Citation Nr: 21001851 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 14-34 943A Date: January 12, 2021 ORDER An increased rating for limitation of flexion due to left knee arthritis in excess of 10 percent prior to February 27, 2017, is denied. An increased rating for limitation of extension due to left knee arthritis in excess of 10 percent prior to February 27, 2017, is denied. An increased rating for residuals of a total knee arthroplasty (TKA) of the left knee to 60 percent from May 1, 2018, to June 19, 2019, and from August 1, 2019, is granted, subject to the regulations governing the payment of monetary awards. An increased rating for right knee arthritis in excess of 10 percent from March 15, 2018, and in excess of 30 percent from May 1, 2019, until November 12, 2020, is denied. An increased rating for residuals of a TKA of the right knee to 60 percent from November 12, 2020, is granted, subject to the regulations governing the payment of monetary awards. FINDINGS OF FACT 1. Prior to February 27, 2017, the Veteran’s left knee arthritis was manifested primarily by range of motion from 0 degrees extension to, at worse, 90 degrees flexion, without instability, subluxation or other knee disability. 2. From May 1, 2018, to June 19, 2019, and from August 1, 2019, the Veteran’s residuals of a total left knee replacement have been manifested by chronic residuals consisting of severe painful motion or weakness. 3. Prior to March 15, 2018, the Veteran’s right knee arthritis was consistently manifested by pain and range of motion from, at worse, 0 degrees extension to 90 degrees flexion, without instability, subluxation or significant functional loss. 4. From May 1, 2019, until November 12, 2020, the residuals of the Veteran’s right TKA were manifested by an intermediate degree of weakness, pain, and limitation of motion from 0 degrees extension to 90 degrees flexion. 5. As of November 12, 2020, the residuals of the Veteran’s right TKA have been manifested by painful limitation of motion from 25 degrees extension to 90 degrees flexion, which is consistent with severe painful motion. CONCLUSIONS OF LAW 1. The criteria for a rating for impairment of flexion due to left knee arthritis in excess of 10 percent prior to February 27, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260. 2. The criteria for a rating for impairment of extension due to left knee arthritis in excess of 10 percent prior to February 27, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260. 3. The criteria for a rating of 60 percent, but no more, for residuals of a total left knee replacement from May 1, 2018, to June 19, 2019, and from August 1, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 4. The criteria for a rating for right knee arthritis in excess of 10 percent prior to March 15, 2018, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260. 5. The criteria for a rating in excess of 30 percent from May 1, 2019, until November 12, 2020, for residuals of a total right knee replacement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 6. The criteria for a rating of 60 percent, but no more, for residuals of a total right knee replacement from November 12, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1984 to February 1991 In February 2018, a videoconference hearing was held before the undersigned. A transcript of the hearing is associated with the claims folder. The issues were remanded by the Board in July 2018 for additional development of the evidence. They were again remanded by the Board in July 2019 and have now been returned for further appellate action. As an initial matter, the Board notes that pertinent VA treatment records and VA examination reports were associated with the claims file after the most recent July 2020 Supplemental Statement of the Case (SSOC) issued in this case. Under 38 C.F.R. § 19.31(b)(1), an SSOC will be issued will the agency of original jurisdiction (AOJ) receives additional pertinent evidence after a Statement of the Case or the most recent SSOC has been issued and before the appeal is certified to the Board and the appellate record is transferred to the Board. In this case, the additional medical evidence was added to the claims file after the appellate was record was transferred to the Board in August 2020. The Board has also not requested a waiver of initial AOJ review pursuant to 38 C.F.R. § 20.1305 because the Veteran was issued a November 2020 rating decision that addressed the issues of entitlement to increased ratings for the disabilities addressed in this decision. Accordingly, while not addressed in an SSOC, the Veteran was provided notice of this additional evidence and the AOJ has considered it conjunction with a separate claim for increased ratings for the same disabilities on appeal to the Board. Accordingly, the Board does not find that the Veteran is prejudiced by its proceeding to an adjudication of his claim. Increased Rating Ratings for impairment of flexion due to left knee arthritis, in excess of 10 percent, and left knee extension in excess of 10 percent prior to February 27, 2017, in excess of 30 percent for residuals of a left knee total knee replacement from May 1, 2018, to June 19, 2019, and in excess of 30 percent from August 1, 2019 The Veteran contends that his left knee arthritis is more disabling than currently evaluated. It is noted that service connection was initially granted by rating decision dated in December 1991, with a 10 percent rating being awarded under Diagnostic Code 5010 for traumatic arthritis. The rating was increased to 20 percent in a February 2002 rating decision, but reduced to 10 percent based upon clear and unmistakable error (CUE) in a prior, by a proposed rating decision dated in June 2012 and effectuated by rating decision