Citation Nr: 21003294 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 16-05 131 DATE: January 21, 2021 ORDER Entitlement to a disability rating in excess of 30 percent for left knee arthroplasty for the period prior to August 25, 2014 is denied. Entitlement to a 60 percent disability rating, but no higher, for left knee arthroplasty from October 1, 2015 to July 14, 2020 (excluding periods of temporary total ratings) is granted. Entitlement to a disability rating in excess of 60 percent for left knee arthroplasty from July 14, 2020 is denied. FINDINGS OF FACT 1. From October 15, 2013 to August 24, 2014, the Veteran’s left knee arthroplasty was manifested by no more than intermediate degrees of residual weakness, pain, or limitation of motion. 2. From October 1, 2015 to July 14, 2020, the Veteran’s left knee arthoplasty was manifested by chronic residuals of severe painful motion or weakness. 3. From July 14, 2020, the Veteran’s left knee arthroplasty was manifested by no more than chronic residuals of severe painful motion or weakness. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent from October 15, 2013 to August 24, 2014 for left knee arthroplasty have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 2. The criteria for a 60 percent disability rating, but no higher, from October 1, 2015 to July 14, 2020 for left knee arthroplasty (excluding period of temporary total ratings) have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055.  3. The criteria for a disability rating in excess of 60 percent from July 14, 2020 for left knee arthroplasty have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 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 November 1967 to November 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this case in September 2018 for further development. In an October 2020 rating decision, the RO granted temporary total 100 percent schedular ratings for the left knee disability pursuant to 38 C.F.R. § 4.30 from August 25, 2014 to September 30, 2015, and from June 3, 2016 to July 31, 2017. During these same periods, the Veteran was awarded special monthly compensation. After the corresponding temporary 100 percent ratings periods expired, 30 percent ratings were in effect from October 1, 2015 to June 2, 2015 and from August 1, 2017 to July 13, 2020. A higher 60 percent rating was granted, effective July 14, 2020. The decision herein excludes the periods in which the temporary total 100 percent ratings were in effect. The Board notes that additional VA treatment records have been associated with the claims file since the October 2020 supplemental statement of the case (SSOC). However, the Board finds that readjudication of the claim by the Agency of Original Jurisdiction (AOJ) is not warranted as the newly associated evidence is either not pertinent or duplicative to the issue of entitlement to an increased for left knee arthropathy. Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (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 veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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 veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509 - 10 (2007). By way of history, the Veteran’s left knee arthroplasty was rated as 30 percent disabling prior to August 25, 2014 under 38 C.F.R. § 4.71a, Diagnostic Code 5055. He underwent a total left knee arthroplasty revision on August 25, 2014. He was provided a 100 percent disability rating during his period of convalescence post-surgery from August 25, 2014 to September 31, 2014 under 38 C.F.R. § 4.30 and for one year following the implantation of his prosthesis from October 1, 2014 to September 31, 2015 under Diagnostic Code 5055. He was then assigned a 30 percent disability rating from October 1, 2015 to June 2, 2016. He underwent a total left knee replacement revision on June 3, 2016. He was provided a 100 percent disability rating during his period of convalescence post-surgery from June 3, 2016 to July 31, 2016 and for one year following the implantation of his prosthesis August 1, 2016 to July 31, 2017 under Diagnostic Code 5055. He was then assigned a 30 percent disability rating from August 1, 2017 to July 13, 2020 and a 60 percent disability rating from July 14, 2020. The periods when the Veteran was assigned 100 percent disability ratings are excluded from consideration as he was in receipt of the highest schedular rating. Initially, the Board notes that the Veteran is in receipt of a 60 percent rating for his left knee arthroplasty from July 14, 2020. Pursuant to the rating criteria, no other higher or separate rating is warranted under any of the other diagnostic codes pertaining to the knee for this period. Diagnostic Codes 5256 to 5263 govern ratings of the knee and provide a maximum 60 percent rating for various knee symptoms; therefore, a rating in excess of 60 percent is not assignable under any other Diagnostic Code pertinent to rating a disability of the knee. See generally 38 C.F.R. § 4.71a, Diagnostic Codes 5256 – 5263; see also 38 C.F.R. § 4.68, Diagnostic Code 5164 (providing that the combined rating for disabilities of an extremity at the knee level shall not exceed the rating for the amputation at that elective level, were amputation to be performed, i.e., 60 percent). Additionally, as 60 percent is the maximum disability rating one can receive under the amputation rule, no higher disability rating is available and a discussion of ratings under other potentially applicable Diagnostic Codes is not warranted for this period. Diagnostic Code 5055 provides that a 100 percent rating for one year following implantation of a prosthesis. After that, a minimum 30 percent rating is assigned with intermediate degrees of residual weakness, pain or limitation of motion rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5260 (limitation of flexion of the knee), or 5262 (limitation of extension of the knee). A 60 percent rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Diagnostic Code 5055 provides that a 100 percent rating for one year following implantation of a prosthesis. After that, a minimum 30 percent rating is assigned with intermediate degrees of residual weakness, pain or limitation of motion rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5260 (limitation of flexion of the knee), or 5262 (limitation of extension of the knee). A 60 percent rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Under Diagnostic Code 5260, which contemplates limitation of leg flexion, a 0 percent 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; and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260.  Under Diagnostic Code 5261, which contemplates limitation of extension of the leg, a 0 percent rating is warranted for extension limited to 5 degrees; a 10 percent rating is warranted for extension limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261.  Separate ratings may also be assigned for limitation of flexion and limitation of extension of the same knee. 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. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005).  Under Diagnostic Code 5257, which contemplates recurrent subluxation or lateral instability, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability of the knee; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability of the knee; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board observes that the words “slight,” “moderate,” and “severe” are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Use of terminology by VA examiners or other physicians, although an element of evidence 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. Diagnostic Code 5258 provides for a 20 percent evaluation on the basis of dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. This is the only available evaluation under Diagnostic Code 5258. Diagnostic Code 5259 provides for a 10 percent evaluation on the basis of symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. This is the only available evaluation under Diagnostic Code 5259. Diagnostic Codes 5256, 5262, and 5263 also address ratings for knee disabilities. However, in this case, the evidence does not demonstrate ankylosis of the knee (Diagnostic Code 5256), impairment of the tibia and fibula (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263); thus, the Diagnostic Codes pertaining to such impairments are not applicable.  When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Further, under 38 C.F.R. § 4.45, consideration must be given to weakened movement, premature or excess fatigability and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 206 - 07 (1995). Moreover, the intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. 38 C.F.R. § 4.59. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id.; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis).  In determining if a higher rating is warranted on this basis, pain itself does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. 1. Entitlement to a disability rating in excess of 30 percent for left knee arthroplasty prior to August 25, 2014 is denied. In a May 2014 VA examination, the Veteran reported that while he underwent a total left knee arthroplasty in 2006, his knee had never improved. His left knee currently hyperextended and was painful with standing. He was only able to stand for minutes and walk for 500 feet; he was unable to climb stairs. The Veteran reported flare ups that occurred once or twice a week with severe pain, swelling, and decreased strength. He reported that during a flare up, he had to stay at home and try to keep weight off his left leg. Upon initial range of motion testing, the Veteran had left knee flexion to 90 degrees (80 degrees with painful motion) and extension to 0 degrees. There was no additional loss of motion upon repetitive use testing, but had less movement than normal, excess fatigability, pain on movement, instability of station, and disturbance of locomotion after repetitive use. The examiner found that no change in range of motion was anticipated due to flare ups or repetitive use over time. The Veteran had left knee medial-lateral instability (1+ or 0 – 5 millimeters) and a meniscus condition, but no current symptoms. He regularly used a cane. The examiner found that the Veteran had intermediate degrees of residual weakness, pain, or limitation of motion and chronic residuals consisting of severe painful motion or weakness. In a June 2014 addendum opinion, the examiner found that the Veteran had pain with walking, climbing stairs, and standing. She opined that this would be consistent with intermediate degrees of residual weakness, pain, or limitation of motion and that it would be incorrect to state that the Veteran had chronic residuals with severe painful motion or weakness with this degree of disability. In a July 2014 notice of disagreement, the Veteran contended that the “rating team member” had not given detailed reasons as to why an increased rating had not been assigned. According to VA treatment records from May 2013 to July 2014, the Veteran’s left knee had pain, swelling, limitation range of motion, and instability. It also locked and/or gave out at times, which resulted in falls or near falls. He had difficulties getting up from chairs and lower surfaces, climbing stairs, and ambulating. The Veteran ambulated using crutches, a cane, and a brace. In December 2013 and April 2014, the Veteran’s left knee had flexion to 120 degrees and extension to 0 degrees. In July 2013, it was noted that the Veteran fell as he was walking with a cane when he became distracted and lost his balance. He stated that he had “tripped” although there was no obvious hazard in his path. In May 2014, the Veteran reported that after redoing and painting his deck, his left knee had been bothering him. He had a lot of pain, was unable to stand without his knee locking, and had difficulty maintaining a slight bend in his knee without it giving out. In July 2014, according to a witness, the Veteran stood up, took a few steps, became dizzy, and fell to his knee on the floor. The Veteran reported that his knee gave out when he got up from his chair. In a November 2020 argument, the Veteran’s representative cited DeLuca v. Brown, 8 Vet. App. 202 (1995), Mitchell v. Shinseki, 25 Vet. App. 32 (2011), and 38 C.F.R. § 4.59 and highlighted that VA had to consider functional impairment due to painful motion, flare ups, or other factors. He further contended that records showed that the Veteran had limitation of extension. In May 2014, the Veteran underwent a VA examination for his left knee disability in which his range of motion testing was assessed, including where pain began during range of motion and repetitive motion testing. The examiner also described the functional loss and limitations caused by his left knee disability during flare ups and after repeated use over time. Although this VA examination does not contain the results of passive and non weight bearing ranges of motion, the examination is adequate to decide the claim. The diagnostic criteria for orthopedic conditions do not require the results of passive range of motion testing and do not discern between weightbearing and non weight bearing, and do not consider range of motion of the opposite joint (if undamaged). The rating criteria for orthopedic conditions require consideration of ranges of motion, where applicable, and functional loss as set forth in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). This information is provided in the VA examination of record and it is adequate to rate the Veteran’s service-connected left knee disability on appeal.  Based on a careful review of all the subjective and clinical evidence, the Board finds that from October 15, 2013 to August 24, 2014, the Veteran’s left knee arthroplasty does not warrant a higher 60 percent rating under Diagnostic Code 5055. In other words, the Veteran’s left knee arthroplasty did not manifest as chronic residuals consisting of severe painful motion or weakness in the affected extremity. On that basis, the Board finds that the clinical findings at the May 2014 VA examination and June 2014 addendum opinion provide the most favorable evidence. While the May 2014 VA examiner found that the Veteran’s left knee arthroplasty was manifested by intermediate degrees of residual weakness, pain, or limitation of motion and chronic residuals consisting of severe painful motion or weakness in the affected extremity, the June 2014 examiner clarified that the left knee arthroplasty was manifested by intermediate degrees of residual weakness, pain, or limitation of motion. Initial range of motion testing showed flexion to 80 degrees with painful motion and extension to 0 degrees and no additional loss of motion due to flare ups or repetitive use. Additionally, VA treatment records show that while the Veteran had left knee pain, swelling, limitation of range of motion, and instability, his range of motion was not significantly limited (with flexion to 120 degrees and extension to 0 degrees), his knee only occasionally gave out, and he was still able to do activities, such as redoing and painting his deck. The Board is sympathetic to the Veteran’s reported left knee symptomatology; however, the evidence does not warrant a higher 60 percent disability rating for left knee arthroplasty for the period prior to August 25, 2014 under Diagnostic Code 5055. Therefore, the Board finds that prior to August 25, 2014, the Veteran’s left knee arthroplasty is no more than 30 percent disabling. The Board has considered whether a separate disability rating is appropriate under another diagnostic code. However, the evidence does not demonstrate flexion limited to at least 45 degrees, extension to at least 30 degrees, or symptomatic meniscus condition. As such, Diagnostic Codes 5258, 5259, 5260, and 5261 are not applicable. Thus, separate ratings for the Veteran’s left knee arthroplasty under Diagnostic Codes 5258, 5259, 5260, and 5261 are not supported by the evidence of record. The Board notes that the May 2014 VA examination shows that the Veteran had left knee instability. However, as instability is already contemplated by the Veteran’s 30 percent rating under Diagnostic Code 5055, specifically weakness of the left knee, assigning a separate rating for left knee instability would constitute pyramiding, as it would result in the compensation of the same symptom under two separate diagnostic codes. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Thus, separate ratings for the Veteran’s left knee disability under Diagnostic Codes 5257, 5258, 5259, 5260, and 5261 are not supported by the evidence of record. In summary, the preponderance of the evidence weighs against the Veteran’s claim for a disability rating in excess of 30 percent for left knee arthroplasty from October 15, 2013 to August 24, 2014. Therefore, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a 60 percent disability rating for left knee arthroplasty from October 1, 2015 to June 2, 2016 is granted. In a January 2016 lay statement, the Veteran detailed the medical history of his left knee disability, to include his left knee surgeries. He reported undergoing a revision of the prosthesis in 2014, but the revision failed. By this time, he was limping badly, having difficulties walking, and unable to navigate the stairs. He also had pain described as “8 out of 10.” He now wore a full-length brace constantly. Without the brace, he fell frequently and with the brace, he fell occasionally. His primary care doctor had set up an appointment for him to acquire a wheelchair. According to VA treatment records from October 2015 to June 2016, the Veteran’s left knee had instability and increased weakness. He had to ambulate with a left knee brace and cane, and in January 2016 he presented to the clinic in a wheelchair and in April 2016 he sought a wheelchair for his residence. In February 2016, it was noted that he ambulated slowly and with some difficulty, and his tolerance for walking and standing was limited. It was also noted that the Veteran presented with weakness, decreased dynamic stability, poor endurance for ambulation, and overall instability of the left knee associated with a loose left total knee arthroplasty prosthesis. The Veteran reported increased weakness and falling about six times in the last six months (approximately beginning August 2015). He had left knee flexion to 125 degrees and extension to 0 degrees. In March 2016, the Veteran reported falling about once a month for the past six months and being unable to bend over due to left knee pain and instability. The falls were attributed to his left knee. He was limited to his household and short community distances. His left knee lacked full extension but was still functional. His balance was good sitting and fair standing. In April 2016, he had increased weakness with frequent falls. The gradual worsening of the bilateral lower extremity weakness had been persistent for months. It was noted that the Veteran’s chronic left knee injury contributed to his reported lower extremity weakness. The Veteran’s spouse reported Based on a careful review of all of the evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s left knee arthroplasty warrants a 60 percent disability rating from October 1, 2015 to June 2, 2016. In other words, his left knee arthroplasty was manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity. In this case, VA treatment records show that the Veteran’s left knee had increased pain and weakness resulting falls occurring once a month from August 2015. Eventually, his weakness worsened to the point that he ambulated slowly and with some difficulty and eventually used a wheelchair. The VA treatment records were consistent with his January 2016 lay statement regarding his left knee pain and weakness. Significantly, there is also no evidence of record to the contrary. Accordingly, a higher 60 percent disability rating for left knee arthroplasty from October 1, 2015 to June 2, 2016 is warranted. The Veteran is not entitled to a schedular disability rating in excess of 60 percent. As stated above, a 100 percent rating will be assigned for one year following the prosthetic replacement of a knee joint. Moreover, and again as stated above, a disability rating greater than 60 percent is not available for the residuals of the prosthetic replacement of a knee joint because such a rating would exceed the maximum 60 percent allowable under the “amputation rule.” As such, the Veteran is entitled to a 60 percent disability rating, but no more, for his service-connected left knee arthroplasty from October 1, 2015 to June 2, 2016. The Board has considered whether a separate disability rating is appropriate under another diagnostic code. However, the evidence does not demonstrate flexion limited to at least 45 degrees, extension to at least 30 degrees, or symptomatic meniscus condition. As such, Diagnostic Codes 5258, 5259, 5260, and 5261 are not applicable. Thus, separate ratings for the Veteran’s left knee arthroplasty under Diagnostic Codes 5258, 5259, 5260, and 5261 are not supported by the evidence of record. The Board notes that VA treatment records indicate that the Veteran had left knee instability. However, as instability is already contemplated by the Veteran’s 60 percent rating under Diagnostic Code 5055, specifically weakness of the left knee, assigning a separate rating for left knee instability would constitute pyramiding, as it would result in the compensation of the same symptom under two separate diagnostic codes. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Thus, separate ratings for the Veteran’s left knee disability under Diagnostic Codes 5257, 5258, 5259, 5260, and 5261 are not supported by the evidence of record. Accordingly, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the criteria for 60 percent rating, but no higher, for left knee arthroplasty have been met from October 1, 2015 to June 2, 2016. 3. Entitlement to a 60 percent disability rating for left knee arthroplasty from August 1, 2017 to July 13, 2020 is granted. VA treatment records from January 2018 to February 2020 show that the Veteran had progressive weakness in his left knee following his knee surgery in 2016. He was initially able to walk with a walker, but he had progressive weakness and was now wheelchair bound as of August 2019. In January, April, and May 2018, he reported his knee giving out on him and falling several times, about two to three times a month, so he largely used a wheelchair. Based on a careful review of all of the evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s left knee arthroplasty warrants a 60 percent disability rating from August 1, 2017 to July 13, 2020. In other words, his left knee arthroplasty was manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity. In this case, VA treatment records show that the Veteran’s left knee had progressively weakened since his June 3, 2016 surgery until his needed to use a wheelchair. His knee also gave out and he fell several times, about two to three times a month. Significantly, there is also no evidence of record to the contrary. Therefore, the Board finds that from August 1, 2017 to July 13, 2020, the Veteran’s left knee arthroplasty warrants a 60 percent disability rating. The Veteran is not entitled to a schedular disability rating in excess of 60 percent. As stated above, a 100 percent rating will be assigned for one year following the prosthetic replacement of a knee joint. Moreover, and again as stated above, a disability rating greater than 60 percent is not available for left knee arthroplasty because such a rating would exceed the maximum 60 percent allowable under the “amputation rule.” As such, the Veteran is entitled to a 60 percent disability rating, but no more, for his service-connected left knee arthroplasty from August 1, 2017 to July 13, 2020. The Board has considered whether a separate disability rating is appropriate under another diagnostic code. However, the evidence does not demonstrate flexion limited to at least 45 degrees, extension to at least 30 degrees, or symptomatic meniscus condition. As such, Diagnostic Codes 5258, 5259, 5260, and 5261 are not applicable. Thus, separate ratings for the Veteran’s left knee arthroplasty under Diagnostic Codes 5258, 5259, 5260, and 5261 are not supported by the evidence of record. The Board notes that VA treatment records indicate that the Veteran had left knee instability. However, as instability is already contemplated by the Veteran’s 60 percent rating under Diagnostic Code 5055, specifically weakness of the left knee, assigning a separate rating for left knee instability would constitute pyramiding, as it would result in the compensation of the same symptom under two separate diagnostic codes. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Thus, separate ratings for the Veteran’s left knee disability under Diagnostic Codes 5257, 5258, 5259, 5260, and 5261 are not supported by the evidence of record. Accordingly, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the criteria for 60 percent rating, but no higher, for left knee arthroplasty have been met from August 1, 2017 to July 13, 2020. 4. Entitlement to a disability rating in excess of 60 percent for left knee arthroplasty from July 14, 2020 is denied. According to a private treatment record, the Veteran underwent a total knee replacement revision in the left knee on June 3, 2016. In a July 14, 2020 VA examination, the Veteran reported being in rehabilitation intermittently to learn how to walk since his 2016 left knee surgery. He had been using a wheelchair for two years. His current left knee symptoms included pain and inability to bear weight. He did not report flare ups. Upon initial range of motion testing, the Veteran’s left knee had flexion to 120 degrees and extension to 30 degrees. Pain was noted on examination which resulted in functional loss. Pain was specifically noted only on extension. There was objective evidence of pain on passive range of motion testing and upon non weight bearing. There was no additional loss of range of motion upon repetitive use testing. Pain, weakness, lack of endurance, and incoordination significantly limited functional ability with repeated use over time, specifically resulting in left knee flexion to 120 degrees and extension to 35 degrees. There was reduction in muscle strength, but no muscle atrophy or ankylosis. The Veteran was unable to perform the joint stability test because he was wheelchair bound. He had a meniscus condition resulting in a meniscus tear and frequent episodes of joint pain. He constantly used a wheelchair. The Veteran’s left knee arthroplasty resulted in functional impact, to include being unable to do a job that required standing or walking. In a November 2020 argument, the Veteran’s representative cited DeLuca v. Brown, 8 Vet. App. 202 (1995), Mitchell v. Shinseki, 25 Vet. App. 32 (2011), and 38 C.F.R. § 4.59 and highlighted that VA had to consider functional impairment due to painful motion, flare ups, or other factors. He further contended that records showed that the Veteran had limitation of extension. In July 2020, the Veteran underwent a VA examination for his left knee disability in which his range of motion testing was assessed, including where pain began during range of motion and repetitive motion testing. The examiner also described the functional loss and limitations caused by his left knee disability after repeated use over time. Although this VA examination does not contain the results of passive and non weight bearing ranges of motion, the examination is adequate to decide the claim. The diagnostic criteria for orthopedic conditions do not require the results of passive range of motion testing and do not discern between weightbearing and non weight bearing, and do not consider range of motion of the opposite joint (if undamaged). The rating criteria for orthopedic conditions require consideration of ranges of motion, where applicable, and functional loss as set forth in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). This information is provided in the VA examination of record and it is adequate to rate the Veteran’s service-connected left knee disability on appeal.  By assigning the increased 60 percent disability rating under Diagnostic Code 5055 from October 1, 2015 (excluding the periods for which a temporary total rating has been assigned), the Board declines to consider whether the Veteran is entitled to an additional disability evaluation under other applicable codes. Based on a careful review of all the subjective and clinical evidence, the Board finds that from July 14, 2020, the Veteran’s left knee arthroplasty does not warrant a higher 100 percent rating under Diagnostic Code 5055. In other words, it was not within one year following the prosthetic replacement of a knee joint, which last occurred on June 3, 2016. The Board is sympathetic to the Veteran’s reported left knee symptomatology; however, the evidence does not warrant a higher 100 percent disability rating for left knee arthroplasty at any point other than for which he has received a temporary total rating. from July 14, 2020 under Diagnostic Code 5055. A 60 percent rating is the highest schedular rating allowed, aside from the temporary 100 percent ratings as has been assigned. Moreover, and again as stated above, a disability rating greater than 60 percent is not available for left knee arthroplasty because such a rating would exceed the maximum 60 percent allowable under the “amputation rule.” As such, the Veteran is entitled to a 60 percent disability rating, but no more, for his service-connected left knee arthroplasty from July 14, 2020. The Board has considered whether a separate disability rating is appropriate under another diagnostic code. However, the evidence does not demonstrate flexion limited to at least 45 degrees, symptomatic removal of the semilunar cartilage, or dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion. As such, Diagnostic Codes 5258, 5259, and 5260 are not applicable. Thus, separate ratings for the Veteran’s left knee arthroplasty under Diagnostic Codes 5258, 5259, and 5260 are not supported by the evidence of record. The evidence shows that the Veteran’s left knee extension was limited to 35 degrees, which warrants a 40 percent rating under Diagnostic Code 5261. Recently, the Court found that the phrase “severe painful motion” in the 60 percent rating criteria under Diagnostic Code 5055 was not synonymous with limitation of motion, although limitation of motion may be considered in evaluating painful motion. Tedesco v. Wilkie, 31 Vet. App. 360, 365 – 66 (2019). However, the Board finds that the Veteran’s limitation of extension is already contemplated by his 60 percent rating under Diagnostic Code 5055, specifically severe painful motion, especially as the July 2020 VA examination showed that the limitation of extension was due to painful motion. As such, assigning a separate rating for left knee limitation of extension would constitute pyramiding, as it would result in the compensation of the same symptom under two separate diagnostic codes. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Thus, separate ratings for the Veteran’s left knee disability under Diagnostic Codes 5257, 5258, 5259, 5260, and 5261 are not supported by the evidence of record. In summary, the preponderance of the evidence weighs against the Veteran’s claim for a disability rating in excess of 60 percent for left knee arthroplasty from July 14, 2020. Therefore, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Ko, Associate 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.