxity of the left knee. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes 5257, 5260, and 5261 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background The discharge report of medical history stated that the veteran had right knee problems since July 1991, secondary to knee strain, diagnosed as patello-femoral syndrome in November 1991, and right arthroscopic knee surgery in May 1992. The veteran also reported tenderness of the left knee in August 1991. The October 1991 x-rays of the bilateral knees showed no significant bone or joint abnormality in either knee. In November 1991, the examiner instructed the veteran to avoid such activities as dancing, bowling, roller skating, prolonged walking/standing, or other strenuous activity during nontraining periods. In December 1991, the left knee was tender to palpitation medially, and the veteran had mild to moderate pain with squatting or walking. There was no effusion. In a 1992 medical history, the veteran reported painful, stiff, and swollen/red joints, and difficulty walking. The left knee was tender but had full range of motion in February 1993. The veteran underwent a VA examination in April 1995, at which time it was reported that two years earlier the veteran underwent arthroscopy of the right knee and reportedly had debridement of loose tissue. There was no history of inflammatory arthritis involving either knee. The veteran complained of an aching pain in the knees bilaterally, worse with prolonged sitting. He recently had to quit his job as a truck driver due to recurrent knee pain. Examination revealed that the right knee was cool without warmth or effusion. There was a full range of motion. There was slight crepitus of the right knee with extremes of flexion. The medial collateral ligament (MCL) and lateral collateral ligament (LCL) showed no laxity, and the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were intact. The patellar inhibition test was negative. The McMurray's test was positive. The left knee was cool without effusion. There was full painless range of motion. There was no ligamentous laxity. ACL and PCL were intact, and patellar inhibition test was negative. The impression included a history of right knee internal derangement with arthroscopic surgery and left knee arthralgia. X-rays of the bilateral knees demonstrated no evidence of recent fracture, dislocation, or other bone or suprapatellar effusion or other soft tissue abnormality. There was no degenerative joint disease. The impression was a negative examination. In July 1995, the veteran reported pain and giving out of his knees since 1991. The July 1995 x-rays of the bilateral knees demonstrated the soft tissues, bony structures of the knee joint to be well maintained bilaterally. The impression was no bone or joint abnormality noted. The July 1995 magnetic resonance imaging (MRI) demonstrated that there was no cartilaginous abnormality. The ligaments were intact, and no other significant finding was demonstrated. The impression was that no significant finding was revealed. The August 1995 assessment was knee pain. The September 1995 assessment was a chronic reinjured left knee, possible overuse syndrome or tendonitis joint laxity of both feet. At the September 1995 consultation a week later, the veteran reported onset of intermittent swelling and stiffness of the bilateral knees 4 years ago that caused him to quit work as a long distance truck driver. The assessment was likely arthralgia or arthritis. The veteran underwent a VA examination in April 1996 for postoperative chondromalacia patellae of the right knee and patellofemoral pain syndrome of the left knee. The veteran reported symptoms of pain, greater in the left than the right, particularly on squatting, going up and down stairs, or with prolonged standing or sitting. He took Piroxicam and Flexeril for these conditions. His knees occasionally gave out, and he wore Velcro and plastic knee supports occasionally. There was no locking, swelling, stiffness, or decreased range of motion. Physical examination of the lower extremities revealed thigh circumference of 39 cm on the right and 40 cm on the left and calf circumference of 36 cm on the right and 36-1/2 cm on the left. Examination of the knees showed no tenderness, swelling, or deformity. The patella was normal in position and mobility bilaterally and was nontender on the right and mildly tender on the left. There was mild laxity of the MCL and LCL bilaterally. Both knees had full extension, and both knees could flex to 140 degrees without pain or crepitus. The diagnosis was status postoperative right knee with retropatellar arthralgia and ligament laxity and left knee retropatellar arthralgia and ligament laxity. The July 1996 progress note stated that the veteran had patellofemoral symptoms for 5 years. The patella was shaved by arthroscopy in 1992 and improved for a few months. Now, it was worsening. Symptoms were aggravated by stairs and associated instability. Examination revealed moderate crepitus of the patellofemoral