Citation Nr: 1514815 Decision Date: 04/07/15 Archive Date: 04/21/15 DOCKET NO. 10-07 188 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to an increased disability rating (or evaluation) for left knee degenerative arthritis status post total left knee replacement (a left knee disability), in excess of 10 percent from September 20, 2007 to November 17, 2009, and in excess of 30 percent from February 1, 2011. 2. Entitlement to an increased disability rating (or evaluation) in excess of 10 percent for right knee degenerative arthritis status post total right knee replacement (a right knee disability). 3. Entitlement to an increased disability rating (or evaluation) in excess of 10 percent for the service-connected recurrent lumbar strain (a lumbar spine disability). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Ragheb, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from June 1973 to June 1997. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Baltimore, Maryland, RO has jurisdiction of the current appeal. The Board has reviewed both the Veterans Benefits Management System (VBMS) and the "Virtual VA" files so as to ensure a total review of the evidence. In an April 2010 rating decision, the RO assigned a 30 percent rating for the left knee disability from February 1, 2011, thus creating a "staged" rating for different periods, and denied an increase in excess of 10 percent for the right knee disability. Although a higher disability rating has been assigned for the left knee disability for one stage of the rating, as reflected in the April 2010 rating decision, both knee rating issues remain in appellate status as the maximum ratings have not been assigned for any period. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). The issue of entitlement to an increased rating for the service-connected lumbar spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the rating period from September 20, 2007 to November 17, 2009, the left knee disability was manifested by degenerative arthritis with painful, noncompensable limitation of motion of the knee. 2. For the rating period from September 20, 2007 to November 17, 2009, the left knee disability was not manifested by recurrent subluxation or lateral instability, limitation of flexion to 30 degrees, limitation of extension to 5 degrees, malunion or non-union of the tibia and fibula, favorable or unfavorable ankylosis, or genu recurvatum with weakness. 3. For the rating period from September 20, 2007 to November 17, 2009, the Veteran had a meniscal tear of the left knee, with episodes of locking, pain, and effusion in the left knee. 4. The Veteran underwent total left knee replacement on November 17, 2009. 5. For the rating period from November 17, 2009 to January 1, 2010, the Veteran was in receipt of a temporary total rating for convalescence after total left knee replacement surgery. 6. For the rating period from January 1, 2010 to February 1, 2011, the Veteran was in receipt of a schedular rating of 100 percent following implantation of left knee prosthesis. 7. For the rating period from February 1, 2011, the Veteran has had chronic residuals of total left knee replacement surgery consisting of severe painful motion and weakness in the left knee. 8. For the rating period from September 20, 2007 to December 27, 2011, the right knee disability was manifested by degenerative arthritis with painful, noncompensable limitation of motion of the knee. 9. For the rating period from September 20, 2007 to December 27, 2011, the right knee disability was not manifested by recurrent subluxation or lateral instability, limitation of flexion to 30 degrees, limitation of extension to 5 degrees, malunion or non-union of the tibia and fibula, favorable or unfavorable ankylosis, or genu recurvatum with weakness. 10. For the rating period from September 20, 2007 to December 27, 2011, the Veteran had a history of right knee meniscus surgery, with episodes of locking, pain, and effusion in the right knee. 11. The Veteran underwent total right knee replacement surgery on December 27, 2011. 12. For the rating period from December 27, 2011 to July 1, 2012, the Veteran was in convalescence associated with total right knee replacement surgery. 13. For the rating period from July 1, 2012 to July 1, 2013, a 100 percent schedular rating is assigned for one year following implantation of right knee prosthesis. 14. For the rating period from July 1, 2013, the Veteran had chronic residuals of total right knee replacement surgery consisting of severe painful motion and weakness in the right knee. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for a disability rating of 20 percent, but no higher, for the service-connected left knee degenerative arthritis status post total left knee replacement, for the rating period from September 20, 2007 to November 17, 2009, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5258 (2014). 2. Resolving reasonable doubt in favor of the Veteran, the criteria for an increased rating of 60 percent for left knee degenerative arthritis status post total knee replacement are met for the rating period from February 1, 2011. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2014). 3. Resolving reasonable doubt in favor of the Veteran, the criteria for a disability rating of 20 percent, but no higher, for the service-connected right knee degenerative arthritis status post total right knee replacement, for the rating period from September 20, 2007 to December 27, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5258 (2014). 4. Resolving reasonable doubt in favor of the Veteran, the criteria for a temporary total rating under 38 C.F.R. § 4.30 for the rating period from December 27, 2011 to July 1, 2012 for convalescence following total right knee replacement surgery on December 27, 2011 have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.30 (2014). 5. Resolving reasonable doubt in favor of the Veteran, the criteria for an increased schedular rating of 100 percent for right knee degenerative arthritis status post total right knee replacement are met for the one year rating period from July 1, 2012 to July 1, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2014). 6. Resolving reasonable doubt in favor of the Veteran, the criteria for an increased rating of 60 percent for right knee degenerative arthritis status post total knee replacement are met for the rating period from July 1, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). 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); 38 C.F.R. § 3.159(b). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increased rating, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment and earning capacity, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). With regard to the issues of increased rating of the left knee and right knee disabilities, the RO issued an October 2007 preadjudicatory notice letter to the Veteran, which met the VCAA notice requirements. With regard to the duty to assist, VA has made reasonable efforts to obtain relevant records and evidence with respect to the issue adjudicated herein. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records (STRs), post-service VA and private treatment records, relevant VA examination reports, and lay statements by the Veteran, spouse, and coworkers in support of the claims or issues on appeal. In October 2007 and June 2013, VA provided the Veteran with VA medical examinations to help determine the severity of the right and left knee disabilities. Taken together, as the above-referenced VA medical examination reports were written after interviews with the Veteran, examinations of the Veteran, and contain findings and measurements regarding the severity of the Veteran's right and left knee disabilities supported by clinical data, the Board finds that the above-referenced VA medical examination reports are adequate for VA rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board is aware that the October 2007 VA examination report indicates that the claims file was not reviewed. The Board is using the October 2007 VA medical examination reports to help determine the Veteran's contemporaneous right and left knee symptomatology and impairment, not to establish service connection. In addition, the Board notes that the Veteran was capable of informing the October 2007 VA examiner of the right and left knee symptoms at that time, in fact did so, and that the Veteran's reported symptoms were specifically noted in the October 2007 VA examination report. See, e.g., Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (holding that VA cannot reject a medical opinion simply because it is based on a history supplied by a veteran, but the strength of the opinion depends rather upon the accuracy of the facts asserted by the veteran). As the Veteran was capable of supplying the information regarding his then current right and left knee symptomatology and functional impairment, and the October 2007 VA examiner made clinical findings with respect to the right and left knee disabilities, the October 2007 VA examiner's failure to review the claims file does not render the October 2007 VA examination report inadequate on the relevant question of the current level of severity of the right and left knee symptomatology, specifically including the findings measured at that examination, which are valid measures independent of any history. See id. (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); VAOPGCPREC 20-95 (stating that the determination as to whether review of prior medical records is necessary in a particular case depends largely upon the scope of the examination and the nature of the findings and conclusions the examiner is requested to provide). Moreover, neither the Veteran nor his authorized representative challenged the adequacy of the October 2007 VA examination. Therefore, the Board finds that the October 2007 VA medical examination report is adequate for rating purposes. As such, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. Mayfield, 19 Vet. App. at 1328. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of the claims or issues on appeal. Disability Rating Legal Authority Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2014). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The U.S. Court of Appeals for Veterans Claims (Court) has held that staged ratings are appropriate for an increased rating claim when 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 (2007). The Board finds that the right and left knee disabilities did increase during the rating period on appeal, so warrant staged ratings as discussed in detail below. The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. In this case, the weight of the evidence demonstrates that the right and left knee disabilities did not undergo an increase within the one year period before the claim was filed with VA in September 2007. Pyramiding, that is the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14 (2014). However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. The Board has reviewed all the evidence in the Veteran's claims file with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Left and Right Knee Disability Rating Analyses With respect to the left knee disability, the Veteran is in receipt of a 10 percent rating from September 20, 2007 to November 17, 2009 under Diagnostic Code (DC) 5010, a temporary total (100 percent) rating under 38 C.F.R. § 4.30 from November 17, 2009 to January 1, 2010, a 100 percent rating from January 1, 2010 to February 1, 2011 under DC 5055, and a 30 percent rating from February 1, 2011 under DC 5055. Because the Veteran was in receipt of a 100 percent rating from November 17, 2009 to February 1, 2011, the Board will only address the periods or stages from September 20, 2007 to November 17, 2009 and from February 1, 2011 forward with respect to the left knee. As for the right knee, the Veteran is in receipt of a 10 percent rating for the entire appeal period starting from September 20, 2007. DC 5010 provides that arthritis due to trauma is to be rated as degenerative arthritis under DC 5003. 38 C.F.R. § 4.71a. VA General Counsel has interpreted that a veteran who has arthritis and instability of the knee may be rated separately under DCs 5003, or limitation of motion codes (DCs 5260, 5261), and 5257. See VAOPGCPREC 23-97. VA General Counsel has also interpreted that, when X-ray findings of arthritis are present and a veteran's knee disability is rated under DC 5257, the veteran would be entitled to a separate compensable rating under DC 5003 if the arthritis results in limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Furthermore, to warrant a separate rating from DC 5257, for arthritis based on X-ray findings and limited motion under DC 5260 or 5261, the limited motion 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 of arthritis and painful motion under 38 C.F.R. § 4.59. Under DC 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involve. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints, affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. A 20 percent rating is assigned under DC 5003 for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 more minor joints, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a. DC 5055, for knee replacement (prosthesis), provides criteria for rating impairment arising from the prosthetic replacement of a knee joint. For one year following the implantation of knee prosthesis, a 100 percent disability rating is assigned. Thereafter, the minimum disability rating which may be assigned post-knee replacement is 30 percent. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, adjudicators are instructed to rate by analogy to DCs 5256 (knee ankylosis), 5261 (limitation of leg extension), or 5262 (impairment of the tibia and fibula). 38 C.F.R. § 4.71a. The diagnostic codes that focus on limitation of motion of the knee are DCs 5260 and 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that when considering DCs 5260 and 5261 together with 38 C.F.R. § 4.71 a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate ratings for limitations in both flexion and extension under DC 5260 (leg, limitation of flexion) and DC 5261 (leg, limitation of extension). Under DC 5260, a 10 percent rating is assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating is assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating is assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, a 10 percent rating is assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating is assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating is assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating is assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating is assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a. Left Knee Rating from September 20, 2007 to November 17, 2009 and Right Knee Rating from September 20, 2007 to December 27, 2011 The Veteran contends that the left and right knee disabilities have been manifested by more severe symptomatology than that contemplated by the 10 percent rating. Specifically, the Veteran stated that these disabilities have increased in severity and that increased ratings are warranted. See September 2007 VA Form 21-4138. He also stated that, during this period, both knees popped from time to time and created a sensation that both knees would give out. See July 2008 Veteran statement. The Veteran's wife stated that the Veteran had a great deal of knee pain daily and that he consistently got up to stretch out his legs to relieve knee pain. See July 2008 spouse statement. The Veteran indicated that he experienced excruciating pain in both knees that was so unbearable while driving that he had to stretch his legs during a red light in order to alleviate his pain. See February 2010 VA Form 9. The Veteran's coworker, W.C., wrote that the Veteran's back and knee problems made simple tasks difficult for him and that the Veteran had to use the elevators instead of the stairs, took breaks at his desk instead of going to the break room, and brought lunch to work instead of leaving the office in order to ease the pressure on the back and knees. See July 2008 statement by W.C. Another coworker, J.H., stated that the Veteran appeared to be in constant pain, especially when he walked, and that the Veteran frequently got up from his desk and walked around to help relieve the pain in the knees. J.H. also reported that the Veteran walked with a limp when he first stood up from a seated position, sat in the front during the weekly lunch meetings to have room to stretch his legs, and avoided the stairs. After a review of all the record, lay and medical, the Board finds that the weight of the evidence is in equipoise on the question of whether the Veteran has meniscal tear of the left knee, with episodes of locking, pain, and effusion in the left knee, and a history of right knee meniscus surgery, with episodes of locking, pain, and effusion in the right knee that more nearly approximate the criteria for a rating of 20 percent rating under Diagnostic Code 5258. First, the Board finds that the weight of all the lay and medical evidence is against assignment of a higher rating than 10 percent for either knee under DC 5260 as the record establishes that left knee flexion did not more nearly approximate 30 degrees at any point during the rating period from September 20, 2007 to November 17, 2009, and that right knee flexion did not more nearly approximate 30 degrees at any point during the rating period from September 20, 2007 to December 27, 2011. 38 C.F.R. § 4.71a. The October 2007 VA examination report showed that left knee flexion was between 90 and 100 degrees and right knee flexion was to 90 degrees, which was not limited by pain and after repetitive use testing. See 38 C.F.R. §§ 4.40, 4.45, 4.59. There was no additional loss of left or right knee flexion due to painful motion, weakness, instability, or acute flare-ups after repetitive use. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. A January 2008 VA treatment record showed left knee flexion to 105 degrees and right knee flexion to 100 degrees. A November 2008 VA treatment record showed that the Veteran had left knee flexion to about 100 degrees and right knee flexion between 85 and 90 degrees. A February 2009 VA treatment record showed that left knee flexion was to 120 degrees and right knee flexion was to 100 degrees. A March 2009 VA treatment record showed that left knee flexion was between 115 and 120 degrees. Finally, an October 2010 VA treatment record showed right knee flexion to 110 degrees. The Board finds that the weight of the lay and medical evidence of record demonstrates that the Veteran's right and left knee disabilities do not warrant disability ratings in excess of 10 percent under DC 5261 as the evidence demonstrates that left knee extension did not more nearly approximate 15 degrees for the rating period from September 20, 2007 to November 17, 2009 and right knee flexion did not more nearly approximate 15 degrees for the rating period from September 20, 2007 to December 27, 2011. 38 C.F.R. § 4.71a. The October 2007 VA examination report shows that right and left knee extension was to 0 degrees, which was not limited by pain and after repetitive use testing. See 38 C.F.R. §§ 4.40, 4.45, 4.59. There was no additional loss of left or right knee extension due to painful motion, weakness, instability, or acute flare-ups after repetitive use and the Veteran denied incoordination and weakness of both knees during the October 2007 VA examination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. A January 2008 VA treatment record noted that the Veteran lacked about 5 degrees of full extension. A November 2008 VA treatment record showed that the Veteran had full extension of both knees. Finally, a July 2011 VA treatment record shows passive right knee extension to 5 degrees. The Board has considered the October 2007 VA examiner's notations of abnormal gait at times, the mild effect of the bilateral knee disability on chores, as well as the lay statements by the Veteran of the functional limitations of walking, prolonged sitting, standing, driving, and climbing stairs; these functional limitations or impairment are considered under the rating criteria based on limitation of motion, to include as due to pain. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 5260, 5261; see also DeLuca, 8 Vet. App. 202. To alternatively consider this as evidence of pain throughout right and left knee range of motion still does not warrant a rating in excess of 10 percent, but would only raise an assertion of complete ankylosis due to pain with no movement whatsoever. See 38 C.F.R. § 4.59. The Court rejected such an assertion in Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (rejecting veteran's contention that pain, even if experienced throughout the range of motion on examination, warrants a higher rating under the diagnostic codes providing ratings for limitation of motion). Rather, it is the functional limitation, i.e., the additional limitation of motion, caused by pain or the other DeLuca factors, that must be considered in determining whether a higher rating is warranted. See Mitchell, 25 Vet. App. at 38-43 (explaining that, although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded). The October 2007 VA examination report showed a specific finding that the Veteran had no ankylosis of the right or left knees. The evidence of record does not otherwise show ankylosis of the right or left knee at any point during the rating period from September 20, 2007 to November 17, 2009 for the left knee, and from September 20, 2007 to December 27, 2011 for the right knee. The Board finds that the weight of the lay and medical evidence of record demonstrates that a separate rating is not warranted at any point during the respective rating period for each knee under DC 5257 as the weight of the evidence establishes that there was no recurrent subluxation or lateral instability of the left knee from September 20, 2007 to November 17, 2009, or the right knee from September 20, 2007 to December 27, 2011. 38 C.F.R. § 4.71a. The Veteran asserted that he had feelings of weakness and giving way of both knees. See June 2008 Veteran statement. A report of subjective feeling of giving out, even if credibly reported and found to have occurred, does not establish actual recurrent subluxation or lateral instability. Subluxation is "incomplete or partial dislocation." Antonian v. Brown, 4 Vet. App. 179, 182 (1993) (nonprecedential decision citing Dorland's Illustrated Medical Dictionary 1599 (27th ed. 1988)); see also Pond v. West, 12 Vet. App. 341 (1999). Instability is a "lack of steadiness or stability." Dorland's Illustrated Medical Dictionary 958 (31st ed. 2007). Functional instability is the "inability of a joint to maintain support during use." Id. The Veteran has not otherwise reported, nor does the evidence reflect, that the Veteran had actual instability or subluxation of either knee. Throughout the rating period from September 20, 2007 to November 17, 2009 for the left knee and from September 20, 2007 to December 27, 2011 for the right knee, the record shows specific medical findings of no recurrent subluxation or lateral instability of either knee so as to warrant a disability rating under DC 5257. The October 2007 VA examination report shows that the Veteran reported feelings of instability but denied feelings of giving way, weakness, or any episodes of dislocation or subluxation. The October 2007 VA examiner found no instability, subluxation, or dislocation of either knee. January 2009, February 2009, and January 2010 VA treatment showed notations that there was no instability of either knee. A July 2011 VA treatment record showed medical findings of no instability or subluxation of the right knee, to include after performing posterior drawer sign, anterior drawer sign, and Lachman tests. Other treatment records during the rating period from September 20, 2007 to November 17, 2009 for the left knee and from September 20, 2007 to December 27, 2011 for the right knee do not show reports by the Veteran or medical findings of lateral instability or recurrent patellar subluxation/dislocation. Accordingly, to the extent that feelings of giving way or instability are similar to pain or weakness, and limit the Veteran's lateral stepping, such symptoms have been considered under limitation of motion due to pain, to include as due to flare-ups of pain. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a; see also DeLuca, 8 Vet. App. 202. Other diagnostic codes do not provide the Veteran with a more beneficial disability rating for the right and left knee disabilities. See Schafrath, 1 Vet. App. at 595. In this regard, because the weight of the lay and medical evidence shows no right or left knee ankylosis, impairment of the tibia and fibula by malunion or nonunion, or genu recurvatum, the criteria of DCs 5256, 5262, and 5263 do not apply for the rating period from September 20, 2007 to November 17, 2009 for the left knee, and from September 20, 2007 to December 27, 2011 for the right knee. 38 C.F.R. § 4.71a. The Board has considered the Veteran's complaints of bilateral knee clicking, snapping, and popping, as well as crepitus, which is defined as the grating sensation caused by the rubbing together of the try synovial surfaces of joints. See Dorland's Illustrated Medical Dictionary 429 (32d ed. 2012). To the extent that clicking, snapping, popping, or crepitus was painful, and caused limitation of knee motion, these symptoms have been considered under limitation of motion due to pain, to include as due to flare-ups of pain. See 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a; see also DeLuca, 8 Vet. App. 202. As noted above, the Veteran is currently in receipt of a 10 percent rating under DC 5010, which in turn is rated under DC 5003, for the left knee disability from September 20, 2007 to November 17, 2009, and for the right knee disability from September 20, 2007 to December 27, 2011. The maximum rating under DC 5010-5003 is 10 percent. An alternative code, DC 5258, allows for a higher (single and maximum) 20 percent disability rating for dislocation of semilunar cartilage with frequent episodes of joint "locking," pain, and effusion. As DC 5258 provides for a potentially higher rating of 20 percent, and is applicable to this Veteran's knee disabilities based on symptoms and findings of the knees, the Board finds that DC 5258 is potentially more favorable to the Veteran than DC 5010-5003, and will apply DC 5258. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as it is supported by reasons and bases as well as the evidence. Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See also Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the diagnostic code associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). Upon review of all the evidence, lay and medical, and considering DC 5258, the Board finds that, for the rating period from September 20, 2007 to November 17, 2009 for the left knee, and from September 20, 2007 to December 27, 2011 for the right knee, the evidence is in relative equipoise as to whether the service-connected left knee and right knee disabilities manifested dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint, so as to warrant the next higher (20 percent) rating for each knee. The record reflects that the Veteran has a history of a right knee meniscal tear, and a February 2008 VA Magnetic Resonance Imaging (MRI) report showed that there was a chronic degenerative type of tear of the left lateral meniscus and to a lesser extent of the left medial meniscus with a small joint effusion. VA treatment records and statements by the Veteran show multiple complaints of knee locking which caused difficulty with walking. The Veteran is competent to report on symptoms of locking of the knees and the Board finds his reports to be credible. Moreover, VA treatment records show findings of right and left knee effusion. While the October 2007 VA examiner opined that there were no meniscal abnormalities of the right or left knees, the October 2007 VA examination took place prior to the February 2008 MRI, which showed that there was a chronic degenerative tear of the left lateral meniscus. The October 2007 VA examination also took place prior to complaints of bilateral knee locking and medical findings of bilateral joint effusion. Although the Veteran did not indicate the frequency of left and right knee locking symptoms, the Board resolves reasonable doubt in the Veteran's favor to find that, from September 20, 2007 to November 17, 2009 for the left knee, and from September 20, 2007 to December 27, 2011 for the right knee, and finds that the criteria for a higher (single and maximum) 20 percent disability rating for dislocation of semilunar cartilage with frequent episodes of joint "locking," pain, and effusion of each knee have been met. 38 C.F.R. §§ 4.3, 4.7. The Veteran may not be assigned separate ratings under both DC 5003 and DC 5258. The Veteran's left and right knee disabilities have been manifested by degenerative arthritis, joint "locking," painful motion, weakness, stiffness, swelling, feelings of giving way, lack of endurance, fatigability, and functional impairment including with prolonged walking, prolonged sitting, and climbing of stairs. Both diagnostic codes overlap in ratings based on pain and locking as forms of limitation of motion; therefore, assigning separate ratings under both DC 5003 and DC 5258 would violate the prohibition against pyramiding. 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 261 (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition); see also Arthur J. Helfet, Clinical Features of Injuries to the Semilunar Cartilages, in Disorders of the Knee 110 (Arthur J. Helfet ed., 2d ed. 1982) (removal of the semilunar cartilage may resolve restriction of movement caused by tears and displacements of the menisci). As such, the Board finds that a 20 percent rating under DC 5258 is warranted as use of DC 5258 is more potentially and actually favorable to the Veteran. As noted above, in any case involving knee pain or locking, separate ratings may not be assigned under DCs 5003 and 5258 because to do so would constitute pyramiding; therefore, because the Board is granting an increased rating of 20 percent for each knee under DC 5258, the 10 percent rating under DC 5003 (previously labeled as 5010) will be discontinued. This change in diagnostic code does not amount to a reduction, as the rating of the Veteran's left and right knee disabilities increases from 10 percent to 20 percent for each knee as a result of this decision. Within this context, the Board also finds that as the criteria for a disability rating in excess of 10 percent were not met under DC 5260 or 5261, the criteria for a disability rating in excess of 20 percent under those diagnostic codes are also not met. Based on the foregoing, the Board finds that the preponderance of the evidence weighs against the assignment of a disability rating for each of the left and right knee disabilities in excess of 20 percent for the rating period from September 20, 2007 to November 17, 2009 for the left knee and from September 20, 2007 to December 27, 2011 for the right knee. 38 C.F.R. §§ 4.3, 4.7, 4.71a. Temporary Total Rating Pursuant to 38 C.F.R. § 4.30 for December 2011 Total Right Knee Replacement Surgery Temporary total ratings will be assigned from the date of hospital admission and continue for one, two, or three months from the first day of the month following hospital discharge when treatment of a service-connected disability results in: (1) surgery necessitating at least one month of convalescence; (2) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (3) immobilization by cast, without surgery, of one major joint or more. An extension of one, two, or three months beyond the initial three months may be granted and extensions of one or more months up to six months beyond the initial six months period may be made, upon approval of the Veterans Service Center Manager. 38 C.F.R. § 4.30. The term "convalescence" does not necessarily entail in-home recovery. Felden v. West, 11 Vet. App. 427, 430 (1998). Convalescence is defined as "the stage of recovery following an attack of disease, a surgical operation, or an injury." Id. at 430 (citing Dorland's Illustrated Medical Dictionary, 374 (28th ed. 1994)). The recovery has been defined as "the act of regaining or returning toward a normal or healthy state." Id. (citing Webster's Medical Desk Dictionary 606 (1986)). The purpose of a temporary total rating is to aid the appellant during the immediate post-surgical period when he or she may have incompletely healed wounds or may be wheelchair-bound, or when there may be similar circumstances indicative of transient incapacitation associated with recuperation from the immediate effects of an operation. 38 C.F.R. § 4.30. Notations in the medical record as to the claimant's incapacity to work after surgery must be taken into account in the rating. 