Citation Nr: 18153638 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 08-04 018 DATE: November 28, 2018 ORDER Prior to November 18, 2010, a disability rating in excess of 10 percent for lumbosacral strain is denied. Beginning November 18, 2010, a disability rating of 20 percent, but not higher, for lumbosacral strain is granted, subject to the laws and regulations governing the payment of monetary awards. Prior to November 18, 2010, a disability rating of 10 percent, but not higher, for chronic right knee degenerative joint disease is granted, subject to the laws and regulations governing the payment of monetary awards. Prior to November 18, 2010, a disability rating of 10 percent, but not higher, for left knee strain is granted, subject to the laws and regulations governing the payment of monetary awards. An increased disability rating for chronic right knee degenerative joint disease in excess of 10 percent from November 18, 2010, to April 2, 2015, and in excess of 20 percent thereafter is denied. Beginning November 18, 2010, an increased disability rating in excess of 10 percent for left knee strain is denied. An effective date of February 8, 2007, but no earlier, for the award of service connection for right lower extremity (sciatic nerve) associated with lumbosacral strain is granted, subject to the laws and regulations governing the payment of monetary awards. FINDINGS OF FACT 1. Prior to November 18, 2010, the Veteran’s lumbosacral strain was manifested by pain, limitation of range of motion, lack of endurance and frequent fatigue with forward flexion limited to 80 degrees, but it did not result in forward flexion of 60 degrees or less, a combined range of motion of less than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, ankylosis of the entire thoracolumbar spine, or incapacitating episodes. 2. Beginning November 18, 2010, the Veteran’s lumbosacral strain was manifested by pain, limitation of range of motion, cramping with motion, guarding with back extension, and forward flexion limited to less than 60 degrees, but it did not result in forward flexion of 30 degrees or less or ankylosis of the entire thoracolumbar spine or incapacitating episodes. 3. Prior to November 18, 2010, the Veteran’s bilateral knee disabilities manifested as painful motion after repetitive use over time, specifically walking, but did not manifest as flexion limited to 30 degrees or less. 4. From November 18, 2010, to April 2, 2015, the Veteran’s chronic right knee degenerative joint disease did not have extension limited to 15 degrees or more. 5. Beginning April 3, 2015, the Veteran’s chronic right knee degenerative joint disease did not have extension limited to 20 degrees or more. 6. Beginning November 18, 2010, the Veteran’s left knee strain did not have flexion limited to 30 degrees or less. 7. As of the February 8, 2007, VA spine examination, there is medical and lay evidence of mild incomplete paralysis of the sciatic nerve in the right lower extremity associated with lumbosacral strain for which the Veteran was service-connected effective June 2, 2017. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating for lumbosacral strain in excess of 10 percent prior to November 18, 2010, are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 2. Beginning November 18, 2010, the criteria for a disability rating of 20 percent, but not higher, for lumbosacral strain are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 3. Prior to November 18, 2010, the criteria for a disability rating of 10 percent, but not higher, for chronic right knee degenerative joint disease are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 4. Prior to November 18, 2010, the criteria for a disability rating of 10 percent, but not higher, for left knee strain are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 5. The criteria for a disability rating for chronic right knee degenerative joint disease in excess of 10 percent from November 18, 2010, to April 2, 2015, and in excess of 20 percent thereafter are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 6. Beginning November 18, 2010, the criteria for a disability rating in excess of 10 percent for left knee strain are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 7. From February 8, 2007, but no earlier, the criteria for entitlement to service connection for right lower extremity (sciatic nerve) associated with lumbosacral strain are met. 38 U.S.C. §§ 501, 5101(a), 5110; 38 C.F.R. § 3.400(o)(2). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1979 to October 1991. These matters come before the Board of Veterans’ Appeals (Board) on appeal from February 2007 and July 2012 rating decisions. In June 2010, the Veteran testified at a Travel Board hearing before the undersigned, and a transcript is of record. In a February 2016 decision, in pertinent part, the Board denied an increased disability rating for lumbosacral strain prior to April 3, 2015, and granted a 20 percent rating thereafter, and denied increased evaluations for bilateral knee strain. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court), and in a November 2016 order, the Court granted the parties’ Joint Motion for Partial Remand (JMPR), vacated the Board’s decision as to the appealed issues and remanded the matters for further development and readjudication consistent with the JMPR. In April 2017, the Board remanded these issues for further development, and the case has been returned for appellate consideration. The Board finds there has been substantial compliance with its April 2017 remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial and not strict compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)); see also Dyment v. West, 13 Vet. App. 141, 146–47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board’s remand). The Board notes that in an April 2014 rating decision service connection for chronic obstructive pulmonary disease was granted, evaluated as 100 percent disabling effective June 11, 2010. In an October 2017 rating decision, the Veteran was awarded special monthly compensation (SMC) based on housebound criteria being met effective June 2, 2017, and in a July 2018, rating decision, SMC based on aid and attendance criteria was awarded effective June 7, 2018. Increased Rating Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran’s symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Disability evaluations are determined by assessing the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2. If there is a question as to which evaluation should be applied to the veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran’s disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the standard working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. With particular respect to the joints, the disability factors 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. When evaluating joint disabilities rated on the basis of limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or § 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or § 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or § 4.73] criteria.”). Ankylosis is the immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health 68 (4th ed. 1987)). Concerning the range of motion findings of the joints at issue here, the Board notes that not all the VA examination reports include passive range of motion or specify range of motion with and without weight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). The fundamental issue for Correia is that VA examinations perform adequate joint testing for pain. Generally, active range of motion testing produces more restrictive results than passive range of motion testing, in that passive range of motion testing requires the physician to force the joint through its motions. For those examinations of record where range of motion testing was performed only on weight bearing, there is no prejudice to the Veteran in relying on them because such results tend to produce the “worst case scenario” of impairment and thus would tend to support the highest possible rating. The claimant bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107(a); Fagan v. Shinseki, 573 F.3d 1282, 1286–88 (Fed. Cir. 2009). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Here, the Board reviewed all evidence in the claims file, with an emphasis on that which is 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 the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. In March 2005, the Veteran claimed for increased ratings of his service-connected lumbosacral strain and bilateral chondromalacia patella. Hence, the appeal period before the Board begins March 21, 2004, the date VA received the claims for increased ratings, plus the one-year look-back period. 38 U.S.C. §§ 5110(a), (b)(3); 38 C.F.R. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The Veteran essentially contends that his service-connected disabilities are more disabling than contemplated by the assigned ratings. Therefore, the question for the Board, as to each of the Veteran’s service-connected disabilities, is whether his disability picture more nearly approximated the criteria for a higher disability rating. The Board notes that the Veteran is competent to report that which he has perceived through the use of his senses, including the occurrence of pain and other symptoms of his disabilities. See 38 C.F.R. § 3.159(a)(2); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting that lay evidence is competent with regard to facts perceived through the use of the five senses). He is not, however, competent to state whether his symptoms warrant a specific rating under the schedule for rating disabilities, and the Board finds that the objective medical findings are more probative. See Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Prejean v. West, 13 Vet. App. 444, 448–9 (2000). 1. Entitlement to an increased disability rating for lumbosacral strain, evaluated as 10 percent disabling prior to April 3, 2015. In the Board’s February 2016 decision, it denied an evaluation in excess of 10 percent disabling for lumbosacral strain prior to April 3, 2015, and granted an evaluation of 20 percent thereafter. In his appeal to the Court, the Veteran appealed the denial of an increased disability rating prior to April 3, 2015. The Veteran essentially contends that prior to April 3, 2015, his service-connected lumbosacral strain was more disabling than contemplated by the assigned evaluation of 10 percent disabling. In the JMPR, it was agreed that the November 2010 VA spine examination was inadequate based upon to the examiner’s failure to state the Veteran’s functional loss due to pain during flare-ups or repetitive use in terms of degrees of lost range of motion. In considering the evidence of record under the laws and regulations set forth herein, the Board concludes that, prior to November 18, 2010, a disability rating in excess of 10 percent is not warranted, and beginning November 18, 2010, the criteria for a disability rating of 20 percent, but not higher, are met. The Veteran’s lumbosacral strain is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237, currently evaluated as 10 percent disabling prior to April 3, 2015. Under the General Rating Formula for Diseases and Injuries of the Spine, ratings for the thoracolumbar spine are assigned as follows: A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 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 rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Additional notes are as follows: Note (1): Evaluate any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is 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 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. Note (3): 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): Round each range of motion measurement to the nearest five degrees. Note (5): 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): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Per Note (6), intervertebral disc syndrome (IVDS) (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). The Formula for Rating IVDS Based on Incapacitating Episodes provides that incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months warrants a 10 percent evaluation. A 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. See 38 C.F.R. § 4.71a, General Rating Formula, Diagnostic Code 5243. The Formula for Rating IVDS has the following notes: Note (1): For purposes of evaluations under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Note (2): If IVDS is present in more than one spinal segment, provided that the affects in each spinal segment are clearly distinct, evaluate each segment on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. Here, in his appeal to the Court, although the Veteran was critical of only the November 2010 VA examination, for context it is essential to the Board’s analysis to examine all the pertinent medical evidence introduced during the period on appeal. In a March 2005 statement in support of claim, the Veteran claimed for an increased disability rating of his lumbosacral strain. In a June 2005 rating decision, the Regional Office (RO) increased the evaluation of the Veteran’s lumbosacral strain to 10 percent disabling effective March 21, 2005. In June 2005, the Veteran was afforded a VA spine examination, during which he was diagnosed with lumbosacral strain with residuals. The Veteran reported daily pain in his back above the belt line, which was non-radiating and described as a sharp, stabbing pain with movement. He reported it was 7/10 in intensity. He reported that he took two Tylenol three to four times per day and Elavil at night with minimal relief. It was noted that he did not use any assistive devices. He reported being able to perform the activities of daily living but he was unemployed. Upon initial range of motion testing, forward flexion was to 80 degrees with pain; extension was to 20 degrees with pain; left lateral flexion was to 30 degrees without pain; right lateral flexion was to 30 degrees without pain; left lateral rotation was to 30 degrees without pain; and right lateral rotation was to 30 degrees without pain. It was noted that inspection of the lumbar spine revealed normal posture, norma; gait, normal curvature of the spine, and normal symmetry in appearance and normal rhythm of spinal motion. It was noted that there were no additional limitations with repetition of movement during the examination related to pain, fatigue, incoordination, weakness, or lack of endurance. It was noted that the Veteran did have objective evidence of painful motion without spasm, weakness, or tenderness, and he did not have any posture abnormalities. It was noted that the sensory, motor, and reflex examinations were intact. It was noted that an X-ray of the lumbar spine from August 2003 was within normal limits. In February 2007, the Veteran was afforded a VA spine examination, during which he was diagnosed with chronic lumbosacral strain. The Veteran reported back pain daily that radiated into both legs. He reported having difficulty getting into a comfortable position to sleep and having increased limitations with flare-ups. He reported that repetitive motion increased the pain; that he had difficulty with endurance and fatigued easily; and that he could not stand to do any type of work. He reported that he drove and did limited work at home. The examiner noted that it seemed he was taking Tylenol with codeine as needed. It was noted that there was straightening of the lumbar lordosis and that there was not tenderness on palpation. Upon initial range of motion testing, forward flexion was to 80 degrees; left lateral flexion was to 20 degrees with pain; right lateral flexion was to 20 degrees with pain; left lateral rotation was to 30 degrees without pain; and right lateral rotation was to 30 degrees without pain. It was noted that there was no additional loss of range of motion, coordination, fatigue, endurance, or pain level with repetitive use testing. It was noted that the Veteran could barely stand on his heels or toes to walk; reflexes were absent in the knees and ankles; muscle strength was good; and straight leg testing was negative. In the February 2007 rating decision that is on appeal, the RO continued the evaluation of the Veteran’s lumbosacral strain as 10 percent disabling. In June 2010, the Veteran testified before the undersigned during a Travel Board hearing. He stated that he had a lot of pain in his back, taking medication six to seven times a day, and that after sleeping he had stiffness. He stated he had limitations in standing, walking, and doing his chores. He stated he slept three hours, woke, and then slept three more hours each night. He stated he was being seen at VA every three months. He stated that his symptoms were 80 percent worse than they were during the February 2007 VA examination, being a 9/10, whereas before it fluctuated between 7 and 10. He stated that his range of motion had changed in that when he turned he got cramps. In November 2010, the Veteran was afforded a VA spine examination, during which he was diagnosed with lumbosacral strain with residuals. It was noted that he took acetaminophen with fair response. The Veteran reported weekly flare-ups that lasted hours, which were triggered by turning or laying down wrong, lifting, sexual relations, bending, and driving. He reported increased pain and reduced mobility during flare-ups. Numbness and paresthesias were noted with numbness, tingling in the lower back area only. It was noted there was a history of fatigue. The Veteran reported 10 incapacitating episodes of low back pain in a year’s time. It was noted that the Veteran was unable to walk more than a few yards, with the gait described as slow but independent without assistive devices. It was noted that posture was normal. Lumbar flattening was noted. On initial range of motion testing, flexion was to 90 degrees; extension was to 30 degrees; left lateral flexion was to 45 degrees; left lateral rotation was to 30 degrees; right lateral flexion was to 45 degrees; right lateral rotation was to 30 degrees, all with objective evidence of pain. It was noted that there was objective evidence of pain on repetitive motion testing but no additional limitations. It was recorded that motor examination was normal and there was no muscle atrophy. It was indicated that there were not any incapacitating episodes due to IVDS. In April 2015, the Veteran was afforded a VA examination for back (thoracolumbar spine) conditions, during which degenerative arthritis of the spine was diagnosed. The Veteran reported constant mid- to low-back pain with variable intensity of nagging and stabbing, averaging 7/10. He reported that pain increased with trunk twisting and forward bending, and he was unable to identify any alleviating positions or activities. He denied tingling/numbness. He reported taking Tylenol and using a back brace. It was indicated that the Veteran did not report flare-ups. It was noted that he avoided prolonged standing or sitting but otherwise remained functional in activities of daily living, including remaining sexually active. It was noted that he still drove independently. On initial range of motion testing, forward flexion was to 75 degrees; extension was to 5 degrees; right lateral flexion was to 20 degrees; left lateral flexion was to 20 degrees; right lateral rotation was to 30 degrees; and left lateral rotation was to 25 degrees. It was noted that there was pain in all directions of motion but it did not contribute to functional loss. It was noted that there was evidence of pain on weight bearing. It was noted that there was not additional loss of function or range of motion on repetitive use testing. It was noted that there was mild palpable tenderness over mid-spine at T-8 through S-1 levels, and over bilateral paraspinals at L-4 to S-1 levels. It was indicated that the Veteran had guarding, muscle spasm, and localized tenderness that did not result in abnormal gait or abnormal spinal contour. It was stated that there was guarding noted with back extension range of motion due to spasms. It was noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Due to pain, weakness, fatiguability, or incoordination, it was estimated that range of motion was limited on forward flexion from 40 to 75 degrees; extension to 5 degrees; right lateral flexion from 10 to 25 degrees; left lateral flexion from 10 to 20 degrees; right lateral rotation from 15 to 30 degrees; and left lateral rotation from 15 to 25 degrees. It was indicated that muscle strength was normal and there was no muscle atrophy. Reflex examination revealed bilateral ankles as 1+, hypoactive. Sensory examination was normal, and straight leg raising test was bilaterally negative. It was indicated that there were no symptoms of radiculopathy, and there was no ankylosis of the spine. It was noted that the Veteran’s gait was mildly antalgic, favoring the right side due to his right knee condition. It was recorded that he could stand on heels and toes but he declined to attempt to heel/toe walk due to fear of falling. It was indicated that he did not have IVDS. It was noted that he occasionally used a back brace. It was noted that there were imaging studies showing degenerative disc disease and arthropathy. In January 2018, addressing the November 2010 VA examination, the VA examiner who performed an examination in June 2017 was asked to opine on the November 2010 VA examination as to estimated additional loss of function during flare-ups and repetitive use over time. The examiner responded that because the November 2010 examination was not performed under either circumstance, it would be mere speculation to report additional losses. Evaluation prior to November 18, 2010 Based upon a careful review of the foregoing, the Board finds that, prior to November 18, 2010, the date of the Veteran’s VA examination, an evaluation in excess of 10 percent disabling for the Veteran’s lumbosacral strain is not warranted. However, resolving reasonable doubt in favor of the Veteran, the Board finds that an effective date of February 8, 2007, but no earlier, for the award of service connection for right lower extremity (sciatic nerve) associated with lumbosacral strain is warranted. Prior to November 2010, the medical and lay evidence establishes that the Veteran’s lumbosacral strain was not manifested by forward flexion of less than 60 degrees, a combined range of motion of less than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, ankylosis of the entire thoracolumbar spine, or incapacitating episodes. Indeed, during the June 2005 and February 2007 VA examinations, the Veteran’s forward flexion was, at worst, 80 degrees with objective evidence of pain, with no additional loss of range of motion upon repetitive use testing. The Veteran reported fluctuations in severity of pain, with increased pain being the significant aspect of his flare-ups. In June 2005, it was noted that posture, gait, and curvature of the spine were normal, while in February 2007, it was noted that there was straightening of the lumbar lordosis but no indication of muscle spasm or guarding. In addition to schedular criteria, the Board has considered functional loss due to flare-ups of pain, weakness, fatiguability, incoordination, pain on movement, and lack of endurance. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran competently and credibly reported daily pain, need to shift positions frequently, and difficulty with endurance and frequent fatigue, however, the Board finds the objective medical findings more probative. See 38 C.F.R. §§ 3.159(a), 4.40, 4.45, 4.59 (2017); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting lay evidence is competent with regard to facts perceived through the use of the five senses); Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007); see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Prejean v. West, 13 Vet. App. 444, 448–9 (2000). During repetitive use testing, the Veteran’s forward flexion was to 80 degrees with pain, unchanged from the initial range of motion testing. Furthermore, the Veteran did not allege that he had reduced range of motion during flare-ups of pain. A disability rating of 10 percent contemplates the Veteran’s functional loss since his range of motion for forward flexion falls squarely between 60 to 85 degrees. The Board acknowledges the Veteran’s repeated complaints of constant pain. Pain alone, however, is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36–8 (2011). The Board finds that, prior to November 18, 2010, the Veteran was not so limited by the factors noted in DeLuca and 38 C.F.R. §§ 4.40, 4.45, and 4.59 as to constitute forward flexion of 60 degrees or less, a combined range of motion of less than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, ankylosis of the entire thoracolumbar spine, or incapacitating episodes. While flattening of the lumbar lordosis was noted in February 2007 and November 2010, this was not attributed to muscle spasm. Accordingly, the Veteran’s functional loss does not more nearly approximate the criteria for an increased rating. The Board also notes that during the November 2010 examination the Veteran reported 10 incapacitating episodes of low back pain in a year’s time. This was not due to IVDS, however, such that rating alternatively under the Formula for Rating IVDS Based on Incapacitating Episodes is not warranted. The November 2010 and April 2015 examiners specifically indicated that IVDS was not present. Furthermore, the evidence does not establish that these claimed incapacitating episodes were treated by a physician with ordered bedrest. The Board has also considered whether a separate evaluation is warranted for any neurological deficits, and notes that, pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520, the Veteran is service-connected for right lower extremity (sciatic nerve) associated with lumbosacral strain evaluated as 10 percent disabling effective June 2, 2017. Under Diagnostic Code 8520, mild incomplete paralysis warrants a 10 percent disability rating, moderate incomplete paralysis warrants a 20 percent disability rating, moderately severe incomplete paralysis warrants a 40 percent disability rating, and severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability rating. An 80 percent disability rating is warranted for complete paralysis, where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. An accompanying note to the schedule of ratings for diseases of the peripheral nerves directs that the term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Additionally, an accompanying note directs that neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating that may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to an earlier effective date for this separate 10 percent rating for right lower extremity (sciatic nerve) associated with lumbosacral strain is warranted. The Board finds that there was medical evidence of this condition since the February 2007 VA spine examination and lay evidence of this condition since May 2007. It was noted during the February 8, 2007, VA spine examination that reflexes were absent in the knees and ankles. In May 2007, the Veteran testified before a decision review officer that due to pain and numbness in his right leg he had to stop every 50 miles when driving. He also related that in 2004 or 2005 his right knee went numb and gave out while he was riding a bicycle, causing him to fall. During his June 2010 Travel Board hearing, the Veteran testified that his legs went to sleep. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that an effective date of February 8, 2007, but no earlier, for the award of service connection for right lower extremity (sciatic nerve) associated with lumbosacral strain is warranted. As to the Veteran’s left lower extremity, the Board finds that there is no evidence of neurological abnormalities to warrant a separate rating. During the February 2007 VA examination it was noted that reflexes in the knees and ankles were absent, and in June 2010, the Veteran testified that his legs went to sleep. While the Veteran was very specific about related symptomatology in his right leg, he did not make any specific complaints about his left leg that would indicate a correlation to the one-off testing result of no reflexes in the left lower extremity. During the February 2007 examination, muscle strength was good and straight leg raising test was negative. Evaluation beginning November 18, 2010 Beginning November 18, 2010, the Board finds that the evidence establishes that the Veteran’s disability picture more nearly approximated the criteria for a 20 percent disability rating, but not higher. During the Veteran’s June 2010 Travel Board hearing, he stated that his range of motion had changed in that when he turned he developed cramps. The report of the November 2010 VA examination shows that the Veteran reported reduced mobility during flare-ups. The Board agrees with the medical opinion that the November 2010 VA examination report does not contain sufficient data to estimate the Veteran’s additional loss of range of motion during flare-ups, but the April 2015 VA examination report provides adequate guidance. During the April 2015 VA examination, the examiner indicated that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time, and it was estimated that the Veteran’s range of motion was limited on forward flexion to 40 to 75 degrees. This places the Veteran’s range of motion to less than 60 degrees on forward flexion, which corresponds to a disability rating of 20 percent. It was noted that there was guarding with back extension due to spasms and that there was mild palpable tenderness over essentially the entire back. While the April 2015 examiner attributed the Veteran’s antalgic gait to his right knee condition, the Board notes that, during the November 2010 examination, his gait was described as slow and limited to a few yards. Resolving reasonable doubt in favor of the Veteran, the Board finds that this basis also supports an evaluation of 20 percent disabling. The evidence does not support the Veteran’s lumbosacral strain warrants more than an evaluation of 20 percent disabling because it did not manifest as forward flexion of 30 degrees or less or ankylosis of the entire thoracolumbar spine or incapacitating episodes. Again, the Board considered whether a separate evaluation is warranted for any neurological deficits in addition to the service-connected right lower extremity (sciatic nerve) associated with lumbar strain. During the November 2010 examination, it was noted that the motor examination was normal. It was also recorded that there was numbness and paresthesias limited to the lower back area. During the April 2015 examination, it was recorded that muscle strength was normal; reflex testing was hypoactive at both ankles; sensory examination was normal; and straight leg raising test was negative bilaterally. It was noted that there were no symptoms of radiculopathy. In light of essentially normal neurological testing, an additional separate evaluation for neurological deficit in addition to the already service-connected right lower extremity is not warranted. 2. Entitlement to a compensable disability rating for chronic right knee degenerative joint disease prior to November 18, 2010, in excess of 10 percent from November 18, 2010, to April 2, 2015, and in excess of 20 percent thereafter. 3. Entitlement to a compensable disability rating for left knee strain prior to November 18, 2010, and in excess of 10 percent thereafter. In the Board’s February 2016 decision, as to the Veteran’s service-connected chronic right knee degenerative joint disease, it denied entitlement to a compensable disability rating prior to November 18, 2010; in excess of 10 percent from November 18, 2010, to April 2, 2015; and in excess of 20 percent thereafter. As to the Veteran’s service-connected left knee strain, the Board denied entitlement to a compensable disability rating prior to November 18, 2010, and in excess of 10 percent thereafter. In the JMPR, it was agreed that the Board failed to adequately address 38 C.F.R. § 4.59 when it denied a compensable rating for each knee prior to November 18, 2010. The Veteran essentially contends that prior to November 18, 2010, his service-connected bilateral knee disabilities were more disabling than contemplated by the assigned noncompensable evaluation. The Board notes that the JMPR does not raise any specific dissatisfaction with the other assigned evaluations of disability for either knee. In considering the evidence of record under the laws and regulations set forth herein, the Board concludes that, prior to November 18, 2010, the Veteran’s disability picture for both knees more nearly approximated the criteria for a disability rating of 10 percent, but not higher. Beginning November 18, 2010, an increased evaluation for either knee is not warranted based on limitation of motion, instability/subluxation, or impairment of the tibia or fibula. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Specific to knee claims, the Board notes that the VA Office of General Counsel has determined that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97 (July 1, 1997). For a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Codes 5260 or 5261 need not be compensable but must at least meet the criteria for a non-compensable rating. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. See VAOPGCPREC 9-98 (August 14, 1998). VA’s General Counsel has also determined that separate evaluations may be assigned for limitation of flexion and extension of the same joint. VAOPGCPREC 09-2004 (September 17, 2004). Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Id. Diagnostic Code 5256, which evaluates ankylosis of the knee, provides for a 30 percent rating for favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is assigned when there is ankylosis of the knee in flexion between 10 and 20 degrees. A 50 percent rating is assigned when there is ankylosis of the knee in flexion between 20 and 45 degrees. A 60 percent rating is assigned when there is extremely unfavorable ankylosis of the knee in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of the knee, and provides for a 10 percent rating for slight impairment; a 20 percent rating for moderate impairment; and a 30 percent rating for severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Diagnostic Code 5258 provides for when semilunar cartilage is dislocated with frequent episodes of locking, pain, and effusion into the joint, and a 20 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 provides for when semilunar cartilage has been removed, but remains symptomatic, and a 10 percent rating is assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Diagnostic Code 5260, which evaluates limitation of flexion, provides for a noncompensable rating when flexion is limited to 60 degrees; a 10 percent rating when flexion is limited to 45 degrees; a 20 percent rating when flexion is limited to 30 degrees; and a 30 percent rating when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261, which evaluates limitation of extension, provides for a noncompensable rating when extension is limited to 5 degrees; a 10 percent rating when extension is limited to 10 degrees; a 20 percent rating when extension is limited to 15 degrees; a 30 percent rating when extension is limited to 20 degrees; a 40 percent rating when extension is limited to 30 degrees; and a 50 percent rating when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal knee motion is from zero degrees to 140 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5262, which evaluates impairment of the tibia and fibula, provides for a 10 percent disability rating for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating for malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating for malunion of the tibia and fibula with marked knee and ankle disability; and a 40 percent rating for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Diagnostic Code 5263, which evaluates genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated), provides for a 10 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5263. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule of Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. When assigning ratings, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. 38 C.F.R. § 4.68. Amputation not improvable by prosthesis controlled by natural knee action warrants a 60 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5164. The Board has reviewed the Veteran’s medical treatment records for the period on appeal and found that there is no medical evidence of ranges of motion or instability of the knee joints, or impairment of the tibia, fibula or meniscus, beyond that shown by the VA examination reports discussed below. Prior to November 18, 2010 Prior to November 18, 2010, the Veteran’s bilateral knee disabilities initially were rated as bilateral chondromalacia patella under 38 C.F.R. § 4.71a, Diagnostic Code 5260-5010, and then changed to bilateral knee strain under Diagnostic Code 5260. In a March 2005 statement in support of claim, the Veteran claimed for an increased disability rating of his service-connected bilateral knee disability. In a June 2005 rating decision, the RO continued the evaluation of the Veteran’s bilateral knees as noncompensable. In June 2005, the Veteran was afforded a VA joints examination, during which he was diagnosed with bilateral chondromalacia patella with normal knee examination. The Veteran reported intermittent aching and stiffness affecting both knees two to three times per month. He reported aching in both knees after three hours of driving. He reported a history of instability in the right knee, occurring approximately once every other month. He reported that he took two tablets of Tylenol three to four times a day with minimal relief. He reported being able to do activities of daily living but was not employed. It was recorded that the Veteran’s range of motion for both knees was normal and stability was intact. The examiner noted that the knee joints were not painful on motion and that the Veteran was able to squat and arise without discomfort. It was noted that there were no additional limitations with repetitive movement due to pain, fatigue, incoordination, weakness, or lack of endurance. It was noted that there was no objective evidence of heat, redness, swelling, or tenderness of either knee and that stability of both knees was intact. It was indicated that gait was normal and there was no evidence of ankylosis. In February 2007, the Veteran was afforded a VA joints examination, during which he was diagnosed with bilateral knee strain. The Veteran reported daily pain in his right knee, which was increased by repetitive motion doing any type of walking. It was noted that he did not have flare-ups. He reported that he became fatigued and could not stand too long when doing household work. He reported the same symptoms for his left knee. For both knees, initial range of motion was active flexion to 80 degrees with passive flexion to 135 degrees without pain. It was noted that there was no joint line tenderness, no effusion, no crepitation, and the cruciate and collaterals were intact. It was noted that with repetitive range of motion testing there was no change in range of motion, pain, coordination, endurance, or fatigue. In the February 2007 rating decision that is on appeal, the RO continued the evaluation of bilateral knee strain as noncompensable. In May 2007, the Veteran testified before a decision review officer, during which he testified that because of his knees he could not do prolonged walking. He stated that he could walk two or three blocks at a slow pace whereas he used to run six or seven miles a day. During the June 2010 Travel Board hearing, the Veteran testified that his knees were painful and swelled. He stated that at night they got so swollen that it was hard to turn them and they cramped. He stated that his knees limited him getting around his house. He stated that he was in the process of being measured for bilateral knee braces. He stated that his knees were more painful and swelled more than during the February 2007 VA examination. He estimated he had a 50 percent reduction in range of motion. Based upon a careful review of the foregoing and resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s disability picture, prior to November 18, 2010, more nearly approximated an evaluation of 10 percent disabling, but not higher. The Board notes that during the June 2005 and February 2007 VA examinations there was no objective evidence of pain with range of motion testing, including the ability to squat and arise without discomfort. The Veteran, however, competently and credibly reported on a consistent basis that he was unable to walk any appreciable distance. In that the Veteran was not tested immediately following repetitive use over time, his statements as to the presence of painful motion of the knees while walking is more probative than the testing data gathered during a discrete examination. See 38 C.F.R. §§ 3.159(a), 4.40, 4.45, 4.59 (2017); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting lay evidence is competent with regard to facts perceived through the use of the five senses); Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007); see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Prejean v. West, 13 Vet. App. 444, 448–9 (2000). As the Veteran pointed out to the Court, under 38 C.F.R. § 4.59, “it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.” See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (finding the Secretary’s interpretation consistent with the regulation that § 4.59 is not limited to arthritis claims). The Board notes that in the December 1991 rating decision, in which service connection for bilateral chondromalacia patella was granted, it was noted that X-rays of the knees showed evidence of early spur formation involving the superior patella tendinous, insertion of the patella bilaterally. Resolving reasonable doubt in favor of the Veteran, the Board finds that there is probative evidence establishing painful joint motion after repetitive use over time and the presence of healed injury as to each knee. Under Diagnostic Code 5260, the minimum compensable rating is 10 percent, which is warranted pursuant to 38 C.F.R. § 4.59. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5260; see also 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The evidence does not support that the Veteran’s bilateral knee disabilities warrant more than an evaluation of 10 percent disabling under Diagnostic Code 5260 because they did not manifest as flexion limited to 30 degrees or less. Additionally, the Board must consider the other diagnostic criteria related to the knee to determine whether an increased rating, or an additional separate compensable rating, is warranted for the Veteran’s service-connected bilateral knee disabilities. These diagnostic codes, however, do not apply because there is no probative evidence of ankylosis (DC 5256); recurrent subluxation or lateral instability (DC 5257); dislocated semilunar cartilage with frequent episodes of “locking,” pain and effusion into the joint (DC 5258); removal of the semilunar cartilage (DC 5259); extension limited to 10 degrees or more (DC 5261); or genu recurvatum (DC 5263); nor is there evidence of impairment of tibia and fibula to warrant a rating under Diagnostic Code 5262. 38 C.F.R. § 4.71a, Diagnostic Codes 5256–5263. From November 18, 2010, to April 2, 2015 In a July 2012 rating decision, the Veteran’s bilateral knee disabilities were evaluated as 10 percent disabling effective November 18, 2010. In November 2010, the Veteran was afforded a VA joints examination, during which limited flexion of knee was diagnosed. As to the right knee, it was noted that there was giving way, pain, stiffness, decreased speed of joint motion, repeated effusions, and locking episodes several times a week. It was recorded that there were weekly, severe flare-ups of joint disease that lasted hours, which were triggered by standing, walking, and prolonged sitting. Initial range of motion testing of the right knee produced flexion from zero to 140 degrees with normal extension and objective evidence of pain. As to the left knee, it was recorded that there was pain, locking episodes several times a week, repeated effusions, and severe weekly flare-ups, which were triggered by standing, walking, and sitting. Initial range of motion testing of the left knee produced flexion from zero to 140 degrees with normal extension and objective evidence of pain. As to both knees, there was objective evidence of pain following repetitive motion testing but no additional limitations in range of motion. It was indicated that there was no joint ankylosis. It was indicated that there were not constitutional signs of arthritis. It was noted that standing was limited to a few minutes and walking was limited to a few yards. It was noted that there were no assistive devices. It was noted that gait was antalgic. The Board finds that the evidence of record does not support an evaluation in excess of 10 percent under Diagnostic Code 5260 for the Veteran’s bilateral knee disabilities because flexion was not limited to 30 degrees or less. Indeed, it was normal. Additionally, there is no probative evidence of ankylosis (DC 5256); removal of the semilunar cartilage (DC 5259); extension limited to 10 degrees or more (DC 5261); or genu recurvatum (DC 5263); nor is there evidence of impairment of tibia and fibula to warrant a rating under Diagnostic Code 5262. While the examiner noted giving way and repeated effusions, and the Veteran reported locking episodes; there is no evidence that the semilunar cartilage was dislocated or otherwise damaged, and there is no evidence that either knee was unstable during testing. Accordingly, a higher or separate compensable rating is not warranted for recurrent subluxation or lateral instability (DC 5257) or dislocated semilunar cartilage with frequent episodes of “locking,” pain and effusion into the joint (DC 5258). 38 C.F.R. § 4.71a, Diagnostic Codes 5256–5263. As the preponderance of the evidence is against these increased rating claims as to this timeframe, the benefit of the doubt does not apply, and the claims must be denied. See 38 U.S.C. §§ 501, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Beginning April 3, 2015 In a June 2015, rating decision, the Veteran’s right knee disability was evaluated as 20 percent disabling under Diagnostic Code 5010-5261, effective April 3, 2015. Additionally, he was granted service connection for right knee, anterior instability, evaluated as 10 percent disabling under Diagnostic Code 5257, effective April 3, 2015. 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5261. In April 2015, the Veteran was afforded a VA examination for knee and lower leg conditions, during which right knee instability and bilateral degenerative arthritis was diagnosed. The Veteran reported falling due to his right knee giving out, most recently in October/November 2014. He reported that in the past six months he lost his balance without falling three times. He reported constant pain in both knees of varying intensity with the right being worse than the left. Pain increased with standing, such as washing dishes, and with prolonged walking, such as when shopping. He reported that both knees clicked at times and mildly swelled. He reported taking Tylenol and using topical analgesic, and that he stopped doing strengthening exercises because it was not helping. He reported that he wore bilateral braces at home. It was indicated that the Veteran did not report flare-ups and that when he had difficulty bending his leg due to pain, his wife helped him with putting on pants. He also reported that his wife assisted him to wash below his knees when showering. It was noted that he still drove. As to the right knee, initial range of motion testing produced flexion from 10 to 90 degrees and extension from 90 to 10 degrees. On repetitive use testing, due to pain, range of motion was reduced to flexion from 15 to 85 degrees and extension from 85 to 15 degrees. As to the left knee, initial range of motion testing produced flexion from zero to 120 degrees and extension from 120 to zero degrees. On repetitive use testing, due to pain, range of motion was reduced to flexion from zero to 115 degrees and extension from 115 to zero degrees. As for both knees, it was noted that there was pain on weight bearing, no objective evidence of localized tenderness or pain on palpation, and there was no evidence of crepitus. It was noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. As for the right knee, due to pain after repetitive use over time, it was estimated that range of motion was limited on flexion from 70 to 85 degrees. As for the left knee, it was estimated that range of motion was limited on flexion from 105 to 115 degrees. It was noted that the right knee produced swelling, disturbance in locomotion, and interference with sitting. It was stated that there was mild infrapatellar soft tissue swelling without palpable tenderness, there was mild antalgic gait favoring the right side, and there was difficulty flexing the knee during sitting. As for the left knee, there was swelling and mild infrapatellar soft tissue swelling without palpable tenderness. As for both knees, it was indicated that muscle strength was normal and there was no muscle atrophy or ankylosis. It was recorded that there was no history of recurrent subluxation or recurrent effusion. For the right knee, it was noted that the Lachman test for anterior instability was 1+ (0-5 mm). The left knee was normal. It was indicated that the Veteran had not had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. It was indicated he did not have a meniscus (semilunar cartilage) condition. It was noted that he regularly used braces at home for about two hours per day. In June 2017, the Veteran was afforded a VA examination for knee and lower leg conditions. For the right knee, he was diagnosed with knee joint osteoarthritis and knee instability. He reported that sometimes his right knee made him fall, bending forward. He reported that this happened three to four times per week. For the left knee, he was diagnosed with knee strain and knee joint osteoarthritis. The Veteran reported that sometimes his knee pain flared to a 10 and that it did not let him sleep, feeling like someone put a nail through his knee. He reported that he did a couple of sessions of physical therapy and that he was given a brace. He reported that the least pain was a four and that after walking more than 20 feet, standing more than 30 minutes, or load bearing made his pain go to 10. He reported that the pain would ease after one to two hours of rest, and this occurred most days. He reported that he could not squat, run, do yardwork, do prolonged standing, housework, or kneel. For the right knee, upon initial range of motion testing, flexion was from 10 to 85 degrees and extension was from 85 to 10 degrees. It was indicated that muscle strength of the right knee was 4/5 on both flexion and extension, which in part was due to his service-connected back disability. It was recorded that on joint stability testing, posterior instability (posterior drawer test) was 1+ (0-5 mm). It was recorded that on passive range of motion of the right knee, it was zero to 125 degrees with pain, and on weight bearing it was 10 to 40 degrees with pain. It was noted that, on the right knee, there was weakened range of motion from 85 to 120 degrees. For the left knee, initial range of motion testing of the left knee produced flexion from zero to 120 degrees and extension from 120 to zero degrees. It was indicated that muscle strength of the left knee was normal. It was indicated that the left knee joint stability testing was normal. It was recorded that on passive range of motion of the left knee it was zero to 120 degrees with pain, and on weight bearing it was 10 to 60 degrees with pain. For both knees, it was recorded that pain was noted on examination and it caused functional loss in both directions of motion. It was indicated that there was pain on weight bearing, and there was tenderness on palpation of the inferior patella. It was indicated that there was not objective evidence of crepitus. It was indicated that there was no additional functional loss or range of motion on repetitive use testing. The Veteran reported that his knees swelled about five times per week. It was indicated that there was no muscle atrophy or ankylosis. It was noted that the Veteran’s gait was slightly antalgic. It was indicated that the Veteran occasionally used braces. It was noted that arthritis was documented on imaging. For the Veteran’s right knee, the Board finds that the evidence of record does not support an evaluation in excess of 20 percent under Diagnostic Code 5261 because extension is not limited to 20 degrees or more. Additionally, there is no probative evidence of ankylosis (DC 5256); dislocated semilunar cartilage with frequent episodes of “locking,” pain and effusion into the joint (DC 5258); removal of the semilunar cartilage (DC 5259); flexion limited to 45 degrees or less (DC 5260); or genu recurvatum (DC 5263); nor is there evidence of impairment of tibia and fibula to warrant a rating under Diagnostic Code 5262. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258–5263. As noted previously, the Veteran is separately service-connected for right knee, anterior instability, pursuant to Diagnostic Code 5257, evaluated as 10 percent disabling for slight recurrent subluxation or lateral instability. A higher rating is not warranted as there is no evidence of moderate recurrent subluxation or lateral instability. Indeed, during the June 2017 VA examination, joint stability testing for the right knee was normal except the posterior drawer test was 1+ (0-5 mm). As for the Veteran’s left knee disability, an evaluation in excess of 10 percent disabling under Diagnostic Code 5260 is not warranted because it did not manifest as flexion limited to 30 degrees or less. As previously noted, there is no probative evidence to support a higher or an additional separate compensable rating under the other diagnostic codes for disabilities of the knee and leg. 38 C.F.R. § 4.71a, Diagnostic Codes 5256–5263. As the preponderance of the evidence is against these increased rating claims as to this timeframe, the benefit of the doubt does not apply, and the claims must be denied. See 38 U.S.C. §§ 501, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). L. CHU Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Leanne M. Innet, Associate Attorney