dated in August 2012, effective in November 2012. The Veteran appealed the reduction. The rating was then increased to 30 percent following total knee replacement surgery that was performed in March 2017, effective May 1, 2018, in accordance with the provisions of Diagnostic Code 5055. The Veteran underwent additional surgery and was assigned a temporary total rating under the provisions of 38 C.F.R. § 4.30, from June 19, 2019, to August 1, 2019, when the 30 percent rating was reinstated. He has argued that higher ratings are warranted for the rating periods during which he was not in receipt of a 100 percent rating. Where the reduction in evaluation of a service-connected disability or employability status is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments currently being made, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary will be notified at his or her latest address of record of the contemplated action and furnished detailed reasons therefor, and will be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level. Unless otherwise provided in paragraph (i) of this section, if additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. 38 C.F.R. § 3.105(e). The February 2002 rating decision increasing the evaluation of the Veteran’s left knee arthritis was based upon an October 2001 VA examination. At that time, it was noted that the Veteran had severe crepitations in the left knee with range of motion. Flexion of the knee was to approximately 45 degrees, with extension to 0 degrees. There was negative McMurray’s and drawer signs, although the examiner stated that much tension was not applied due to the Veteran’s complaints of pain. X-ray studies showed severe degenerative joint disease of the femoropatellar articulation and mild degenerative joint disease of the femorotibial articulation. There was minimal suprapatellar effusion with decrease since a previous X-ray study. A small patellar spur was noted. The pertinent diagnoses were chronic knee pain; status post arthroscopic surgery on the left, times two; and severe degenerative arthritis of the left knee. An examination was conducted by VA in February 2012. At that time, the diagnosis was bilateral degenerative joint disease of the knees. The Veteran did not report flare-ups that impacted function of the knees. Range of motion of the left knee was from 0 degrees extension to 100 degrees flexion, with pain noted at 100 degrees flexion. The Veteran was able to perform repetitive use testing without additional loss of range of motion or function. Muscle strength testing was normal 5/5. Joint stability testing was normal. There were no additional knee conditions. The Veteran did have a history of meniscal condition, but no meniscal symptoms other than frequent episodes of joint pain. He had not had a total knee joint replacement, but had a history of left knee arthroscopic surgery. X-ray studies showed degenerative or traumatic arthritis of the knees. There was no functional impact on the knee. An examination was conducted by VA in December 2013. At that time, the diagnosis was status post bilateral medial meniscus repair with degenerative changes of both knees. The Veteran reported that he did not have flare-ups. Range of motion of the left knee was from 0 degrees extension to 90 degrees flexion. Painful motion was noted at 90 degrees flexion. The Veteran was able to perform repetitive use testing without further limitations. Functional loss was described as less movement than normal, excess fatigability, incoordination, and pain on movement. The Veteran had tenderness or pain on palpation of the joint line. Muscle strength testing was 5/5. Joint stability testing was normal throughout. There was no patellar subluxation or dislocation. The Veteran had had a meniscal tear with frequent episodes of joint locking, joint pain, and joint effusion. He had not had joint replacement surgery. The Veteran used a brace on a regular basis. The examiner did not find that the Veteran’s knee disability impacted his ability to work as a police officer. The Veteran underwent a total knee replacement of the left knee in February 2017. By rating decision dated in April 2017, the disability rating was then evaluated under Diagnostic Code 5055. Regarding the rating of the Veteran’s left knee disorder prior to the February 2017 total knee arthroscopy (TKA) surgery, as noted, his disability was rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg, as applied under the provisions of Diagnostic Code 5010, for traumatic arthritis. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board notes that from 2007, the Veteran was also separately rated for limitation of extension at 10 percent under Diagnostic Code 5261. This evaluation will be addressed separately from the limitation of flexion. Arthritis due to trauma, substantiated by X-ray findings, shall be rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriated diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. These 10 percent evaluations are combined, not added, under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent evaluation will be assigned where there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. 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; 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 criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The assigned Diagnostic Codes, 5010 and 5260, suggest that the Veteran’s left knee disability was based on limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that the disability has manifested as osteoarthritis and been rated based on painful, compensable limitation of flexion, and that the current disability is manifested by painful noncompensable limitation of flexion. The record shows that the Veteran had compensable limitation of flexion on examination in October 2001 when flexion was shown to be limited to 45 degrees. As noted in the rating decision on appeal, while a 20 percent rating was assigned based upon that examination report, this actually qualifies for only a 10 percent rating, but not more. The rating decision proposed the reduction to 10 percent disability based upon CUE. In reality, evaluation of the Veteran’s left knee impairment actually demonstrated improvement such that the reduction to 10 percent is fully supported by the record. In this regard, the 2012 VA examination showed flexion of the left knee to 100 degrees, without limitation of extension, instability, or evidence of other disability. The 2013 VA examination showed 90 degrees of forward flexion, which, while slightly more limiting, remains double the range of motion demonstrated in 2001. For these reasons, the Board finds that the noncompensable limitation of motion demonstrated warrants a 10 percent rating under the criteria for evaluation of arthritis. 38 C.F.R. § 4.71a, Diagnostic Codes 5010 and 5003. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for left knee arthritis prior to the TKA performed in February 2017. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain and that he eventually needed the TKA surgery. Nevertheless, the record does not demonstrate eligibility for a rating in excess of 10 percent prior to that time. In this regard, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The Board notes that a rating decision dated in July 2008 found that a separate 10 percent rating for impairment of extension was warranted. This 10 percent rating was continued through the date of the left knee TKA surgery. The appeal encompasses the possibility that a rating in excess of 10 percent should be assigned for limitation of extension of the knee. Limitation of extension to 10 degrees warrants a 10 percent rating. A 20 percent rating requires that extension be limited to 15 degrees. Extension limited to 20 degrees warrants a 30 percent rating. A 40 percent rating requires extension to be limited to 30 degrees. A 50 percent rating is awarded for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Review of the VA examinations show that the Veteran’s left knee extension was not limited, with range of motion to a full 0 degrees on both the 2012 and 2013 examinations. As such, a rating in excess of the 10 percent rating assigned for limited extension during this time is not shown to be warranted. Regarding Diagnostic Code 5257, which provides that for slight impairment of the knee, with recurrent subluxation or lateral instability, a 10 percent rating is warranted. For moderate impairment, 20 percent rating is warranted; a 30 percent rating requires severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board notes that the 2012 and 2013 examination reports do not document instability other impairment of the knee joint. As such, a separate rating under this rating criteria is not shown to be warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for arthritis of the left knee due to impairment of flexion and a separate rating in excess of 10 percent impairment of extension, prior to February 2017 when he underwent TKA surgery. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Regarding the Veteran’s claim of an increased rating following the surgeries that established separate 100 percent evaluations, the Board notes that there are two periods under consideration. Thus, the ratings of residuals of a TKA in excess of 30 percent from May 1, 2018, to June 19, 2019, and in excess of 30 percent from August 1, 2019, are for consideration. The record shows that the Veteran underwent TKA surgery of the left knee on February 28, 2017. Pursuant to Diagnostic Code 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. An examination was conducted by VA in March 2018. At that time, the examiner noted instability of the left knee and the diagnosis was total left knee replacement. The Veteran reported worsening pain, worsening atrophy of the left upper knee muscles and anterior instability. Over the past year, he had pain rated 5/10 at rest and 7/10 with activity. This was not helped by pain medication. He described functional loss where walking, standing, and sitting were limited. Range of motion of the left knee was from 5 degrees extension to 60 degrees flexion. The Veteran had trouble squatting and reported pain with flexion and extension. There was evidence of pain with weight bearing. And objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional limitation of motion. The Veteran was not examined immediately after repetitive use over time, but the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain, fatigue, weakness, lack of endurance, and incoordination were said to limit due to repetitive use over time. Range of motion was described as being from 5 degrees extension to 60 degrees flexion. There was no evidence of functional loss during a flare-up. The Veteran reported no flare-ups. There were no additional factors contributing to disability. Muscle strength testing showed strength to be 4/5 in flexion and extension. There was muscle atrophy of the left lower extremity measuring six cm when compared to the right side, at 10 cm above the knee. There was no ankylosis. Joint stability testing showed 2+ anterior instability. There was swelling of the left knee when walking over 40 feet or when standing over 15 minutes. The Veteran had residuals of the left TKA described as chronic residuals consisting of severe painful motion or weakness. The Veteran utilized a cane on a constant basis. The Veteran experienced functional loss in that walking was limited to 40 feet at a time, standing was limited to 15 minutes at a time, and sitting was limited to 20 minutes at a time. There was objective evidence of pain on non-weight bearing. An examination was conducted by VA in May 2019. At that time, the pertinent diagnosis was TKA of the left knee. The Veteran described flare-ups and functional loss as being nagging pain and swelling and interference with his carpentry work (described as a hobby.) Range of motion of the left knee was from 0 degrees extension to 80 degrees flexion. Pain was noted with flexion, but not with weight bearing. The pain was described as being moderate and in the anterior left knee. It did not result in functional loss. The Veteran was able to perform repetitive use testing without additional functional loss. He was not examined immediately after repetitive use over time and there was no description of whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time. The examination was consistent with the Veteran’s description of functional loss during a flare-up, but was not conducted during a flare-up. Muscle strength testing was 5/5. There was no muscle atrophy or ankylosis. There was no recurrent subluxation or instability on testing. The Veteran had had a total knee replacement with an intermediate degree of residual weakness, pain or limitation of motion. The Veteran utilized a brace on a constant basis and a cane occasionally. Functional loss was described as having difficulty with work that required standing for more than one hour or walking for more than one mile. He also had difficulty with kneeling. VA outpatient treatment records also dated in May 2019 show that the Veteran seen for evaluation prior to a planned left knee patellar resurfacing with possible “poly exchange.” He reported having bilateral knee pain and swelling with instability. He currently wore knee braces due to instability and noted significant anterior knee pain with stairs. He also had night pain and often slept in a recliner. The Veteran underwent the resurfacing procedure in June 2019. After this procedure, the Veteran was awarded a temporary total rating under the provisions of 38 C.F.R. § 4.30 until August 1, 2019. In an December 2019 addendum, the VA examiner indicated that the Veteran’s knee condition limited his ability to do jobs that required standing for long periods, walking long distances, and going up or down stairs. The examiner described the Veteran’s bilateral knee disability as severe. It was noted that there was no lateral instability found, despite the Veteran’s complaints of instability, but that the disability was the result of chronic knee pain and limitation in range of motion. VA outpatient treatment records show that the Veteran was scheduled for physical therapy for his knee disabilities. On follow-up evaluation in September 2020, it was noted that the Veteran’s left knee surgical incision had healed well with no erythema, induration, or exudate. Range of motion was from 5 degrees extension to 95 degrees flexion. The knee joint was stable to stresses. Quadricep atrophy was present. The assessment was left TKA patellar resurfacing, doing well. An examination was conducted by VA in November 2020. The diagnoses were total knee replacements of both knees. It was noted that the Veteran had had another arthroscopic surgery of the left knee since the last examination in May 2019. He reported current symptoms and symptoms over the past 12 months of constant stiffness, pain to the back of the knee, and swelling of the left knee. He took the medication Meloxicam by mouth once per day. He reported having no flare-ups, but functional loss that affected ability to perform prolonged standing, walking, kneeling, and climbing. Range of motion of the left knee was from 25 degrees extension to 95 degrees flexion. Pain was noted on examination that caused functional loss on both flexion and extension. There was mild tenderness palpated to the medial and lateral patella. There was pain with weight bearing, but no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with additional loss of motion from 25 degrees extension to 90 degrees flexion. Pain caused this functional loss. There were no other additional contributing factors of disability. Muscle strength testing was 5/5 in flexion and extension. There was no muscle atrophy or ankylosis. Joint stability testing showed no recurrent subluxation or history of lateral instability. There was no recurrent effusion. Stability testing was normal. The TKA was stated to cause intermediate degrees of residuals weakness, pain and limitation of motion. Residual signs of the knee surgery were described as pain and limitation in range of motion. The Veteran utilized a knee brace on an occasional basis. It was noted that the Veteran had lost two to four weeks of work time over the past 12 months due to his bilateral knee replacements and arthritis that affected his ability to perform prolonged standing, walking, kneeling, and climbing. There was objective evidence of pain on passive range of motion testing as well as when the joint was used in non-weight bearing. Review of the record shows that, following the TKA procedure of the left knee, the Veteran had significant impairment of the knee. Range of motion was limited to from 5 degrees extension to 60 degrees flexion and there was muscle weakness and atrophy of the thigh muscles. The March 2018 examiner quantified the Veteran’s knee impairment as having chronic residuals consisting of severe painful motion or weakness. With the resolution of reasonable doubt, the Board finds that these residuals meet the criteria for a 60 percent rating under Diagnostic Code 5055. While the examination performed in May 2019 definitely demonstrated some improvement in range of motion and improved muscle strength, the Veteran then required an additional surgical procedure with pre-operative findings that continued to be consistent with severe impairment. As such the 60 percent rating should be maintained. Regarding the rating after the expiration of the temporary total evaluation, the Board finds that severe impairment continued to be demonstrated as evidenced by the addendum opinion of the VA examiner in December 2019. While the examination in November 2020 quantified the Veteran’s disability as being of intermediate degrees of residuals weakness, pain and limitation of motion, which is the language corresponding with the rating criteria of a 30 percent rating, the examination report documents significant limitation of extension, to 25 degrees, as well as limitation of flexion. As such, the 60 percent rating is shown to be warranted from August 2019, and thereafter, as well. Under these circumstances, the appeal is allowed to this extent. Ratings for right knee arthritis in excess of 10 percent from March 15, 2018, and in excess of 30 percent from May 1, 2019 Service connection for arthritis of the right knee was granted by rating decision dated in July 2000 as secondary to the Veteran’s left knee arthritis. A 10 percent initial rating was awarded at that time. The rating was increased to 20 percent by rating decision dated in March 2010. The Veteran appealed the 2012 rating reduction of the right knee evaluation to 10 percent. An examination was conducted by VA in January 2010. At that time, the Veteran reported having manifestations of right knee stiffness, swelling, and pain after having had a second surgery. He used NSAID medication and bracing for the knee. He had recently had Kenalog and lidocaine injections in the right knee in December 2009. The response to treatment was described as “fair.” The Veteran denied giving way, instability, episodes of dislocation or subluxation, locking, or deformity. He complained of swelling, tenderness, pain, stiffness and weakness. He denied having flare-ups. Examination showed that the Veteran walked with an antalgic gait. The right knee demonstrated effusion, tenderness, and crepitation, but no instability. Range of motion of the right knee was from 0 degrees extension to 90 degrees flexion. There was objective evidence of pain following repetitive motion, but further limitation of the right knee was not documented. There was no ankylosis. X-ray studies showed moderate degenerative changes of the right knee. The Veteran related that his right knee disability affected his employment in that he had decreased mobility and pain, but that he was able to swap shifts with another police officer if he had a flare-up to avoid missing work. An examination was conducted by VA in February 2012. At that time, the diagnosis was degenerative joint disease of both knees. The Veteran reported having had no flare-ups that impaired the function of the knee. Range of motion of the right knee was from 0 degrees extension to 110 degrees flexion. Pain was noted at 110 degrees flexion. The Veteran was able to perform repetitive use testing without additional limitation of function or motion. The Veteran did not have pain or tenderness to palpation of the knee joint line. Muscle strength testing was normal. There was no instability noted on testing. There was no evidence of recurrent patellar subluxation or dislocation. The Veteran had not had joint replacement surgery, but had had arthroscopic surgery on the right knee in 2011. The Veteran used a knee brace on a regular basis. X-ray studies noted degenerative joint disease. An examination was conducted by VA in December 2013. The diagnosis was medial meniscus repair with degenerative changes of the knee. Range of motion was from 0 degrees extension to 90 degrees flexion, with painful motion noted at 90 degrees flexion. The Veteran was able to perform repetitive use testing without additional loss of range of motion, but did have additional loss of function in that he had complaints of incoordination and pain on movement. Muscle strength testing was normal. There was no instability of any knee ligament. It was reported that the Veteran had had a meniscal tear with frequent episodes of joint locking, frequent episodes of pain and joint effusion. He had not had a total knee replacement. He used a knee brace on a regular basis. The Veteran underwent a total right knee replacement on March 15, 2018. As with the left knee, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for right knee arthritis prior to the TKA performed in March 2018. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain and that he eventually needed the TKA surgery. Nevertheless, the record does not demonstrate eligibility for a rating in excess of 10 percent prior to that time. In this regard, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The Board notes that the examination report on which the Veteran’s 20 percent rating is essentially the same as those examinations on which the reduction to 10 percent were based. On all these examinations, the Veteran had noncompensable limitation of motion that would warrant a 10 percent rating under the provisions of Diagnostic Codes 5003 and 5010. At no time has the Veteran’s limitation of flexion approached the 30-degree limit necessary for the 20 percent rating ot be applied. The Board notes that the rating decision that proposed the reduction found that there was CUE in the rating assigned to the Veteran’s left knee, which was far worse at the time the 20 percent rating was awarded, but did not reduce the right knee rating based on CUE. The Board finds that the reverse actually occurred. As noted above, the left knee rating reduction was justified by actual improvement in the range of motion of the knee while the right knee range of motion was essentially unchanged and has always been noncompensable limitation of flexion resulting from arthritis. As such, the Board finds that the reduction to 10 percent is supported by the evidence of record. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The Board has not found that a separate rating based on limitation of extension, repeated subluxation, or instability is warranted. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claim for increased rating for right knee arthritis prior to March 15, 2018, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Pursuant to Diagnostic Code 5055, the Veteran was awarded a total rating for the TKA that was performed on his right knee until May 1, 2019, at which time a 30 percent rating was assigned. An examination was conducted by VA in May 2019. The diagnosis was status post right total knee replacement. The Veteran reported flare-ups that interfered with his carpentry work. Range of motion of the right knee was from 0 degrees extension to 90 degrees flexion. Pain was noted on flexion, but limitation of motion did not result in functional loss. There was no evidence of pain with weight bearing and no sign of tenderness. The Veteran was able to perform repetitive use testing without further limitation of function. The examiner stated that the Veteran was being examined immediately after repetitive use over time and during a flare-up, but there was no significant limitation of functional ability due to pain, weakness, fatigability or incoordination. Muscle strength testing was normal and there was no muscle atrophy. There was no ankylosis and no instability. There was no history of recurrent patellar dislocation. The residuals of the total knee replacement surgery were quantified as being of intermediate degree of weakness, pain, or limitation of motion. The Veteran utilized a brace on a constant basis and occasionally utilized a cane. The examiner commented that it was difficulty of the Veteran to do work that required standing for more than an hour of walking for a long distance of more than a mile. There was no objective evidence of pain on passive range of motion or on non-weight bearing of the right knee. In an December 2019 addendum to the May 2019 examination report, the examiner stated that during the examination, there was no evidence of instability of the right knee and that the Veteran’s knee disability resulted in chronic knee pain and limitation of motion, with no evidence of instability. An examination was conducted by VA in November 12, 2020. The diagnoses were total knee replacements of both knees. He reported current symptoms and symptoms over the past 12 months of intermittent swelling, stiffness, achy and nagging pain in the right knee. He took the medication Meloxicam by mouth once per day. He reported having no flare-ups, but functional loss that affected ability to perform prolonged standing, walking, kneeling, and climbing. Range of motion of the right knee was from 25 degrees extension to 100 degrees flexion. Pain was noted on examination that caused functional loss on both flexion and extension. There was mild tenderness palpated to the medial and lateral patella. There was pain with weight bearing, but no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with additional loss of motion from 25 degrees extension to 90 degrees flexion. Pain caused this functional loss. There were no other additional contributing factors of disability. Muscle strength testing was 5/5 in flexion and extension. There was no muscle atrophy or ankylosis. Joint stability testing showed no recurrent subluxation or history of lateral instability. There was no recurrent effusion. Stability testing was normal. The TKA was stated to cause intermediate degrees of residuals weakness, pain and limitation of motion. Residual signs of the knee surgery were described as pain and limitation in range of motion. The Veteran utilized a knee brace on an occasional basis. It was noted that the Veteran had lost two to four weeks of work time over the past 12 months due to his bilateral knee replacements and arthritis that affected his ability to perform prolonged standing, walking, kneeling, and climbing. There was objective evidence of pain on passive range of motion testing as well as when the joint was used in non-weight bearing. Following the Veteran’s right knee TKA, range of motion of the knee joint was shown to be from 0 degrees extension to 90 degrees flexion. There is no instability and the pain of the knee joint is not shown to cause severe disability or weakness. As such, there is no basis to find that a rating in excess of the 30 percent minimum that is warranted for residuals of a TKA prior to November 12, 2020. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claim for a rating in excess of 30 percent for residuals of a right TKA from May 1, 2019, until November 12, 2020, and the claim must be denied prior to that date. On November 12, 2020, the Veteran’s right knee TKA was shown to cause significant limitation of extension of the knee joint. Limitation of motion was further reduced after repetitive use. While the examiner quantified the Veteran’s disability as being of intermediate degrees of residuals weakness, pain and limitation of motion, the examination report documents significant limitation of extension, to 25 degrees, which in and of itself is enough to meet the criteria for a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board finds that the Veteran’s disability more nearly approximates the severe disability associated with the 60 percent rating. As such, with the resolution of reasonable doubt, the increased rating of the Veteran’s right knee TKA to 60 percent is granted as of November 12, 2020. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph P. Gervasio 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.