joint. There was no increase in the intra-articular fluid. Ligaments were intact. The impression was patellofemoral syndrome postoperative. In the July 1996 notice of disagreement and the September 1996 appeal, the veteran alleged that his knee condition caused pain and discomfort that had increased in frequency and severity. He alleged that the constant pain and pressure in his knees affected his gait and severely limited his ability to work. The veteran alleged that his bilateral knee condition prevented him from stooping, squatting, bending, or lifting anything more than 10 pounds. There were times that he could not walk even a block because of the intensity and severity of pain in his knees. The January 1997 progress note stated that the veteran's patellofemoral symptoms were becoming progressively worse. Examination was unchanged, and the impression was patellofemoral syndrome. The veteran, assisted by his representative, provided sworn testimony at a hearing on April 1997. The veteran wore knee braces whenever he walked long distances or participated in strenuous activities. He testified that his VA examiner told him that there was no real cure other than pain medication. He could only work half a day because he took pain medication. His knees had swelling almost every night unless he drove a truck in his job. He had to put ice on his knees to get to sleep at night. Transcript (April 1997), page 2. If he started work at 9 a.m., by 1 or 2 p.m., he had to go home and ice his knees because they started to swell. Transcript (April 1997), page 3. The veteran testified that his knees were unstable at times. The pain was so sharp that he could have dropped . When he worked 12-14 hours days, he would go home and could not walk. He testified that each knee gave out once in 1995 or 1996. He drove a truck for a company, and his left clutch leg gave out. Another time, he had been swimming, and he dropped on the ground while walking back to the house. Transcript (April 1997), page 4. The veteran underwent a VA vocational rehabilitation assessment in June 1997. He was currently employed as a Maintenance Worker II with a county public works department. The veteran reported that this employment was contraindicated to his service-connected disability because his work required him to operate heavy equipment and manually work on roadways shoveling tar, patching, and using tools such as shovels, picks, concrete saws, and other heavy equipment. He reported that he had to put ice on his knees to reduce swelling after work on many days. Prior to this employment, from February 1996 to January 1997, the veteran was employed with a trucking company as a truck driver. He was also responsible for welding and maintenance work. Again, the veteran reported that this was contraindicated to his service- connected disability but more tolerable than his current job. He was laid off from this employment in January 1997 due to the 1997 floods. Prior to this employment, the veteran worked for another trucking company driving long-haul trucks. However, operation of the truck for such extended periods was too difficult on his knees, and he terminated his employment. The counselor stated that the veteran was currently employed in an occupation that was contraindicated to his service- connected disability, solely for the purpose of financially supporting his daughter. The counselor opined that the veteran should be precluded from heavy lifting, carrying, squatting, and general physical labor due to his service- connected disability of bilateral knees. The counselor opined that the veteran's service-connected disability, including bilateral knee disabilities, had limited his employability in the private sector to that of employment in a light to medium occupation. The counselor opined that the veteran's disability presented functional limitations that interfered with employment potential. For example, the veteran had difficulty bending at the knees, squatting, repetitive climbing, standing and walking on concrete for extended periods, operation of heavy equipment, and utilization of a vehicle clutch for extended periods of time. The veteran reported that his condition was stable and that no surgery was indicated. He went to the VA outpatient clinic every 6 months for follow up examinations. There was no current active treatment for his knee condition aside from monitoring. The counselor opined that the veteran's disability was currently not severe in terms of his ability to maintain employment although his disability precluded him from fully utilizing his skills learned in the military, including that of an aerospace ground equipment mechanic. The veteran was able to contribute the following areas of knowledge to his vocational goal: inventory control, shipping and receiving, supervising, instructing, and some limited computer skills. The counselor foresaw no negative employer attitudes toward the veteran's disability because there were no overt signs of disability, and the veteran presented himself well and had good verbal skills. The July 1997 progress note stated that the veteran's knees continued to be painful, right more severe than the left, with arthroscopy in 1992 and temporary improvement on the left. The examination revealed moderate crepitus with no increase in the intra-articular fluid, and the impression was patellofemoral syndrome. A private physician examined the veteran in April 1998. The veteran was currently a student who did not participate in athletics. The veteran reported knee pain, left worse than the right mostly around the patellae and some around the medial joint lines. He had no recurrent dislocations but sometimes he felt a subluxation episode. His knee occasionally nearly gave way. This happened on both sides sporadically. He had no locking. Physical examination of the left knee, the worse knee, was ligamentaously stable with a negative bound test and no effusion. The veteran had 3+ medial and lateral facet patella tenderness directly at approximately the middle level of the patella and 1+ inferior pole tenderness. There was a mildly positive apprehension sign. The veteran started to guard if the examiner attempted to sublux the patella laterally. The veteran also had 2+ medial joint line and medial patellar retinaculum tenderness. The McMurray's examination produced on valgus testing some medial and lateral pain but no click. The lateral pain was more posterolateral. The right knee examination was almost identical, with the only difference being slightly less medial joint line tenderness than there was on the left and slightly less lateral facet patellar tenderness. There was identical medial facet patellar tenderness. There was also a mildly positive apprehension sign. X-rays taken today looked essentially normal but the sunrise views suggested a very mild degree of lateral tilt of both patellae. The assessment was bilateral patellofemoral pain syndrome. The examiner advised the veteran to avoid high impact activities, particularly running, squatting, or kneeling. The examiner opined that the veteran might eventually require arthroscopic surgery. The same private physician examined the veteran in May 1998. The veteran had some episodes of giving way in his knees in the past several weeks. The brief reexamination was fairly identical to the previous examination. The veteran had a very positive apprehension sign in both knees with attempted lateral subluxation of the patellae. Both patella were circumferentially tender with 3+ medial and lateral facet patellar tenderness and 1+ inferior pole tenderness. There was some retropatellar crepitus with lateral rocking or subluxation attempts. The assessment was bilateral patellofemoral pain syndrome, slightly worse on the left than the right. The veteran underwent a VA examination in June 1998. The veteran reported that he continued to have pain in the left knee that he described as an aching discomfort behind the kneecaps. The knees sometimes felt unstable but did not collapse. There was no report of discrete flares of activity, and the pain seemed to be fairly constant. The veteran required a brace on the left knee. In the past, he had taken Piroxicam and Flexeril as needed for pain. On inspection, the knees were cool without effusion. On palpation, they had no warmth or bulge sign to indicate effusion presence. Both knees had full range of motion. The thigh was without atrophy on either side with 44-cm circumference on the right and 45 cm on the left. Calves had 35 cm. Circumference bilaterally. Patellar inhibition test was positive bilaterally with the veteran complaining of pain. There was no patellofemoral crepitus, and the patellae seemed to track appropriately. The right knee had minimal MCL laxity. No other ligamentous laxity was appreciated by the Lachman's test. The McMurray's test was negative. The left knee had moderate MCL laxity. No other ligamentous laxity was appreciated by the Lachman's test or McMurray's test. Neurological examination revealed that the veteran's gait was unremarkable, and the deep tendon reflexes were 2+ and symmetric. The impression was retropatellar arthralgia with ligamentous laxity of the bilateral knees and left knee status post arthroscopy. In response to the Board remand questions, the residuals of the retropatellar arthralgia and ligamentous laxity were chronic pain to the knees and mild instability as described above. The range of motion was within normal limits without pain. Symptoms included pain with prolonged standing. Functional impairment was such that the veteran was unsuited for a job that required prolonged walking or repetitive squatting. The problem resulted in diminishment of excursion, strength, speed, coordination, and endurance with prolonged standing. The examiner opined that this represented 10 percent diminishment. There were no discrete flares of disease activity. Rather, the veteran had chronic pain with prolonged standing experienced on a daily basis. This was not inflammatory arthritis where you have flares of disease activity with swollen, painful joints. The pain was not visibly manifested on movement of the joints. There was no evidence of disease atrophy. In summary, the examiner opined that the veteran had what he estimated to be mild pain with a slight increase in pain with prolonged standing estimated at about 10 percent with associated 10 percent diminishment of excursion, strength, speed, coordination, and endurance. X-rays of the bilateral knees demonstrated no evidence of recent fracture, dislocation, or other bone or joint abnormality to either knee. There was no evidence of suprapatellar effusion or other soft tissues abnormality. There was no degenerative joint disease. The impression was a negative examination of both knees. The veteran's June 1998 statement alleged that he was scheduled for surgery on his right knee in July 1998. The record does not show that this surgery actually took place. In July 1998, a VA examiner prescribed bilateral knee braces with hinged bars and patella cut outs for stability of both knees. The veteran's September 1998 statement alleged that was now wearing knee braces with metal hinges. He alleged that his VA doctor told him that he would have to wear the braces for the next 5 years. In May 1999, the veteran applied for a clothing allowance because he wore bilateral metal hinged knee braces with patella cutouts. The veteran underwent a VA examination in June 1999 that the examiner further clarified in a September 1999 addendum. The veteran was a truck driver, and he was undergoing a VA work- study program. The veteran reported that his knees bothered him all of the time. In 1992, the veteran underwent a right knee arthroscopy in Holland, which reduced symptoms of pain, swelling, stiffness, and clicking for 8-10 months. During that time, the veteran depended on his right knee, and these symptoms tended to flare up. Over the last 2 years, he had increased instability in both knees, difficulty climbing stairs, bending, stopping, and experienced sequelae of those actions with any kind of overuse. Within the last year, he was given bilateral knee braces for instability of his ligaments. This increased the stability of his bilateral joints but also increased the pain because the veteran tended to overuse the braces. The veteran went to orthopedics every 6 months and used nonsteroidal anti-inflammatory medication for his pain and inflammation. His September 1998 MRI was essentially negative. Today and most recently, the veteran woke up with morning stiffness and swelling. The symptoms increased significantly if he overused his knees so that he could not participate in daily activities. He reported that he could only do 30-40 percent of what he could do 2 years ago. He moved from an upstairs apartment to a ground floor apartment because he could not climb stairs without increased pain, stiffness, or swelling. He tried riding a bicycle and swimming but both activities increased his symptoms. Physical examination revealed that the quadriceps size of his right thigh was 39 cm and of his left thigh was 38.5 cm. With respect to range of motion of the left knee, the knee was in a 20-degree flexion posture secondary to the veteran's inability to relax his quadriceps muscles. He flexed to 105 degrees. There was no intra or periarticular fluid. There was tenderness about the patella and with any kind of patellar movement. The MCL medial and collateral ligaments were loose. Likewise, the ACL was loose. On the right knee, he was in a flexion contracture or posture of 10 degrees for extension and his flexion was 110 degrees. He again had relaxation of his MCL and LCL, and his ACL was also loose. There was no fluid within the right knee intra-articularly or periarticularly. There was tenderness of the patellar movement. The examination was very limited secondary to the veteran's resistance with any kind of range of motion. The veteran restricted both knees, and the examiner felt significant crepitus and popping of the patellae when he tested the range of motion of both knees. The assessment was less than optimal examination secondary to the veteran's discomfort and bilateral patellofemoral syndrome with relaxation of bilateral ACL, MCL, and LCL. The examiner opined that the veteran would meet a DeLuca factor of 20 percent. In September 1999, the June 1999 examiner stated that ligament stability described as "relaxed", "loose", and "flaccid" equated to "slight", "moderate", and "severe", respectively. Therefore, as described on the June 1999 examination report, the loose left knee MCL, LCL, and ACL were moderately unstable; the relaxed right knee MCL and LCL were slightly unstable; and the loose right knee ACL was moderately unstable. Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (1999). The percentage ratings contained in the 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 the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Recurrent subluxation or lateral instability of the knee is entitled to a rating of 10 percent for slight impairment, 20 percent for moderate impairment, and 30 percent for severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1999). Dislocated semilunar cartilage, with frequent episodes of "locking", pain, and effusion into the joint is entitled to a rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5258 (1999). Removal of symptomatic semilunar cartilage is entitled to a rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5259 (1999). Limitation of the flexion of the leg to 60 degrees is entitled to a noncompensable evaluation. Flexion limited to 45 degrees is entitled to a 10 percent rating, flexion limited to 30 degrees to a 20 percent rating, and flexion limited to 15 degrees to a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (1999). Limitation of the extension of the leg to 5 degrees is entitled to a noncompensable evaluation. Limitation of extension of the leg to 10 degrees is entitled to a 10 percent rating, extension to 15 degrees to a 20 percent rating, extension to 20 degrees to a 30 percent rating, extension to 30 degrees to a 40 percent rating, and extension to 45 degrees to a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (1999). Regulations require the evaluation of the complete medical history of the veteran's condition. 38 C.F.R. §§ 4.1, 4.2 (1999). Where evaluation is based on limitation of motion, the question of whether functional loss and pain are additionally disabling must be considered. 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999); DeLuca v. Brown, 8 Vet. App. 202 (1995). Regulations contemplate inquiry into whether there is crepitation, less or more movement than normal, weakened movement, excess fatigability, incoordination and impaired ability to execute skilled movement smoothly, pain on movement, and swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. Id. The provisions of 38 C.F.R. §§ 4.40, 4.45 do not apply to ratings under Diagnostic Code 5257, because that rating code is not predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7, 11 (1996). In VAOPGCPREC 23-97 (1997), VA's general counsel held that a claimant who has arthritis and instability of a knee may be rated separately under diagnostic Codes 5003, for limitation of motion, and 5257, for instability and subluxation. The general counsel subsequently clarified that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Analysis The claim of entitlement to an increased evaluation for retropatellar arthralgia and ligament laxity of the right knee, currently evaluated as 20 percent disabling. The claim for an increased rating is well grounded because the veteran testified at the April 1997 hearing that he experienced increased pain, swelling, and instability of the knees. 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78 (1990). A veteran's assertion that the disability has worsened serves to render the claim well grounded. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). A continued 20 percent rating is warranted under the criteria of Diagnostic Codes 5257, 5258, 5259, 5260, and 5261. A continued 20 percent rating is warranted under the criteria of Diagnostic Code 5257 because the veteran has moderate subluxation and lateral instability. Initially, the evidence showed no subluxation other than the veteran's report of an episode of subluxation to the April 1998 examiner. The evidence showed lateral instability because the veteran evolved from using a Velcro and plastic knee support to a metal knee brace with patellar cutouts, the April 1996 examiner noted mild laxity of the MCL and LCL, and the July 1999 examiner characterized the right MCL and LCL as slightly unstable and the ACL as moderately unstable. Accordingly, a continued 20 percent rating is warranted under the criteria of Diagnostic Code 5257. The most limited range of motion of the right knee was 10-110 degrees in June 1999 when the physician recommended a DeLuca factor of 20 percent for the veteran's additionally disabling functional loss and pain. With respect to functional loss, the veteran's vocational counselor stated that the disability precluded the veteran from fully utilizing his military training as an aerospace ground equipment mechanic. The veteran had to give up a previous career as a long-distance trucker because his knees could not tolerate the prolonged sitting and driving. Although he currently worked as a Maintenance Worker II as a means to support his daughter, the heavy manual labor and heavy equipment work were contraindicated for his disability. In addition, the veteran had given up athletics. He could not dance, sit for long periods of time at the movies, bicycle or walk long distances, or have normal intimate relations with his wife. With respect to pain, since 1991, the veteran reported gradually increasing pain on movement, while squatting, using stairs, and standing or sitting for prolonged periods of time. With respect to crepitation, there was slight crepitus of the right knee in April 1995, moderate crepitus in July 1996, July 1997, and May 1998, and significant crepitus in June 1999. With respect to swelling, the veteran reported having to put ice on his knees after work each day to prevent or reduce swelling, just in order to sleep. With respect to instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing, the vocational counselor stated that the veteran should not work in jobs requiring squatting, heavy lifting, repetitive climbing, standing and walking for extended periods, operation of heavy equipment, and utilization of clutch vehicles for extended periods. Moreover, the June 1998 examiner noted that the veteran's problems resulted in diminishment of excursion, strength, speed, coordination, and endurance with prolonged standing. Thus, the June 1999 examiner reasonably assigned a 20 percent DeLuca factor for additional limitation of motion of the right knee due to flare-ups and pain with repeated use. As a result, the veteran could bend his right knee to about 104 degrees rather than to the normal 140 degrees, and he could straighten his right leg to about 12 degrees under the horizontal rather than to the horizontal. A 20 percent rating was generous because the veteran's ability to flex, or bend, his knee to 104 degrees qualified for a noncompensable rating, and his ability to extend, or straighten, his right leg knee 12 degrees normally qualified for a 10 percent rating. Accordingly, a continued 20 percent rating is warranted under the criteria of Diagnostic Codes 5260 and 5261. A separate rating is not available under Diagnostic Codes 5003 and 5010 because limitation of motion is compensable. A rating greater than 20 percent is not available under Diagnostic Code 5258, and a rating greater than 10 percent is not available under Diagnostic Code 5259. Accordingly, a continued rating of 20 percent is warranted under the criteria of Diagnostic Codes 5257, 5258, 5259, 5260, and 5261. The claim of entitlement to a rating in excess of 20 percent for retropatellar arthralgia and ligament laxity of the left knee. The veteran's claim for a rating in excess of the current 20 percent is well grounded. When a veteran is awarded service connection for a disability and subsequently appeals the initial assignment of a rating for that disability, the claim continues to be well grounded. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999). An increased rating of 30 percent is warranted under the criteria of Diagnostic Codes 5257, 5260, and 5261. A continued 20 percent rating is warranted under the criteria of Diagnostic Code 5257 because the veteran has moderate subluxation and lateral instability. Initially, the evidence showed no subluxation other than the veteran's report of an episode of subluxation to the April 1998 examiner. The evidence showed lateral instability because the veteran evolved from using a Velcro and plastic knee support to a metal knee brace with patellar cutouts, and the July 1999 examiner characterized the left MCL, LCL, and ACL as moderately unstable. Accordingly, a continued 20 percent rating is warranted under the criteria of Diagnostic Code 5257. The most limited range of motion of the left knee was 20-105 degrees in June 1999 when the physician recommended a DeLuca factor of 20 percent, as discussed above, for flare-ups and pain with repeated use of the left knee. Thus, the veteran could bend his left knee to about 98 degrees rather than to the normal 140 degrees, and he could straighten his left knee to 24 degrees under the horizontal rather than to the horizontal. The veteran's ability to flex, or bend, his left knee to 85 degrees qualified for a noncompensable rating. However, his ability to extend, or straighten, his left leg to 24 degrees qualified for a 30 percent rating. A separate rating is not available under Diagnostic Codes 5003 and 5010 because limitation of motion is compensable. Accordingly, an increased rating of 30 percent is warranted under the criteria of Diagnostic Codes 5257, 5260, and 5261. Finally, extraschedular considerations do not apply to either claim because exceptional circumstances have not been demonstrated. The evidence does not reveal that the veteran's service-connected knee disabilities markedly interfere with his employment or require frequent periods of hospitalization. See Smallwood v. Brown, 10 Vet. App. 93, 97-98 (1997); 38 C.F.R. § 3.321(b)(1999). In June 1997, the vocational counselor noted that the veteran could apply his knowledge to occupations in inventory control, shipping and receiving, supervising, instructing, and computing. Indeed, the record shows that the veteran is successfully pursuing an electronics degree, with the long term goal of becoming a professional engineer. ORDER Entitlement to an increased rating for retropatellar arthralgia and ligament laxity of the right knee, currently evaluated as 20 percent disabling, is denied. Entitlement to a 30 percent evaluation is granted for retropatellar arthralgia and ligament laxity of the left knee, subject to the controlling laws and regulations governing the payment of monetary awards. V. L. Jordan Member, Board of Veterans' Appeals