38 C.F.R. § 4.30; see Seals v. Brown, 8 Vet. App. 291, 296-97 (1995); Felden, 11 Vet. App. at 430. While the Veteran has not made any specific contentions with respect to entitlement to a temporary total rating under 38 C.F.R. § 4.30 for convalescence after the December 2011 total right knee replacement surgery, the Board will consider such entitlement as part of the increased rating claim for the right knee disability and because the right knee surgery took place during the increased rating period on appeal. The Board finds that the evidence is in relative equipoise that the December 2012 right knee surgery resulted in severe postoperative residuals so warrants a temporary total rating for convalescence from December 27, 2011 to July 1, 2012. See 38 C.F.R. § 4.30(a)(2), (b)(1). The record reflects that the Veteran underwent total right knee replacement on December 27, 2011 with postoperative complications that resulted in an extra week spent at the hospital. The Veteran missed five weeks of work due to persistent swelling, anemia, and difficulty with physical therapy. In March 2012, the Veteran was seen by an orthopedic surgeon multiple times and was diagnosed with an infected total right knee replacement; therefore, the Veteran underwent a right knee resection arthroplasty on March 22, 2012. The March 2012 arthroplasty resulted in a five-day hospital stay and postoperative complications that were not as severe as the complications after the December 2011 surgery. The Veteran continued to have post-right knee surgery complications, including renal failure. See April 2012 R.Q., D.O., statement; June 2013 VA examination report. The Veteran's private orthopedist indicated that the Veteran was scheduled for another right knee resection surgery in March 25 with an expectation that the Veteran would stay in the hospital for 4 to 5 days, and would be off work for 5 weeks thereafter, although it was possible for the Veteran to return to work after 4 weeks. Id. The record reflects that the Veteran underwent right knee revision surgery on May 25, 2012 and was discharged from the hospital on May 30, 2012. Resolving reasonable doubt in the Veteran's favor, the Board finds that the December 2011 total right knee replacement surgery resulted in severe postoperative residuals, to include incompletely healed surgical wounds, until July 1, 2012; as such, the Veteran was in convalescence from December 27, 2011 to July 1, 2012. 38 C.F.R. § 4.30(a)(2). While the record does not show that the Veteran had stumps of recent amputation of the right knee, therapeutic immobilization of the right knee, application of a body case, necessity of house confinement, or prohibition on regular weight-bearing on the right knee as a result of the December 2011 right knee surgery, the Board is resolving doubt in favor of the Veteran by granting a five-month extension of the one-month convalescence period under 38 C.F.R. § 4.30 in light of the complications, hospitalizations, and multiple right knee surgeries that the Veteran underwent as a result of the December 2011 total right knee replacement surgery. The Board has also taken into account the convalescence period after the May 2012 surgery as per the April 2012 letter by R.Q., D.O. The Board finds that the weight of the lay and medical evidence of record is against extension of the convalescence period beyond the first 6 months pursuant to 38 C.F.R. § 438 C.F.R. § 4.30(b)(2). The weight of the evidence demonstrates that the Veteran was not in convalescence after July 1, 2012 due to severe postoperative residuals of the December 2011 right knee total replacement surgery, such as incompletely healed right knee surgical wounds, stumps of recent amputation of the right knee, therapeutic immobilization of the right knee, application of a body case, necessity of house confinement, or prohibition on regular weight-bearing on the right knee by requiring the use of crutches or a wheelchair. A July 2012 private treatment record shows that the Veteran was doing well, that he ambulated with a cane, that he reported mild pain with range of motion, and denied drainage from the right knee surgical wound. Upon examination in July 2012, the private orthopedist assessed significant effusion of the right knee, and recorded right knee flexion to approximately 95 degrees and full right knee extension. The July 2012 private orthopedist indicated that the surgical wound was healing well. A July 2012 VA radiology report noted total right knee prosthesis with large joint effusion. In July 2012, the Veteran underwent an aspiration of the right knee, but effusion continued to affect range of motion of the right knee. An August 2012 private treatment record shows that the Veteran reported intermittent pain and swelling of the right knee. Upon examination in August 2012, the private orthopedist assessed moderate effusion of the right knee, and recorded right knee flexion to approximately 95 degrees and full right knee extension. A September 2012 private treatment record shows that the Veteran reported intermittent right knee pain which he rated at 3 out of 10 in severity, as well as right knee stiffness. Upon examination in September 2012, the private orthopedist assessed minimal right knee edema, and recorded right knee flexion to approximately 95 degrees and full right knee extension. The private orthopedist also indicated that the right knee was still warm with a small effusion. An October 2012 private treatment record shows that the Veteran reported intermittent right knee pain which he rated at 2 out of 10 in severity, as well as right knee stiffness. Upon examination in October 2012, the private orthopedist again assessed minimal right knee edema, and recorded right knee flexion to approximately 95 degrees and full right knee extension. The private orthopedist also indicated that the right knee was still warm with a small effusion and palpable scar tissue. A November 2012 private radiology report shows an assessment of total right knee prosthesis with moderate joint effusion. A November 2012 private treatment record shows that the Veteran reported intermittent right knee pain which he rated at 2 out of 10 in severity, as well as right knee stiffness that did not improve with physical therapy. Upon examination in November 2012, the private orthopedist assessed minimal right knee edema, and recorded right knee flexion to approximately 95 degrees and full right knee extension. The orthopedist also indicated that the right knee was still warm with a small effusion and palpable scar tissue with but nonpalpable skin masses lymphadenopathy of the right knee, leg, or thigh. On December 7, 2012, the Veteran underwent a right knee manipulation under anesthesia (MUA) in order to help reduce right knee stiffness and improve range of motion. A December 7, 2012 VA treatment record showed that the Veteran had improved ambulation and range of motion of the right knee. Based on the foregoing, the lay and medical evidence reflects that the