Citation Nr: 1336032 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 09-37 029A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased rating for left knee patellofemoral syndrome, status post-total knee replacement revision, in excess of 10 percent prior to August 4, 2008 and from October 1, 2008 through July 6, 2009; and in excess of 60 percent since March 1, 2011. 2. Entitlement to an increased rating for degenerative disc and joint disease of the lumbosacral spine, in excess of 20 percent. 3. Whether new and material evidence has been received to reopen a claim of service connection for a right knee disorder, to include as secondary to left knee patellofemoral syndrome. 4. Entitlement to service connection for a right knee disorder, to include as secondary to left knee patellofemoral syndrome. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from December 1977 through December 1981, and additional Reservist service until November 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri in November 2008, and the RO in Roanoke, Virginia in May 2010. In the November 2008 decision, the RO assigned a temporary total (100 percent) evaluation during a period of hospitalization for the Veteran's service-connected left knee disorder, and a 10 percent evaluation thereafter. Additionally, the RO denied the Veteran's claim for an increased rating for degenerative disc and joint disease of the lumbosacral spine. The Veteran appealed these decisions and perfected his appeals to the Board. With regard to the Veteran's left knee rating, the Veteran was subsequently assigned an additional period of total rating following two surgical interventions of the left knee, after which a 60 percent rating was assigned. Because the Veteran's claim for an increased rating of the left knee has been continuously on appeal, the period on appeal covers both the periods of temporary total ratings and the periods of less than total ratings. However, as a 100 percent rating is the highest rating available, the issue indicated above has been styled to reflect that only those periods during which a total rating was not in effect as on appeal to the Board. In the May 2010 rating decision, the RO denied the Veteran's application to reopen his previously denied claim of service connection for the right knee. The Veteran appealed from the determination in that case, and perfected his appeal to the Board. The Board notes that the Veteran had previously requested a hearing before a Member of the Board. However, in August 2012 VA received a statement from the Veteran withdrawing his request. Consideration of the Veteran's appeal has included review of all documents within the Virtual VA paperless claims processing system. The documents within the system include VA treatment records of the knees and low back. All relevant documents within the paperless claims processing system are part of the Veteran's claims file and have accordingly been considered as part of the Board's adjudication of these matters. FINDINGS OF FACT 1. Prior to August 4, 2008, left knee patellofemoral syndrome was productive of 130 degrees of motion without objective evidence of pain, instability, giving way, incoordination, episodes of dislocation, subluxation, effusion, or locking. 2. From October 1, 2008 until July 6, 2009 left knee patellofemoral syndrome, status post-total knee replacement revision was productive of full range of motion, with pain throughout such range and no instability, giving way, incoordination, episodes of dislocation, subluxation, effusion, or locking. 3. Since March 1, 2011 left knee patellofemoral syndrome, status post-total knee replacement revision has been productive of chronic severe painfully motion of the left knee. 4. Throughout the period on appeal, degenerative disc and joint disease of the lumbosacral spine has been productive of limitation of forward flexion to not less than 50 degrees, with no addition functional limitation due to pain or repetitive motion. 5. In a November 2007 decision, the RO denied service connection for a right knee disorder. The Veteran did not file an appeal, and the decision became final. 6. The evidence associated with the claims file following the November 2007 decision relates to unestablished facts that are necessary to substantiate the Veteran's service connection claim, including evidence of a connection between the claimed right knee disorder and service-connected left knee replacement. The newly received evidence is neither cumulative nor redundant of evidence previously of record, and raises a reasonable possibility of substantiating the claim. 7. Chondromalacia patella with degenerative joint disease of the right knee was aggravated by service-connected disabilities of the low back and left knee. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome were not met or more nearly approximated prior to August 4, 2008. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a, Diagnostic Code 5099-5020 (2013). 2. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome were not met or more nearly approximated at any time from October 1, 2008 until July 6, 2009. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a, Diagnostic Code 5099-5020 (2013). 3. The criteria for a rating in excess of 60 percent for left knee patellofemoral syndrome, post-total knee replacement revision have not been met or more nearly approximated at any time since March 1, 2011. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a, Diagnostic Code 5055 (2013). 4. The criteria for a rating in excess of 20 percent for degenerative disc and joint disease of the lumbosacral spine have not been met or more nearly approximated at any time during the rating period on appeal. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.71a, Diagnostic Code 5242 (2013). 5. The November 2007 RO decision denying service connection for a right knee disorder became final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2013). 6. Evidence received since the November 2007 RO decision is new and material to reopen a claim of service connection for a right knee disorder. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2013). 7. The criteria for service connection of chondromalacia patella with degenerative joint disease of the right knee on the basis of aggravation due to a service-connected disability have been met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). VCAA notice should be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In this case, the RO provided a VCAA notice letter to the Veteran in June 2008, prior to the initial adjudication of the increased rating claims on appeal. The letter notified the Veteran of what information and evidence must be submitted to substantiate the claims, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. The Veteran was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claims to the RO. The content of the letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). For an increased-compensation claim, the US Court of Appeals of Veterans Claims (the Court) has held that § 5103(a) required, at a minimum, that VA notify the claimant that, to substantiate a claim, the medical or lay evidence must show a worsening or increase in severity of the disability. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). While the Veteran was not provided specific notice of the need to show a "worsening or increase in severity" in order to substantiate his claims prior to the initial adjudication on appeal, the Veteran was provided with explicit notice in June 2008 of the applicable rating criteria. Thus the Veteran was made aware of what the evidence must show, and VA constructively informed the Veteran of the need for evidence showing a worsening or increase in severity of the claimed disabilities. Based on the foregoing, timely and adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2013); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . or all [Social Security Administration] disability records must be sought - only those that are relevant to the veteran's claim"). In this case, service records have been obtained, as have records of private and VA treatment as well as records from the Social Security Administration (SSA). These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issues before the Board. The Veteran was afforded VA examinations in June 2006, March 2011, and February 2013, during which the examiners conducted physical examinations of the Veteran, took down the Veteran's history, considered the lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions and offered opinions based on history and examination that are consistent with the record. While only the February 2013 examiner was provided with a claims file for review, the matters at issue relate to assessment of the Veteran's current level of physical disability. Furthermore, because the Veteran provided accurate, competent lay histories to VA examiners, the Board finds such examinations to have been adequate. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2013); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). The Board finds that all necessary development has been accomplished. In addition to the evidence discussed above, the Veteran's statements in support of the claims are also of record. The Board has carefully considered such statements and concludes that no available outstanding evidence has been identified. Additionally, the Board has reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. For these reasons, the Board finds that the duties to notify and assist the Veteran in the development of these claims have been met, so that no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). With regard to VA's duties to notify and assist as they relate to the Veteran's claim of service connection for a right knee disorder, the Board is granting, in full, the benefits sought on appeal and thus VA has no further duty to notify or assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects the ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2013). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran was previously awarded service connection and assigned initial disability ratings for left knee patellofemoral syndrome, status post-total knee replacement revision, and for degenerative disc and joint disease of the lumbosacral spine. The Veteran did not appeal from the initial ratings assigned; rather the Veteran seeks increased ratings. On a claim for increased rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found; such separate disability ratings are known as staged ratings. In Hart v. Mansfield, the Court extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." Hart v. Mansfield, 21 Vet. App. 505, 511 (2007). Increased Rating for the Left Knee In the November 2008 decision on appeal, the Veteran, whose left knee had previously been rated as 10 percent disabling, was granted a temporary total (e.g., 100 percent) evaluation based on surgical treatment necessitating convalescence pursuant to 38 C.F.R. § 4.30 (2013), effective August 4, 2008. The foregoing regulation provides for (1) a temporary total ratings in certain circumstances including surgery necessitating at least one month of convalescence, (2) surgery with severe postoperative residuals, and (3) immobilization by cast, without surgery, of one major joint or more). 38 C.F.R. § 4.30(a). Following the temporary total evaluation, a 10 percent rating was reinstated, effective October 1, 2008. In a rating decision of August 2009, the Veteran was assigned a total rating based Diagnostic Code 5055 which, as discussed in greater detail below, affords a 100 percent rating for one year following prosthetic replacement of the knee joint. See 38 C.F.R. § 4.71a, DC 5055 (2013). The 100 percent rating was effective July 7, 2009, and a 30 percent rating was made effective September 1, 2010. In subsequent, May 2010 and January 2013 rating decisions, the Veteran's 100 percent rating was extended and a 60 percent rating was made effective March 1, 2011. The Veteran's left knee disability was initially rated under 38 C.F.R. 4.71a, Diagnostic Code (DC or Code) 5099-5020. Hyphenated Codes are used when a rating under one Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2013). The appellant's specific disability is not listed on the Rating Schedule, and the RO assigned Diagnostic Code 5099 pursuant to 38 C.F.R. § 4.27, which provides that unlisted disabilities requiring rating by analogy will be coded by the numbers of the most closely related body part and "99." See 38 C.F.R. § 4.20 (2013). The RO determined that the most closely analogous Diagnostic Code was 38 C.F.R. § 4.71a, DC 5020, for synovitis - which is "inflammation of a synovial membrane usually with pain and swelling of the join." Harder v. Brown, 5 Vet. App., 183, 184 (1993). In the August 2009 rating decision, however, the RO recharacterized the Veteran's service-connected left knee disability to be rated under 38 C.F.R. § 4.71a, DC 5055 which is the Code for rating knee replacements. While the RO has characterized the appropriate Code for rating the Veteran's knee differently throughout the periods on appeal, the Board will nonetheless explore all potentially applicable Codes in determining the appropriate Code most favorable to the Veteran. VA regulations direct that DC 5020 is to be rated on limitation of motion of the affected parts as degenerative arthritis under DC 5003, except that Note (2) to DC 5003, which provides that the 20 percent and 10 percent ratings based on X-ray findings with no limitation of motion of the joint, is not to be utilized in rating under DC 5020. 38 C.F.R. § 4.71a. Diagnostic Code 5003 provides that degenerative arthritis that is 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. Additionally, a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion is 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. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate Diagnostic Codes, the compensable limitation of motion should be rated under the appropriate Diagnostic Codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Limitation of motion of the knee is rated under DCs 5260 and 5261. DC 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. DC 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). 38 CFR §4.71a. As stated, the Veteran is currently rated under DC 5055 for prosthetic replacement of the knee joint. Under this Code, a 100 percent rating is to be assigned for 1 year following implantation of a knee prosthesis. Where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is assigned. With evidence of intermediate degrees of residual weakness, pain or limitation of motion, the disability should be rated by analogy to DCs 5256, 5261, or 5262. Finally, DC 5055 provides a 30 percent minimum rating in the case of all knee joint replacements. Id. With regard to DC 5262, impairment of tibia and fibula are rated as 40 percent where there is evidence of nonunion, with loose motion, requiring brace. With malunion of the tibia and fibula, a 30 percent rating is assigned for marked knee or ankle disability, a 30 percent rating for moderate knee or ankle disability, and a 10 percent rating is assigned on malunion of the tibia and fibula with slight knee or ankle disability. Id. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2013). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In addition, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when symptoms are most prevalent ("flare-ups") due to pain, weakness, premature or excess fatigability, and incoordination. DeLuca, 8 Vet. App. 202 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The record shows that on VA orthopedic consultation in March 2008 the Veteran had mild left knee medial laxity which was "only questionable." There was also mild Lachman's of the left knee as compared with the right. During a June 2008 VA examination, the Veteran stated that his left knee symptoms were becoming progressively worse. There was no history of instability, giving way, or incoordination, nor had there been any episodes of dislocation, subluxation, effusion, or locking. The knee had motion from zero to 130 degrees without evidence of pain on active motion. X-ray imaging from April 2008 was reviewed and showed a radial tear involving the posterior horn of the medical meniscus. In July 2008 the Veteran underwent evaluation in preparation for a left knee arthroscopy. The Veteran endorsed an uncomfortable patellofemoral joint and range of motion of the patella appeared to be appropriate. The Veteran underwent arthroscopic examination in August 2008, which confirmed traumatic arthritis with a grade 3 cartilage lesion of the lateral tibial plateau and synovitis. On post arthroscopy follow-up in October 2008 the Veteran was able to fully extent and fully flex the left knee. He complained of significant pain in the patellofemoral joint and pain throughout the left knee generally; pain was also present with resistance to extension. In July 2009, the Veteran underwent a total left knee replacement. The replacement itself was uneventful, and on the second day after the procedure left knee flexion was to 60 degrees. In October 2009 the Veteran sought consultation at a private facility regarding his left knee replacement. On consultation it was noted that since his July 2009 knee replacement, the Veteran had arthroscopic lysis of adhesions with manipulation but did not end up with improved function of the knee. His range of motion at the time was from 20 to 90 degrees, and significant effusion and synovitis were present. In January 2010 the Veteran underwent a total left knee arthroplasty revision at a private facility following a determination that prior left knee prosthesis had been too large. X-ray imaging at a private facility in January 2010 was compared with imaging made in October 2009. The knee revision showed no evidence of subluxation, dislocation, fracture line, or other changes to suggest any post-surgical complication. There were some immediate postoperative soft tissue changes; however these were described as expected. On VA examination in March 2011, the Veteran reported that following the total knee replacement in July 2009, his left knee remained swollen for six months prompting him to seek treatment at a private facility where it was recommended that that original prosthesis was too big and needed to be replaced. Following surgery to replace the prosthesis with a smaller one, the Veteran endorsed several courses of physical therapy and having had fluid drained from the knee several times. The Veteran used a cane to ambulate at all times and he reported that his knee remained swollen and painful. The Veteran's left knee symptomatology included deformity, giving way, instability, pain, stiffness, weakness, incoordination, decreased speed of the motion, and repeated effusions, but no episodes of dislocation or subluxation. Flare-ups were severe and weekly, lasting three to seven days at a time. Flare-ups were precipitated by damp weather, walking up or down stairs, walking more than a few yards, and standing for longer than 10 to 15 minutes. The Veteran said that flare-ups affected his entire life and mood, rendering him unable to be active, and in need of help bathing and dressing. The Veteran's range of motion was from zero to 70 degrees with objective evidence of pain on active motion of the knee and on repetitive motion of the knee. There were no additional limitations after three repetitions of motion and the joint was not ankylosed. X-ray imaging revealed a revised left total knee replacement with long femoral and tibial stem components. There was no peri-hardware lucency and moderate joint effusion was noted. The Veteran's left knee disability prevented many activities of daily living including chores, shopping, sports and recreation, with moderate impacts on traveling, feeding, bathing, dressing, toileting, and grooming. The Veteran's total left knee replacement and total revision arthroplasty resulted in pain and swelling, and he was unable to ambulate more than a few steps without rest, and used a cane at all times. On VA orthopedic consultation in April 2011 the Veteran's left knee had passive range of motion from -20 to 90 degrees with pain. The knee was stable to varus and valgus stress test and pain was present when the patella and condyles were palpated. On reviewing the Veteran's history of left knee replacement followed by revision of the replacement, the reviewing physician opined that the Veteran had very poor results associated with total left knee replacement, which were characterized as "the worst I have seen." The Veteran had a severe form of arthrofibrosis, which was not improved on surgical intervention. Rating Prior to August 4, 2008 Prior to August 4, 2008, the Veteran's left knee disorder was rated as 10 percent disabling under DC 5099-5020. As indicated, ratings under this Code are rated using the criteria of DC 5003 for arthritis which itself directs that ratings are based on limitation of motion under the appropriate Code. Prior to surgical intervention in July 2008, the June 2008 VA examination shows that the Veteran had motion from zero to 130 degrees without objective evidence of pain. Accordingly, the Veteran's left knee motion was not limited to a compensable degree under DCs 5260 or 5261 which would require evidence of limitation to 45 degrees of flexion or 10 degrees of extension. See 38 C.F.R. § 4.71a, DCs 5260, 5261. Returning, to DC 5003, a 20 percent rating is not warranted prior to August 4, 2008 as the evidence fails to show involvement of two or more major joints or two or more minor joint groups. The Board has also considered whether a higher rating may be available under a different Code. To that end, however, prior to August 4, 2008 the Veteran denied any prior history of instability, giving way, or incoordination, nor had there been any episodes of dislocation, subluxation, effusion, or locking. Furthermore, that the Veteran had 130 degrees of motion shows that the knee was not ankylosed, and there was no evidence of tibia or fibula impairment. Accordingly, even considering the potentially applicable Codes with criteria for schedular ratings above 10 percent, a rating of greater than 10 percent was not warranted. See 38 C.F.R. § 4.71a, DCs 5256, 5257, 5258, and 5262. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Rating from October 1, 2008 until July 6, 2009 The Veteran was assigned a temporary total rating for convalescence, pursuant to 38 C.F.R. § 4.30, following his August 2008 arthroscopic examination. Following such period, a 10 percent rating was assigned. The Board finds that a rating in excess of 10 percent from October 1, 2008 until July 6, 2009 is not warranted. Specifically, in October 2008, although the Veteran had significant pain in the patellofemoral joint and pain throughout the left knee generally, he maintained full range of extension and flexion of the knee. In considering the Veteran's level of functional limitation of motion pursuant to DeLuca, 8 Vet. App. 202, the Board has taken in to account that motion was painful throughout its range. Nonetheless, while pain was present throughout motion, the Veteran's range of motion was not functionally limited as evidenced by having full range of motion. As with the prior period of appeal here too the Board has considered whether a higher rating may be available under a different Code. Between October 2008 and July 2009, the Veteran did not have instability, subluxation, effusion or locking, or of tibia or fibula impairment. Accordingly, even considering the potentially applicable Codes with criteria for schedular ratings of greater than 10 percent, a rating in excess of 10 percent was not warranted at any time from October 1, 2008 to July 6, 2009. See 38 C.F.R. § 4.71a, DCs 5256, 5257, 5258, and 5262. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Rating from March 1, 2011 Beginning in July 2011, the Veteran underwent a total knee replacement followed by a revision of the initial replacement. As stated previously, DC 5055 provides for a 100 percent rating for one year following prosthetic knee implantation. 38 C.F.R. § 4.71a. The Veteran's 100 percent rating from July 7, 2009 until March 1, 2011 is in compliance with the directives of DC 5055. Also as previously stated, DC 5055 provides for a 60 percent rating for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. A rating in excess of 60 percent under DC 5055 is warranted only for one year following prosthetic knee implantation. As the Veteran's last left knee replacement surgery was more than one year ago, a 100 percent rating is not warranted under this Code. A review of the Codes otherwise applicable to the knee (DCs 5256 - 5263) reflects that a schedular rating in excess of 60 percent is not provided for under such Codes. Accordingly, as there are no applicable schedular ratings available, other than under 5055, the Board finds that a rating in excess of 60 percent for the period from March 1, 2011 is not warranted. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Lumbar Spine In the November 2008 decision on appeal, the Veteran was denied a rating of greater than 20 percent for service connected degenerative disc and joint disease of the lumbosacral spine. The Veteran's current 20 percent evaluation, effective January 10, 2005, rates the Veteran's low back disability under 38 C.F.R. § 4.71a, DC 5242, and the General Rating Formula for Diseases and Injuries of the Spine. Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), spondylolisthesis or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), and degenerative arthritis of the spine (DC 5242) (for degenerative arthritis of the spine, see also DC 5003). The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See also Plate V, 38 C.F.R. § 4.71a. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4) provides that the rater is to round each range of motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6) provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a. A review of the Veteran's claims file shows that on VA primary care consultation in September 2007, range of motion of the back was limited due to pain. There was midline tenderness, and negative straight leg raise, and bilateral lower extremity patellar deep tendon reflexes were abnormal. It was determined that the Veteran's lower extremity symptoms were likely due to neck disorder, not a lumbar disorder. On physical therapy consultation in October 2007 the Veteran had 25 degrees of forward flexion of the lumbar spine and 10 degrees of extension. The assessment was of decreased lumbar range of motion with pain. The Veteran had poor posture and weakness in the core stabilizers. In a February 2008 pain consultation, the Veteran complained of lower back pain radiating into the right leg. A review of x-ray imaging of the lumbar spine from November 2007 revealed that the vertebral column was in satisfactory alignment. There was no sign of compression and disc spaces were maintained. Imaging did reveal a calcification below the tip of the spinous process at the L1 level. Range of motion was limited to 30 degrees of flexion and 15 degrees of extension - both limited by pain. The impression was of lumbar spondylosis, lumbago, and right L5 radiculopathy. In March 2008 the Veteran was able to bend forward to approximately 52 degrees, and backward extension was to approximately 10 degrees (observations were estimated without use of instrumentation). All ranges of motion were limited by pain. Weakness was present in the left lower extremity, and straight leg raise caused low back pain bilaterally at 60 to 70 degrees. On VA examination in June 2008, the Veteran endorsed some history of paresthesias, leg or foot weakness, stiffness, and other weakness. There had been no incapacitating episodes of spinal disease and the Veteran's gait was normal. Lower extremity sensory examination was normal, as were ankle and knee jerk tests. The lumbar spine had 90 degrees of flexion and 20 degrees of extension without pain on active motion, but with objective evidence of pain following repetitive motion. Lasegue's sign was negative. There were no effects on usual daily activities; however, the effect on the Veteran's then-occupation as a medical laboratory technician was significant. On VA rheumatology consultation in July 2008, the Veteran endorsed pain in his low back, swelling in the knees, and pain from the low back radiating into both legs. Nonetheless, the Veteran had no neurologic symptoms other than some persistent numbness on the lateral aspect of the right foot. In March 2011, the Veteran underwent a VA examination during which he stated that several courses of physical therapy, steroid injections, and prescription pain medication had been ineffective in reducing low back symptomatology. The Veteran endorsed foot or leg weakness, numbness, and paresthesias. The Veteran's low back pain was severe, constant and daily, with radiation down the right leg and into the right foot. Radiating pain was of a burning, tingling, and numbing type. The examiner reported that in the preceding 12 months the Veteran had been instructed by his primary care physician to remain on bedrest sometime in September 2010. The examiner did not indicate the duration of the bedrest episode. On physical examination the Veteran's gait was antalgic. Flexion was to 50 degrees with extension to 15 degrees and objective evidence of pain on active motion and of pain following repetitive motion. There were no additional limitations following repetitive motion. Sensory examination findings during the March 2011 VA examination showed that the right sciatic nerve was affected with decreased vibration sensation, pain or pinprick sensation light touch sensation and dysesthesia, all affecting the right great toe in particular. Lasegue's sign was positive on the left side. Radiographic imaging confirmed spondylosis with disc disease at the L4-5 and L5-S1 levels. The diagnoses were degenerative disc disease and degenerative joint disease with right lower extremity radiculopathy. The Veteran's symptoms affected most activities of daily living other than feeding. Due to the numbness in his right great toe the Veteran was unable to stand for more than 15 minutes, unable to carry loads of greater than a few pounds, and unable to bend over or lift anything. In determining the appropriate rating, the Board begins by noting that right lower extremity radiculopathy has been granted service connection and separately rated; it is not the subject of the immediate appeal. Additionally, with regard to other neurologic abnormalities, none have been shown to be due to service connected degenerative disc and joint disease. See 38 C.F.R. § 4.71a, DC 5242, Note (1). Having reviewed the entire record during the period on appeal, the Board finds that the Veteran's service-connected low back symptoms correspond to the 20 percent rating criteria throughout the period on appeal. As previously stated, in order for a higher rating than the current 20 percent rating, the evidence must show either forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. 38 CFR § 4.71a. Here, the Board recognizes that a physical therapy note in October 2007 indicates forward flexion only to 25 degrees and a February 2008 pain consultation notes forward flexion was to 30 degrees. Nonetheless, 38 CFR § 4.46 (2013) cautions that accurate measurements should be insisted on when applying rating criteria, and that, specifically, "[t]he use of a goniometer in the measurement of limitation of motion is indispensable in examinations conducted within the Department of Veterans Affairs." With regard to the October 2007 and February 2008 range of motion findings, it is unclear how such measurements were derived. In contrast, measurements taken during June 2008 and March 2011 VA examinations can be presumed to have been made through the use of a goniometer as this is the usual practice of VA examiners when conducting VA examinations for rating purposes. See Ashley v. Derwinski, 2 Vet. App. 307, 308 (1992) ("There is a presumption of regularity under which it is presumed that government officials 'have properly discharged their official duties,'" quoting United States v. Chem. Found., Inc., 272 U.S. 1, 14-15, 47 S.Ct. 1, 71 L.Ed. 131 (1926)). Thus, measurements taken at VA examination are found to be more probative and accurate in describing of the Veteran's current level of symptomatology for rating purposes. Accordingly, the Board finds that the more probative evidence shows the Veteran's forward flexion has been not less than 50 degrees throughout the period on appeal. The Board recognizes that in the March 2011 VA examination during which the Veteran's forward flexion was recorded as being limited to 50 degrees, the report does not indicate at what point pain began. Nonetheless, the examiner documented the Veteran's functional limitation due to pain and noted that even following repetitive motion there were no additional limitations. With regard to the single March 2011 report on VA examination that in September 2010 the Veteran was instructed by a physician to remain on bedrest until he felt he "could move around." In order for a rating of greater than 20 percent under DC 5243 for incapacitating episodes, such episodes must have been for at least 4 weeks, but no more than 6 weeks. Here, while the Veteran has indicated a single period of physician-directed bedrest, that the period was limited to a single month, or less, indicates that it was not for a duration which would warrant a higher rating. 38 C.F.R. § 4.71a, DC 5234. Thus, after reviewing all of the evidence, lay and medical, the Board finds the Veteran's degenerative disc and joint disease of the lumbosacral back has been not more than 20 percent disabling throughout the period on appeal. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has also considered whether referral for extraschedular ratings is warranted for any period on appeal regarding the Veteran's service-connected left knee or low back. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here the schedular rating criteria used to rate the Veteran's service-connected disabilities above, reasonably describe and assess the Veteran's disability level and symptomatology. The criteria rate the disability on the basis of limitation of motion, instability and other disturbances, malformation of the skeletal system, and in the case of DC 5055, a history of prosthesis implantation. Thus, the demonstrated manifestations - namely limitation of motion of the knee and back with a history of prosthesis implantation of the knee - are contemplated by the provisions of the rating schedule. As the Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate. Furthermore, the Board notes that with regard to limitation of motion, the rating criteria based on such limitation are considered in light of additional functional limitations due to such factors as pain, fatigability, and flare-ups; hence incorporating such factors into the DC criteria themselves. Finally, the schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App at 442; see also 38 C.F.R. § 4.21 (2013). For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's left knee and low back disabilities, and referral for consideration of an extra-schedular evaluation is not warranted. Finally, the record reveals that the Veteran has claimed that he is rendered unemployable by virtue of his left knee and low back disabilities. To that end, however, the Veteran was awarded a total disability rating based on individual unemployability in a RO decision of January 2013, effective March 1, 2011. The Veteran has not disagreed with the assignment of such date, and the matter is not before the Board. Service Connection for a Right Knee Disorder The Veteran is seeking to reopen a previously denied claim of entitlement to service connection for a right knee disorder, to include as secondary to his service-connected left knee disability. Generally, a claim which has been denied may not thereafter be reopened and allowed based on the same record. 38 U.S.C.A. § 7105 (West 2002). However, pursuant to 38 C.F.R. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2013). In determining whether evidence is "new and material," the credibility of the new evidence must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Regardless of the RO's determination as to whether new and material evidence has been received, the Board has a jurisdictional responsibility to determine whether a claim previously denied by the RO is properly reopened. See Jackson v. Principi, 265 F.2d 1366 (Fed. Cir. 2001) (citing 38 U.S.C.A. §§ 5108, 7105(c) (West 2002)). Accordingly, the Board must initially determine whether there is new and material evidence to reopen service connection for a right knee disorder. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low" See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. In order to prevail on the issue of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Here, in an August 2005 rating decision, the RO denied a claim of service connection for a right knee disorder on the basis that the record lacked any evidence of an in-service occurrence, or onset within one year of a chronic disability under 38 C.F.R. § 3.309, and no evidence linking a right knee disorder to service. The Veteran did not submit a timely notice of disagreement and the denial became final. In October 2010 the Veteran sought to reopen the claim; however the RO denied the claim to reopen in November 2007. That decision was also not appealed and became final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.156(a),(b), 20.302, 20.1103 (2013). Since the most recent final denial in November 2007, VA has received statements from two separate VA physicians associating the Veteran's right knee symptomatology and current diagnoses with his service-connected left knee disability. One such statement was sent to VA in a letter of July 2011 while the other was contained in a February 2013 VA examination report. As these both represent evidence not previously submitted to agency decision makers and relates to unestablished facts necessary to substantiate the claim, the Board finds that the additional evidence is new and material to reopen service connection for a right knee disorder. Service Connection for a Right Knee Disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004) The term "active military, naval, or air service" includes active duty, any reserve service periods of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty, and any period of or inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C.A. §§ 101(22), 101(24) (West 2002); 38 C.F.R. § 3.6 (2013). The record reflects that following full-time active duty, the Veteran had a period of duty as a Reservist. Individual periods of ACDUTRA and INACDUTRA have not been verified, however the Veteran does not contend, and the evidence does not otherwise show, that the claimed right knee disorder is related to a disease or injury during ACDUTRA and INACDUTRA. Thus the Board finds that the lack of such verification is not detrimental to the Veteran's claim. Except as provided in 38 C.F.R. § 3.300(c), a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2013). This includes any increase in disability (aggravation) that is proximately due to or the result of a service connected disease or injury. See 38 C.F.R. § 3.310(b) (2013). Establishing service connection on a secondary basis requires (1) medical evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran contends that his service-connected left knee patellofemoral syndrome either caused or aggravated a right knee disorder. On VA examination in June 2005, the Veteran endorsed intermittent, but daily pain in the knees, which was aggravated by standing for more than 15 minutes. The Veteran denied any specific injuries of the right knee, and on physical examination the Veteran's gait was normal. Motion of the knee was from zero to 110 degrees, limited by pain, but at 110 degrees of flexion pain was in the back not the knees. The assessment was ob bilateral patellofemoral syndrome of the knees. On VA examination in June 2008, the right knee had motion from zero to 140 degrees without evidence of pain on active motion. X-ray imaging of the right knee at a private facility in April 2010 revealed a corticated osseous density abutting the medial aspect of the patella which "could pertain to sequela of remote trauma." Mild upper and lower pole patella osteophytes were noted, as well as soft tissue thickening, suggesting prepatellar bursitis. On VA examination in March 2011, range of motion was from zero to 120 degrees, again without evidence of pain on active motion. X-ray imaging showed mild medial compartment narrowing. In April 2011 the Veteran complained of right leg pain. The knee had full extension, and flexion to 135 degrees. Medial joint line tenderness and patellar tendon tenderness were present, and patellar inhibition test was positive. McMurray maneuvers were negative for any mechanical clinks; although most manipulations were productive of pain. The diagnosis was diffuse right knee pain. A July 2011 notation from a VA doctor indicated that, given the Veteran's history, it is more likely than not that his right knee pain may be related to his left knee and low back. Specifically, favoring his left knee causes a shift in body mechanics that can cause strain on the right side. On VA examination in February 2013, the Veteran stated that since the time of his left knee replacement he had begun to notice trouble ascending stairs, with the right knee buckling and causing the Veteran to catch himself with his left leg. The Veteran's right knee pain was constant and the knee sometimes swelled. Range of motion of the knee was from zero to 110 degrees, without objective evidence of painful motion, and no change on repetitive use testing. On radiographic imaging the impression was of fraying posterior tip anterior horn meniscus, and grade 1 intrasubstance degenerative signal medial meniscus. Based on a complete physical examination and interview, including a review of the claims file the VA examiner concluded that the Veteran's right knee chondromalacia patella and degenerative joint disease is less likely than not due to or the result of service-connected left knee replacement and revision as the left and right knee conditions arose from routine biomechanical stress over many years of weight-bearing. However, the examiner went on to concluded that the Veteran's right knee condition is likely permanently worsened by his service-connected left knee condition which has led to chronic and significant gait impairment. The change in gait alters and increases the biomechanical stresses across the contralateral right knee joint, thereby worsening the right knee condition over time beyond its natural progression Based on the foregoing, the Board finds that the Veteran's right knee chondromalacia patella with degenerative joint disease is not caused but is aggravated by his service-connected left knee disability and thus service connection for the Veteran's right knee disorder is established on a secondary basis due to aggravation. Service connection is thus established and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Ratings in excess of 10 percent for left knee patellofemoral syndrome, status post-total knee replacement revision prior to August 4, 2008 and from October 1, 2008 through July 6, 2009 is denied. A rating in excess of 60 percent for left knee patellofemoral syndrome, status post-total knee replacement revision since March 1, 2011 is denied. A rating in excess of 20 percent for degenerative disc and joint disease of the lumbosacral spine is denied. New and material evidence having been received, the appeal to reopen service connection for a right knee disorder is granted. Service connection for chondromalacia patella with degenerative joint disease of the right knee is granted. ____________________________________________ MATTHEW D. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs