Citation Nr: 20007016 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 19-11 741 DATE: January 28, 2020 ORDER Entitlement to an increased initial evaluation in excess of 30 percent from September 2, 2005 to July 31, 2008 for residuals post total right knee replacement with tibia and fibula impairment, hereinafter right knee disability, is denied. Entitlement to an increased evaluation in excess of 60 percent from July 31, 2008 for right knee disability, exclusive of periods of temporary total evaluation, is denied. Entitlement to an increased initial evaluation in excess of 10 percent from September 2, 2005 for left knee degenerative joint disease with chondromalacia, hereinafter left knee disability, is denied. FINDINGS OF FACT 1. From September 2, 2005 to July 31, 2008, the Veteran’s service-connected right knee disability is manifested by limitation of flexion at worst to 95 degrees, limitation of extension at worst to zero degrees, occasional swelling, weakness, and pain on motion; ankylosis, crepitus, subluxation, and instability have not been shown. 2. From July 31, 2008, exclusive of periods of temporary total evaluation, the Veteran’s service-connected right knee disability is productive of chronic residuals consisting of severe painful motion or weakness in the affected extremity, limitation of flexion at worst to 70 degrees, extension at worst to 30 degrees; ankylosis, crepitus, subluxation, and instability have not been shown. 3. From September 2, 2005, the Veteran’s service-connected left knee disability is manifested by limitation of flexion at worst to 90 degrees, limitation of extension at worst to zero degrees, occasional swelling, weakness, and pain on motion; ankylosis, crepitus, subluxation, and instability have not been shown. CONCLUSIONS OF LAW 1. From September 2, 2005 to July 31, 2008, the criteria for the assignment of a disability rating in excess of 30 percent for a right knee disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Codes 5055-5262 (2018). 2. From July 31, 2008, exclusive of periods of temporary total evaluation, the criteria for the assignment of a disability rating in excess of 60 percent for a right knee disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Codes 5055-5262 (2018). 3. From September 2, 2005, the criteria for the assignment of a disability rating in excess of 10 percent for a left knee disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2018).   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1958 to June 1959. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran’s right knee was originally characterized at the time of service connection as right knee degenerative joint disease with chondromalacia, and on December 22, 2015, the Veteran filed a notice of disagreement with the evaluation of the two knee disabilities, and no other area of disagreement. After the December 2018 rating decision which increased the right knee evaluation to 60 percent, independent of periods of temporary total evaluation, the Veteran filed another notice of disagreement dated May 22, 2019 where he objected to the evaluation of his right knee disability and also the effective date. However, VA considers that May 2019 notice of disagreement to be moot, pursuant to the letter from VA to the Veteran and his representative dated January 25, 2020. As that May 2019 notice of disagreement is considered moot, the Board will consider the original December 2015 notice of disagreement as the procedural document pertinent to this appeal for the bilateral knee disabilities and proceed accordingly. See 38 C.F.R. § 20.201 (2018). By way of background, the Veteran was originally granted service connection in a January 2015 rating decision for his right and left knee disabilities, effective from September 2, 2005. In a December 2018 rating decision, the evaluation for the right knee disability was increased to 60 percent disabling, effective July 31, 2008. In addition, the Veteran has had two periods where his right knee evaluation was 100 percent for temporary periods following right knee replacement surgeries on August 15, 2016 and March 7, 2018. The grant of an increased rating during the course of an appeal does not affect the pendency of that appeal. AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claim is still in controversy and on appeal. Id. When a Veteran files a claim for an increased rating, he is presumed to be seeking the maximum benefit under any applicable theory, including TDIU. See generally Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447 (2009). In light of this principle, entitlement to special monthly compensation (SMC) has been found to be an inferable issue anytime a veteran is requesting increased benefits. Akles v. Derwinski, 1 Vet. App. 118 (1991). The Veteran was awarded a TDIU in a December 2019 rating decision, effective from November 8, 2016, the earliest date possible based on the evidence of record. The Veteran was awarded SMC pursuant to 38 U.S.C. § 1114, subsection (s) and 38 C.F.R. § 3.350(i) on account of his two total arthroplasties of the right knee in August 2016 and March 2018. There is no further lay or medical evidence the Veteran is housebound in fact, requires aid and attendance, or that his disabilities result in loss of use of a limb, blindness or deafness. 38 U.S.C. §§ 1114(s), (l), (k); 38 C.F.R. § 3.350(a), (b), (i). The Board thus finds that no further discussion of TDIU or SMC is appropriate or necessary at this time. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. § §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board….to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Increased Schedular Ratings - General Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. § Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § §§ 3.321(a), 4.1. If two disability evaluations are potentially applicable, 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When evaluating musculoskeletal disabilities based on 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.”). The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, the United States Court of Appeals for Veterans’ Claims (Court) recently addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. The Board also notes recent case law where the Court held that 38 C.F.R. § 4.59 does not solely condition the evaluation based on range of motion measurements for a particular diagnostic code, but rather “it conditions that award on evidence of an actually painful, unstable, or maligned joint or periarticular region and the presence of a compensable evaluation in the applicable diagnostic code.” Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Board considers not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § § 4.25. However, the evaluation of the same “disability” or the same “manifestations” under various diagnoses is not allowed. See 38 C.F.R. § § 4.14. A claimant may not be compensated twice for the same symptomatology as “such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity.” See 38 U.S.C. § 1155 (2012); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See 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, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. Knee Disabilities: Legal Standards The Veteran’s right knee is evaluated under two diagnostic codes: Diagnostic Code 5055 for knee replacement (prosthesis), and Diagnostic Code 5262, tibia and fibula impairment. Excluding the periods of temporary total evaluation pursuant to 38 C.F.R. § 4.30, which are not under appeal and thus will not be discussed, the Veteran’s right knee is rated with a 30 percent evaluation from the effective date of service connection, September 2, 2005, to July 31, 2008, and 60 percent thereafter. The Veteran’s left knee is rated under Diagnostic Code 5260, leg limitation of flexion, with an evaluation of 10 percent effective from September 2, 2005. Under Diagnostic Code 5055, for prosthetic replacement of the knee joint, a 100 percent rating is warranted for one year following implantation of the prosthesis. A 60 percent rating is warranted if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is to be rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5261 (limitation of extension) or 5262 (impairment of the tibia and fibula). The regulation prescribes a minimum rating of 30 percent under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5055. VA’s General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under DC 5260 and a compensable limitation of extension under DC 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability. VAOPGCPREC 23-97 (July 1, 1997). Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). However, based on the medical evidence before the Board, ankylosis, recurrent subluxation, lateral instability, a meniscus condition to include dislocated semilunar cartilage or its removal, and genu recurvatum have not been found or associated with the Veteran’s right knee disability and thus will not be considered here. In assigning hyphenated diagnostic codes, the number assigned to the residual condition on the basis of which the rating is determined will generally represent injuries. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a non-compensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a non-compensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5262, a 10 percent rating is warranted for malunion with slight knee or ankle disability. A 20 percent rating is warranted for malunion with moderate knee or ankle disability; a 30 percent rating is warranted for malunion with marked knee or ankle disability; and a 40 percent rating is warranted for nonunion with loose motion, requiring a brace. 38 C.F.R. § 4.71a. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also VAOPGCPREC 9-04 (holding that separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned). 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 of the evidence for “equitable and just decisions.” 38 C.F.R. § 4.6. Evidence and Analysis The Veteran is seeking increased ratings for each of his knee disabilities, contending at the time of the notice of disagreement that the evaluations awarded at the time of service connection were not reflective of the true level of disability. The right knee was originally characterized at the time of its initial grant of service connection as right knee degenerative joint disease, status post total knee replacement, under Diagnostic Code 5055. The left knee was described as left knee degenerative joint disease with chondromalacia, left knee postoperative, under Diagnostic Code 5260. While the Veteran’s knees are rated under different diagnostic codes, they were examined together by both VA and private medical practitioners. The Board will thus discuss each of the examinations, and then discuss the diagnostic codes for each knee separately. Each knee’s rating was originally effective from September 2, 2005. The Veteran received his first VA examination for his knees in July 2008. The examiner diagnosed bilateral knee degenerative joint disease, with the right knee having been replaced in 2002. X-rays of the left knee indicated osteoarthritis. The examiner noted an antalgic gait, a negative McMurray’s test, left knee anterior crepitus deformity, mild right knee varus deformity, but with no instability. The right knee measured plus 10 degrees to minus 95 degrees in flexion, with pain noted at 90 degrees. Extension was measured at plus 10 degrees. The left knee was measured at zero to 120 degrees of flexion with pain noted at 100 degrees, and zero degrees of extension. The examiner found no additional range of motion loss due to pain, weakness, fatigue, incoordination, or lack of endurance following repetitive use. The Veteran next received a VA examination for his knees in July 2015. The left knee was diagnosed with degenerative joint disease, and the right knee was noted to have been replaced via total knee arthroplasty. The examiner noted the Veteran as ambulatory in no acute distress. The Veteran reported flare-ups of pain in the areas of each knee. The right knee exhibited zero to 115 degrees of flexion, and 140 to zero degrees of extension. Evidence of pain with weight bearing was noted. For the left knee, there was zero to 130 degrees of flexion, and 140 degrees to zero for extension. There was no ankylosis, no history of right or left knee recurrent subluxation, no instability, no tibial/fibular impairment, or a semilunar cartilage meniscus condition. For the right knee, the examiner noted the right knee as status post arthroscopic synovectomy and partial patellectomy from November 2013. The Veteran received another VA examination in September 2016. The Veteran had recently undergone a second right knee total arthoplasty, in August 2016. Right knee flexion was zero to 88 degrees, and extension was 140 to 15 degrees. Difficulty with prolonged standing and walking was noted. Pain was noted on range of motion in flexion, but there was no pain on weight bearing. The left knee was reported with zero to 120 degrees flexion and 140 to zero degrees extension. For the left knee, there was no pain on motion and no pain with weight-bearing, and no evidence of crepitus. No flare-ups were noted for either knee. There was no ankylosis and no instability noted for either knee. Some swelling was noted on the right knee. After the Veteran underwent a third right knee total arthoplasty in March 2018, he received another VA examination for his knees in May 2018. This examination was also conducted to address the Veteran claiming service connection separately for his right knee due to impairment of the tibia and fibula. Here, the Veteran’s right knee measured 30 to 70 degrees in flexion, and 70 to 30 degrees in extension. The examiner made a note that the Veteran’s neutral position for his right knee was a minus 30 degrees of flexion. Severe pain was noted in range of motion testing in both flexion and extension. Crepitus was noted and objective evidence of localized tenderness or pain on palpation was noted. The Veteran reported that tenderness went from his anterior knee joint down to his anterior tibia to the ankle. The left knee was measured at zero to 90 degrees flexion and 140 to zero degrees extension. Pain was noted on range of motion testing in both flexion and extension. No flare-ups were reported for either knee. Muscle strength for the right knee was 5 on a scale of 5 but the left knee was only 3 on the same scale of 5. There was no ankylosis, no instability for either knee, and no history of recurrent subluxation or recurrent effusion. The examiner described the right knee, with its history of three total arthroplasties, as exhibiting chronic residuals consisting of severe painful motion or weakness. The Veteran reported constant use of a cane to assist ambulation and occasional use of a walker. The Veteran’s most recent VA knee examination was in September 2019. The right knee’s updated diagnosis was residuals post total right knee replacement with tibia and fibula impairment. The Veteran noted he was now in a wheelchair because he was unable to walk with his right knee anymore. Right knee flexion was measured at zero to 80 degrees, and extension 140 to 15 degrees. Pain was noted on both flexion and extension, with objective evidence of localized tenderness or pain on palpation of the joint. No crepitus was noted. The left knee measured at zero to 120 degrees of flexion and 140 to zero degrees of extension, with some pain on motion but it did not result in functional loss. The left knee did indicate signs of crepitus. Muscle strength for the right knee was 4 on a scale of 5, and the left knee was 5 on a scale of 5. Muscle atrophy was noted for the right knee, but not for the left knee. No ankylosis or instability was noted for either knee. The examiner noted for the right knee frequent episodes of pain due to the knee replacements. 1. Entitlement to an increased initial evaluation in excess of 30 percent from September 2, 2005 to July 31, 2008 for residuals post total right knee replacement with tibia and fibula impairment 2. Entitlement to an increased evaluation in excess of 60 percent from July 31, 2008 for right knee disability, exclusive of periods of temporary total evaluation For the Veteran’s right knee, for the period September 2, 2005 to July 31, 2008, the Board finds that an evaluation in excess of 30 percent is not met or approximated. The Board notes the Veteran’s right knee total arthroplasty and the language of Diagnostic Code 5055, which requires a minimum evaluation of 30 percent following prosthetic replacement of the knee joint. The Board notes that during this appeal period, the Veteran did not have a knee replacement which would warrant a 100 percent evaluation for a year after the implantation of the prosthesis. Diagnostic Code 5055, 38 C.F.R. § 4.71a. A higher evaluation of 60 percent under Diagnostic Code 5055 is not warranted unless evidence demonstrates chronic residuals consisting of severe painful motion or weakness in the affected extremity. A higher evaluation of 40 percent is not warranted for ankylosis of the knee unless the evidence shows ankylosis in flexion between 10 degrees and 20 degrees under Diagnostic Code 5256. Additionally, a higher evaluation of 40 percent is not warranted for limitation of extension unless the evidence shows extension limited to 30-44 degrees under Diagnostic Code 5261. A higher evaluation under Diagnostic Code 5262 for impairment of the tibia and fibula is not warranted unless the evidence shows nonunion of the tibia and fibula with loose motion, requiring a brace. For the Veteran’s right knee, from July 31, 2008, the Board finds that an evaluation in excess of 60 percent is not met or approximated, exclusive of the periods of temporary total evaluation under Diagnostic Code 5055 or 38 C.F.R. § 4.30 as noted and appropriate. The Board does note that the Veteran had two total right knee replacements in this appeal period, on the dates of August 15, 2016 and again on March 7, 2018. As such, pursuant to Diagnostic Code 5055, the Veteran’s temporary total evaluation for one year following August 15, 2016, to August 15, 2016 is appropriate. For the second right knee replacement in this appeal period, which occurred on March 7, 2018, the RO awarded a temporary total evaluation for one year pursuant to Diagnostic Code 5055 and then an extended period of temporary total evaluation under 38 C.F.R. § 4.30 to May 1, 2019, at which time the Veteran’s evaluation for his right knee reverted to 60 percent. A higher evaluation of 100 percent under Diagnostic Code 5055 is only warranted for one year following prosthetic replacement of the knee joint. The Board has considered other diagnostic codes for the Veteran’s right knee disability, to include ankylosis (Diagnostic Code 5256), disabilities involving cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint (Diagnostic Code 5258), removal of the semilunar cartilage (Diagnostic Code 5259), and genu recurvatum (Diagnostic Code 5263), and found them to not apply to the Veteran’s right knee disability picture in this period. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5260, 5261, 5262, 5263. The Board notes the Veteran’s limitations of flexion and extension and impairment of the tibia and fibula pursuant to the medical evidence and Diagnostic Codes 5260, 5261, and 5262, but finds the Veteran’s highest possible ratings and therefore the greatest possible benefit to the Veteran derive from evaluations under Diagnostic Code 5055. Additionally, the Board has considered the statements regarding flareups by the Veteran, but based on the medical evidence, even with estimates of motion loss in terms of degrees during periods of flare-ups, the criteria for higher evaluations based on range of motion have not been met or approximated. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board also acknowledges the assertion by the Veteran’s representative that he deserves a higher rating because of the severe pain suffered by the Veteran with his right knee disability, citing Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). However, the Board notes that the holding of Saunders determines that pain can be a disability, and that disability refers to functional impairment. Id. As such, Saunders is appropriate for service connection determinations, where the issue of pain can possibly be determined to be a disability in the requirement that a current disability must exist. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Here, this appeal involves the already-service connected issues of two knee disabilities, and the level of their evaluations based on the evidence in the applicable time period. As discussed above, 38 C.F.R. § 4.59 does not solely condition the evaluation based on range of motion measurements for a particular diagnostic code, but rather “it conditions that award on evidence of an actually painful, unstable, or maligned joint or periarticular region and the presence of a compensable evaluation in the applicable diagnostic code.” Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). In other words, the Board notes and emphasizes that the rating criteria takes into account pain in a particular area, in this case the knee, and allows for the appropriate evaluation in such instances, as here. The Board notes the Veteran’s right knee disability receives higher evaluation for both periods using Diagnostic Code 5055, and that the determination of the left knee evaluation does involve the recognition of the painful motion envisioned by 38 C.F.R. § 4.59. For the foregoing reasons, then, the Board finds that a 30 percent rating, but no higher, for right knee disability is warranted for the period from September 2, 2005 to July 31, 2008, and a 60 percent rating, but no higher, is warranted for the period from July 31, 2008, excluding periods of temporary total evaluation. All potentially applicable diagnostic codes have been considered, and there is no basis to assign an alternative evaluation for the Veteran’s leg disabilities other than that discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Staged ratings are not warranted beyond that discussed, as the Veteran has had a stable level of symptomatology throughout the appeal period. Any increases in severity were not sufficient for a higher rating for the reasons discussed above. See Hart, 21 Vet. App. 505. 3. Entitlement to an increased initial evaluation in excess of 10 percent from September 2, 2005 for left knee degenerative joint disease with chondromalacia, hereinafter left knee disability For the Veteran’s left knee, for the entire period on appeal, the Board finds that an evaluation in excess of 10 percent is not met or approximated. A rating of 10 percent is appropriate due to painful motion of the knee, where the minimum compensable evaluation is 10 percent because 38 C.F.R. § 4.59 allows for consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. Painful, unstable, or misaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint, which for the left knee, is 10 percent. 38 C.F.R. § 4.59; see Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016); Petitti v. McDonald, 27 Vet. App. 415 (2015). A higher evaluation of 20 percent is not warranted for limitation of flexion unless the evidence shows a limitation of flexion of 16-30 degrees under Diagnostic Code 5260, or a limitation of extension of 15-19 degrees under Diagnostic Code 5261. The Board has considered other diagnostic codes for the Veteran’s left knee disability, to include ankylosis (Diagnostic Code 5256), disabilities involving cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint (Diagnostic Code 5258), removal of the semilunar cartilage (Diagnostic Code 5259), malunion/nonunion of the tibia and fibula (Diagnostic Code 5262), and genu recurvatum (Diagnostic Code 5263), and found them to not apply to the Veteran’s right knee disability picture in this period. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5260, 5261, 5262, 5263. Additionally, the Board has considered the statements regarding flareups by the Veteran, but based on the medical evidence, even with estimates of motion loss in terms of degrees during periods of flare-ups, the criteria for higher evaluations based on range of motion have not been met or approximated. Sharp v. Shulkin, 29 Vet. App. 26 (2017). For the foregoing reasons, then, the Board finds that a 10 percent rating, but no higher, for left knee disability is warranted for the entire period on appeal, from September 2, 2005. All potentially applicable diagnostic codes have been considered, and there is no basis to assign an alternative evaluation for the Veteran’s leg disabilities other than that discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Staged ratings are not warranted beyond that discussed, as the Veteran has had a stable level of symptomatology throughout the appeal period. Any increases in severity were not sufficient for a higher rating for the reasons discussed above. See Hart, 21 Vet. App. 505. Neither the Veteran nor his representative has raised any other issues concerning the lumbar spine, radiculopathy, and right knee disabilities, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369–70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Setter, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.