Veteran had moderate to severe residuals of total right knee replacement from July 1, 2012; however, such residuals did not rise to the level required for convalescence under 38 C.F.R. § 4.30(a)(2). The evidence of record starting from July 2012 shows that surgical wounds were well healed and that the Veteran did not need therapeutic immobilization of the right knee joint or was prevented from weight bearing. The record also reflects that there was no necessity of house confinement. In fact, the Veteran returned to work in July 2012 and was performing physical therapy, albeit some of the exercised were difficult. Moreover, the Veteran consistently had full knee extension with flexion to approximately 95 degrees. This disability picture does not more nearly approximate the impairment resulting from the need for convalescence due to severe residuals such as contemplated under 38 C.F.R. § 4.30 for the period starting from July 1, 2012. Moreover, any symptoms and impairment resulting from severe residuals of the December 2011 total right knee replacement for the period from July 1, 2012 are contemplated by the 100 percent schedular rating awarded for one year from July 1, 2012 to July 1, 2013 as discussed in more detail below. For these reasons, the Board finds that a temporary total rating for convalescence is not warranted from July 1, 2011 as a result of residuals from the December 27, 2011 total right knee replacement surgery. See 38 C.F.R. § 4.30(a)(2), (b)(1). Right Knee 100 Percent Schedular Rating from July 1, 2012 to July 1, 2013 After review of the lay and medical evidence of record, the Board finds that the evidence shows that the criteria for a 100 percent schedular rating from July 1, 2012 to July 1, 2013 under DC 5055 are met for the right knee disability. The evidence shows that the Veteran had total right knee replacement on December 27, 2011, and has been awarded a temporary total rating for convalescence pursuant to 38 C.F.R. § 4.30 from the date of the right knee surgery on December 27, 2011 to July 1, 2012. DC 5055 provides for a 100 percent rating for 1 year following implantation of prosthesis beginning after initial grant of the 1-month total rating assigned under 38 C.F.R. § 4.30. The temporary total rating pursuant to 38 C.F.R. § 4.30 will be followed by an open rating reflecting the appropriate schedular rating. See 38 C.F.R. § 4.30(a). Therefore, pursuant to DC 5055, a 100 percent schedular rating is warranted for one year starting from July 1, 2012 (the day of expiration of convalescence period under 38 C.F.R. § 4.30) to July 1, 2013. Left Knee Rating from February 1, 2011 and Right Knee Rating from July 1, 2013 After reviewing all the lay and medical evidence of record, the Board finds that the evidence is in relative equipoise that, after the period of convalescence and one year schedular 100 percent rating period following the November 2009 left knee arthroplasty and the December 2011 right knee arthroplasty, both knees have demonstrated chronic residuals consisting of severe painful motion or weakness. The June 2013 VA examiner opined that both knees have chronic residuals of bilateral knee arthroplasty consisting of severe painful motion or weakness. During the June 2013 VA examination, the Veteran reported that he had chronic bilateral knee pain with the right knee being worse than the left one. The Veteran also noted that residuals of the November 2009 left knee arthroplasty and the December 2011 right knee arthroplasty included multiple right knee surgeries and chronic aching pain, chronic swelling, decreased range of motion, and weakness. While VA treatment records and the Veteran's statements reveal that the Veteran has more pain and weakness in the right knee than the left knee, the Board is resolving doubt with respect to the left knee in light of the June 2013 VA examiner's opinion. Because the evidence shows chronic residuals that more nearly approximate severe painful motion and weakness of the left knee from February 1, 2011 and of the right knee from July 1, 2013, the criteria for a 60 percent rating under DC 5055 are met for the left Knee from February 1, 2011, and for the right knee for the rating period from July 1, 2013. A 60 percent rating is the highest rating available for residuals following knee replacement under DC 5055 and contemplates all the Veteran's bilateral knee symptoms. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation would have been warranted for the right and left knee disabilities for any part of the appeal period. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. Turning to the first step of the extraschedular analysis, with respect to the claim for an increased rating for right and left knee disabilities, the Board finds that all the and impairment caused by the Veteran's right and left knee disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria under DC 5258 specifically provide ratings for meniscal tears and resulting episodes of locking, pain, and effusion. The schedule rating criteria also contemplate limitation of motion due to painful arthritis (DC 5003, 38 C.F.R. § 4.59 ), and contemplate disability ratings based on limitation of motion, including as due to pain, lack of endurance, and other limiting factors. See 38 C.F.R. §§ 4.21, 4.40, 4.45, 4.59, 4.71a; see also DeLuca at 202. In this case, considering the lay and medical evidence, the right and left knee disabilities have been manifested by a meniscal tear of the left knee and history of a right knee meniscal tear, with episodes of pain, locking, and effusion, as well as painful motion of both knees, these symptoms and resulting impairment are contemplated by the schedular rating criteria. Moreover, symptoms of stiffness are considered as similar to painful motion or limited motion, and reported symptoms of crepitus, feelings of giving way, clicking, snapping, and popping are similar to limited motion of the knee as due to pain, weakness, incoordination, or fatigability, which have all been incorporated into the schedular criteria, and were considered in this case in assessing severity of knee disabilities as limited by reported symptoms that include pain and during flare-ups. Id. The Veteran's complaints of increased pain on weight-bearing, walking, prolonged sitting, and climbing of stairs are part of, "like," and analogous to the symptom and functional impairment of pain on movement, which is already contemplated in the 20 percent rating. The Board may not compensate the Veteran twice for the same symptoms and impairment. 38 C.F.R. § 4.14 (avoidance of pyramiding). The Board has additionally considered ratings under alternate schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology, to include DCs 5256 to 5263. Moreover, the schedular rating criteria under DC 5055 specifically provide a 100 percent rating for the one year period following a knee replacement, and provide ratings for the chronic residuals thereafter based on the severity of symptoms and functional impairment, without limitation as to the factors that may be considered. In this case, the evidence shows chronic residuals of severe painful motion or weakness of left knee from February 1, 2011 and of the right knee from July 1, 2013, which is contemplated by the criteria for a 60 percent rating under DC 5055 for the left knee from February 1, 2011, and for the right knee for the rating period from July 1, 2013. Therefore, the Board finds that the record does not reflect that the Veteran's right and left knee disabilities are so exceptional or unusual as to warrant referral for consideration of the assignment of a higher rating on an extraschedular basis. According to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be entitled to "consideration [under 38 C.F.R. § 3.321(b)] for referral for an extra-schedular evaluation based on multiple disabilities, the combined effect of which is exceptional and not captured by schedular evaluations." Referral for an extraschedular rating under 38 C.F.R. § 3.321(b) is to be considered based upon either a single service-connected disability or upon the "combined effect" of multiple service-connected disabilities when the "collective impact" or "compounding negative effects" of the service-connected disabilities, when such presents disability not adequately captured by the schedular ratings for the service-connected disabilities. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. There is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the symptoms reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect of the Veteran's symptoms on his occupation and daily life. In the absence of exceptional factors associated with the service-connected right knee and left knee disabilities, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is potentially an element of all increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the record does not reflect, and the Veteran does not allege, that he is unemployable due to the service-connected disabilities. The record reflects that the Veteran is currently employed by the federal government. The record reflects that the Veteran has difficulty with prolonged walking, prolonged sitting, and climbing stairs, as well as difficulty with driving due to prolonged sitting. The June 2013 VA examiner noted that the bilateral knee disabilities affected the Veteran's ability to work in that he missed many days of work and no longer has any sick leave. Therefore, the record reflects that the Veteran is currently working with some limitation on prolonged walking, prolonged sitting, and climbing stairs, as well as using up his sick leave at work. As stated above, the schedular rating criteria are intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. As such, the Veteran is already being compensated for any difficulties at work resulting from the service-connected disabilities. For the reasons above, and in light of the fact that the Veteran is currently working, the Board finds that an inferred claim for a TDIU has not been raised and, therefore, is not before the Board on appeal. See Rice, 22 Vet. App. 447 ORDER An increased disability rating of 20 percent for the service-connected left knee degenerative arthritis status post total left knee replacement, for the period from September 20, 2007 to November 17, 2009, is granted; an increased disability rating of 60 percent, for the period from February 1, 2011, is granted. An increased disability rating of 20 percent for the service-connected right knee degenerative arthritis status post total right knee replacement, for the period from September 20, 2007 to December 27, 2011, is granted; a temporary total (100 percent) rating for convalescence following total right knee replacement surgery, for the period from December 27, 2011 to July 1, 2012, is granted; an increased disability rating of 100 percent, for the period from July 1, 2012 to July 1, 2013, is granted; an increased disability rating of 60 percent, for the period from July 1, 2013, is granted. REMAND Increased Rating for Lumbar Spine Disability Where a claimant asserts that the disability in question has increased in severity since the most recent rating examination, an additional examination is appropriate where the competent medical evidence is otherwise insufficient to decide the claim. See VAOPGCPREC 11-95; Caffrey v. Brown, 6 Vet. App. 377 (1995); Green v. Derwinski, 1 Vet. App. 121 (1991). In a February 2015 statement, the Veteran's representative stated that, because the most recent VA examination of record was conducted in October 2007, a new examination is needed to help determine the current severity of the service-connected lumbar spine disability. Because the Veteran's representative is asserting that the lumbar spine disability has increased in severity since the October 2007 VA examination, the Board finds that a remand for an updated VA examination is warranted. See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where the record does not adequately reveal current state of claimant's disability, fulfillment of statutory duty to assist requires a contemporaneous medical examination - particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination); Caffrey, 6 Vet. App. at 381 (the Board should have ordered a contemporaneous examination of a veteran because an exam was too remote in time to adequately support a decision on appeal for an increased rating). Accordingly, the issue of entitlement to an increased rating for the service-connected lumbar spine disability is REMANDED for the following actions: 1. Schedule the Veteran for the appropriate VA examination to help ascertain the current extent of the service-connected lumbar spine disability, to include an assessment of the severity of any neurological manifestations of the lumbar spine disability. The relevant documents in the claims folder should be made available for review in connection with this examination. All indicated tests and studies should be performed. 2. Thereafter, the AOJ should readjudicate the issue increased rating for lumbar spine disability on appeal. If the benefit sought on appeal is not granted, the Veteran and representative should be provided with a supplemental statement of the case (SSOC), and afforded the appropriate time period within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2014). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs