Citation Nr: 21003370 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 13-28 597 DATE: January 21, 2021 ORDER Entitlement to service connection for a left knee disability, to include as secondary to service-connected right knee disability, is denied. Entitlement to service connection for a low back disorder, to include as secondary to service-connected right knee disability, is denied. Entitlement to an increased evaluation in excess of 10 percent from March 2, 1999 to April 24, 2012, for right knee arthritis is denied. Entitlement to a separate disability rating of 10 percent for instability under Diagnostic Code 5257 for the service-connected right knee disability from June 18, 2009, to April 24, 2012, is granted. Entitlement to an increased evaluation in excess of 30 percent since April 24, 2012, exclusive of a period of temporary total evaluation, for right knee arthritis is denied. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities is denied. FINDINGS OF FACT 1. A left knee disability manifested more than one year after active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 2. A left knee disability is not caused or aggravated by a service-connected disability. 3. A low back disability manifested more than one year after active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 4. A low back disability is not caused or aggravated by a service-connected disability. 5. From March 2, 1999 to April 24, 2012, the Veteran’s service-connected right knee disability has been manifested by limitation of flexion at worst to 140 degrees, limitation of extension at worst to zero degrees, occasional swelling, weakness, crepitus, and pain on motion; ankylosis, subluxation, and instability have not been shown. 6. From June 18, 2009 to April 24, 2012, the Veteran’s right knee disability has been manifested by slight instability; moderate instability of the right knee is not more nearly approximated at any time during this period. 7. From April 24, 2012, exclusive of a period of temporary total evaluation, the Veteran’s service-connected right knee disability is productive of total knee replacement with intermediate degrees of residual weakness, pain, or limitation of motion, limitation of flexion at worst to 125 degrees, extension at worst to zero degrees; ankylosis, crepitus, subluxation, and instability have not been shown. 8. The evidence of record does not show that the Veteran’s service-connected disabilities alone preclude him from obtaining or maintaining substantially gainful employment consistent with his level of education and work history on a schedular or extraschedular basis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability have not been met or approximated. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2020). 2. The criteria for entitlement to service connection for a low back disability have not been met or approximated. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3,310 (2020). 3. From March 2, 1999 to April 24, 2012, the criteria for a disability rating in excess of 10 percent for a right knee arthritis disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Codes 5259-5010 (2020). 4. From June 18, 2009, to April 24, 2012, the criteria for a separate rating of 10 percent, but not higher, for the service-connected right knee disability on the basis of instability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2020). 5. From April 24, 2012, exclusive of a period of temporary total evaluation, 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 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.30, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2020). 6. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16, 4.19 (2020).   REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1972 to March 1976. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2009 rating decision, by the Department of Veterans Affairs, Regional Office, located in St. Petersburg, Florida (RO). In that rating decision, the RO denied an evaluation in excess of 10 percent for right knee disability, and denied the claims for service connection for left knee and low back disorders. The Veteran appealed the denial of his claims. By the way of a May 2012 rating decision, the RO awarded a 100 percent disability rating from April 24, 2012 to May 31, 2013 based on one month of convalescence following right knee total replacement surgery and then one year for implantation of prosthesis, and thereafter, assigned a 30 percent rating. As the grant does not award the full benefit sought for the period prior to April 24, 2012 and period since June 1, 2013, the issue of increased rating for right knee disability remains on appeal. 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 claims are still in controversy and on appeal. Id. In January 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) during a Board hearing held at the RO. A copy of the hearing transcript has been associated with the claims folder. At the hearing, the Veteran submitted additional medical evidence with a waiver of initial consideration. The Board remanded the issues on appeal for additional development in April 2018. The directives having been substantially complied with, the matter again is before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). When a Veteran files a claim for an increased rating, he or she is presumed to be seeking the maximum benefit under any applicable theory, including a total disability evaluation based on individual unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447, 453–54 (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). Here, TDIU is part of this Board decision and will discussed below. 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). As such, the Board will not infer the issue of entitlement to SMC 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) (2020). 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). Service Connection for Left Knee and Lumbar Back Disabilities Legal Criteria for Service Connection - General Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For arthritis, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been “shown in service,” there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). After the evidence is assembled, it is the Board’s responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’’ in order to prevail.” To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Evidence and Analysis The Veteran filed a claim for service connection for his left knee and his low back in April 2009. The Veteran has also asserted that his left knee and low back disabilities are related to his service-connected right knee, in that his right knee had altered the gait of his normal walk such that it injured his other knee and his low back. The Board notes for discussion purposes that while VA provided examinations for the knees and back, the exams will in essence be discussed twice because of the focus on service connection and etiology for the left knee and the low back in this section, and later in this decision will following the increased ratings claims for the service-connected right knee, with a different focus of the current nature and severity of the right knee. The Veteran had a VA examination for his knees in July 1978, primarily for his right knee complaints and about two years after leaving active service, and the VA examiner noted there was no evidence of left knee pathology. In April 1980, the Veteran went to a private hospital complaining of back and left hip pain. The Veteran denied previous low back problems, and the treating physician noted no issues with the lower back upon x-ray. In May 1992, the Veteran sought private medical care for his back pain complaints. He specifically complained of lower back pain with pain radiating down to the left lower extremity. The private physician examiner noted the Veteran had said to reach over to push a box on the floor, and experienced low back pain in a posterolateral aspect. The Veteran noted to this examiner that the back injury originated in 1986 with a low back strain. Beginning in January 1997, the Veteran received private medical care for his low back, with pain and discomfort in the lower back segments. In May 1999, the Veteran received a VA examination for his knees that included a discussion about his low back problems. This examiner noted no problem or diagnosis with the left knee, and also noted that the Veteran’s low back complaints were not related to service or related to his service-connected right knee. Private medical records Dr. L.S.E. from December 2000 to April 2001 noted a left knee injury and treatment for it. More private records from April to June 2004 from Dr. F.L. noted complaints of low back pain and treatment for that, but there was no discussion of etiology. The latter record noted a diagnosis of lumbar post laminectomy syndrome and lumbar myofascial pain. The Veteran was seen in a military outpatient clinic in September 2009 for complaints of low back pain. The Veteran complained of chronic lower back pain that radiated down to his lower extremities. An MRI taken that day noted degenerative discopathy of the lumbar spine with annular tear noted centrally at the L4-L5 level, mild central canal stenosis of the L4-L5 level, chronic anterior compression deformity of the L2 vertebral body and degenerative facet arthropathy with bilateral nerve root impingement at L5-S1 of the lumbar spine. The Veteran received his first VA compensation and pension examination for his left knee and low back in December 2009. This examiner diagnosed arthritis in the left knee and arthritis in the low back, and considered the onset to be 1990 based on medical records and the Veteran’s own history. The Veteran denied any injury to his left knee prior to his examination. The left knee had some tenderness at the medial joint line but no other symptoms. X-rays were negative for both the left knee or the low back beyond mild arthritis. The medical history indicated three low back surgeries in 1986 for a lumbar laminectomy, again in 1993, and also in 1996. The examiner who recorded the 1993 and 1996 treatments noted the low back injury was not related to any service event. The previous diagnosis from September 2009 of a degenerative discopathy of the lumbar spine was continued. The December 2009 examiner provided a negative opinion for service connection for the left knee, saying it was less likely than not, less than 50 percent probability, that the left knee was related to any service injury, incident, or condition. The examiner’s rationale was that there was no history or pathology of the left knee noted since service. An August 1977 VA outpatient clinic record noted there was no left knee healing or fracture noted, and there was no history of complaint, treatment, or diagnosis for the left knee arthritis now diagnosed continuing into the time of this examination. This examiner also provided a negative opinion for service connection for the low back, saying it was also less likely than not less than 50 percent probability, that the diagnosed low back arthritis was related to service. The examiner’s rationale was that the first note of any condition with the back was a record from 1980, and there were no incidents in service that gave rise to any possible back injury or condition. In July 2013, the Veteran received another VA examination for his low back and his left knee. This examiner diagnosed degenerative changes of the left knee, mild to moderate along the medial joint compartment. The examiner noted a 2000 surgery to address the left knee, and the Veteran could not recall any injury to his left knee. Left knee pain was noted from a June 2004 private visit to a pain management clinic, but no treatment was noted or recalled by the Veteran. This examiner also examined the low back as part of this examination and noted a diagnosis of “history of muscle strain” dating from 1980 and again in 1986, a laminectomy in the lumbar region after injuring the back at work in April 1992, and now status post laminectomy syndrome with degenerative disc disease for the lumbar back. The examiner noted three laminectomy surgeries, in May 1992, April 1996, and May 1997. This examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran’s current left knee disability was related to any in-service condition, incident, or injury. The examiner’s rationale was there was no history, either in the medical records, or from the Veteran regarding a service left knee injury. This examiner also remarked negatively about secondary service connection, saying it was less likely than not, less than 50 percent probability, proximately due to or the result of the service-connected right knee condition. The examiner remarked that the moderate arthritis of the left knee is that consistent with the natural expectations of normal age that would be seen in obese patient. This July 2013 examiner also provided a negative opinion for the Veteran’s low back claim, saying it was less likely than not, less than 50 percent probability, that the Veteran’s low back conditions were related to any service injury, incident, or condition. The examiner’s rationale was that the Veteran’s service records were silent for any chronic back injury, and there were multiple events post-service, to include the 1986 low back muscular strain, the April 1992 work incident for which the Veteran claimed workmen’s compensation, including the three resultant laminectomy surgeries, and then the December 2000 hunting incident. This examiner also remarked negatively about secondary service connection, saying it was less likely than not, less than 50 percent probability, proximately due to or the result of the service-connected right knee condition. The examiner’s rationale was that the back condition likely resulted from the documented work injuries, and that all of the Veteran’s low back treatment resulted from those work or recreational injuries even though the right knee had been service-connected since leaving active service in March 1976. The Veteran received another VA examination for his knees and low back in January 2020. The examiner diagnosed left knee osteoarthritis, with an onset in 2012. The examiner also noted an earlier arthroscopic procedure done on the left knee in 1999. This same examiner diagnosed degenerative arthritis of the spine, with a date of diagnosis of September 2009. Symptoms of lumbosacral pain and stiffness were noted, and the history of three laminectomy surgeries was noted. The Veteran reported flare-ups for both his left knee and low back when he bends over to pick up something heavy. This examiner provided negative opinions for direct service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran’s diagnosed left knee condition was due to any in-service injury, event, or condition. The claims file was silent for chronic left knee issues until 2004, and the diagnosed osteoarthritis was deemed be of degenerative form appearing at a time in the Veteran’s life when degenerative arthritis is more likely to develop, as opposed to any earlier traumatic injury or disease. This examiner also opined in the negative regarding secondary service connection, saying it was less likely than not the claimed left knee condition is proximately due to or the result of the right knee condition. The examiner specifically addressed the Veteran’s allegation that his service-connected right knee forced him to alter his walking gait such that his left knee was now injured, but the examiner opined in the negative, pointing out that an altered gait would not lead to degenerative arthritis in the other knee, and no other left knee condition was diagnosed that might be indicative of a gait problem. This examiner also provided a negative opinion for service connection for the low back claim, saying it was less likely than not, less than 50 percent probability, that the Veteran’s diagnosed low back condition was due to any in-service injury, event, or condition. The claims file was silent for chronic low back issues until the muscle strain noted in 1986, and then the work accident in April 1992 with subsequent surgeries. This examiner also opined in the negative regarding secondary service connection, saying it was less likely than not the claimed low back condition is proximately due to or the result of the right knee condition. The examiner specifically addressed the Veteran’s allegation that his service-connected right knee forced him to alter his walking gait such that it injured his lower back, but the examiner opined in the negative, pointing out that an altered gait would not lead to degenerative arthritis in the lumbar spine area, and no other low back condition was diagnosed that might be indicative of a gait problem. The examiner also noted a variety of complaints in the Veteran’s medical records, but none that could be considered sequelae of the Veteran’s only service-connected condition, the right knee. Even with the April 2012 right knee replacement, medical literature indicates that gait changes are negligible several months after the prosthesis is placed. 1. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right knee disability 2. Entitlement to service connection for a low back disorder, to include as secondary to service-connected right knee disability The Board finds the June/December 2009, July 2013, and January 2020 VA examinations and opinions to be of great probative value. The examiners went into detail with the Veteran’s medical and service history, conducted a thorough review of the claims file, and considered the Veteran’s contentions and clinical medical evidence before providing a negative opinion for both direct and secondary service connection. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). The negative VA opinions considered all of the Veteran’s contentions as to his theories of service connection for his left knee and low back claims. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The VA examiners’ negative opinions were supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran’s contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board acknowledges that the Veteran is competent to testify as to his belief that his left knee and low back disabilities are related to service. In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; “[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of [his] personal knowledge.” Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran is competent to testify about his symptoms relating to his claimed left knee and low back disabilities. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology of a left knee or low back disability. See 38 C.F.R. § 3.159 (a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. The Board also notes that the Veteran’s service records were silent for any chronic left knee or low back symptoms or related complaint, and his first complaint does not arise until 1986 for the low back strain at the earliest. The Board finds the gap in time between the end of active service in 1976 until the 1986 possible occurrence of symptoms of the low back (and later for the left knee) to be probative of a lack of nexus between service and the current complaints. There are no competent medical opinions of probative value in favor of a positive nexus to active service from any VA examiner or medical treatment provider from any source. Upon review of the record, the Board concludes that entitlement to service connection for a left knee and/or a low back condition is not warranted. The Board notes a current diagnoses of arthritis in both the left knee and the low back, and thus the requirement for a current disability is shown. The Board acknowledges the Veteran’s contentions, and the Veteran’s post-service statements are noted. The Board notes that the Veteran’s entrance examination, his service treatment records, and his separation examination were all silent for any chronic left knee or low back symptoms, or related injury or incident that led to the current degenerative arthritis. The final physical of February 1976, a month prior to separation from active service, is silent for any existing left knee or low back symptoms or related injury at the time of separation from active service, and there is no competent evidence to tie the current assertions to any in-service disease or injury. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. With regard to presumptive service connection for degenerative arthritis of the left knee or the low back, the weight of evidence shows no chronic symptoms of this condition during active service, no continuous symptoms of the condition since service, and that the condition did not manifest to a compensable degree within one year of service. As such, presumptive service connection is not warranted. 38 C.F.R. §§ 3.303, 3.309. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran’s claimed left knee and low back disabilities were not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a left knee or low back disability of any extremity on a direct, secondary, or presumptive basis, 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. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 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). The terms “slight,” “marked,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. 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 disability is currently evaluated under two diagnostic codes: Diagnostic Code 5055, leg limitation of flexion, and Diagnostic Code 5010, traumatic arthritis, currently with a 30 percent evaluation since June 1, 2013. From March 2, 1999 forward to April 24, 2012, when the Veteran had a total right knee arthroplasty, the Veteran’s right knee was evaluated under Diagnostic Code 5259, symptomatic removal of semilunar cartilage, and Diagnostic Coe 5010, with an evaluation of 10 percent, excluding a period of temporary total evaluation from April 24, 2012 to June 1, 2013 relating to the Veteran’s right knee total arthroplasty. The Veteran has not appealed the period of the temporary total evaluation and it will thus not be discussed. 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. Under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5010, traumatic arthritis, substantiated by X-ray findings, is rated on limitation of motion of affected parts, as degenerative arthritis under 38 C.F.R. § 4.71a, DC 5003. For DC 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. See also Petitti v. McDonald, 27 Vet. App. 415 (2015). In the absence of limitation of motion, rate as follows: a 10 percent evaluation is assigned for painful or limited motion of a major joint or group of minor joints and may also be applied once to multiple joints if there is no limited or painful motion. A 20 percent is assigned for X-ray evidence that shows involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a. Because DC 5003 requires that “satisfactory of evidence of pain” be “objectively confirmed,” a Veteran’s testimony, alone, is not enough. For the minimum compensable rating for motion which is painful but not actually limited to a compensable degree, a claimant’s bare statement is not satisfactory evidence of painful motion. Petitti v. McDonald, 27 Vet. App. 415, 427 (2015) (holding that painful motion may be “objectively confirmed” by either a clinician, including a claimant’s assertion of painful joints that is confirmed by a clinician’s statement there is a history of “recurrent” joint pain or a layperson who witnessed the Veteran experience difficulty walking, standing, or sitting, or display a facial expression, such as wincing, indicative of pain). In other words, satisfactory lay evidence of painful motion also includes lay descriptions from other than the Veteran of painful motion; lay observations of witnesses of painful motion, lay statements of observed visible behavior or facial expressions during painful motion, as well as lay reports of difficulty walking, standing, sitting, or undertaking other activity. Id. at 429. 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. Diagnostic Code 5256 provides ratings for ankylosis of the knee. A favorable angle in full extension, or in slight flexion between zero and 10 degrees warrants a 30 percent rating. Ankylosis of the knee in flexion between 10 and 20 degrees warrants a 40 percent rating, and between 20 and 45 degrees warrants a 50 percent rating. Extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more, warrants a 60 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Diagnostic Code 5257 provides ratings for recurrent subluxation and/or lateral instability of the knee. A 10 percent rating is assigned for slight recurrent subluxation and/or instability of the knee. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5259, symptomatic removal of semilunar cartilage, there is only a single rating of 10 percent specified: semilunar cartilage, removal of, symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. 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, Diagnostic Code 5260. 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; and a 30 percent rating will be assigned for limitation of flexion of the leg to 20 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. 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. 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, dislocated semilunar cartilage, impairment of the tibia and fibula, and genu recurvatum have not been found or associated with the Veteran’s knee disability and thus will not be considered here. The Board is cognizant of a pending rule change outlined in the Federal Register for VA’s Musculoskeletal System and Muscle Injuries that will include changes to 38 C.F.R. § 4.71a, the source of the rating guidance used in this decision, that will take affect February 7, 2021, after the date of this Board decision. See 85 Fed. Reg. 76453 (to take effect Feb. 7, 2021). However, the Board notes that none of the draft changes would have any different effect on the rating adjudication, and the Board will thus proceed with the remainder of its decision. 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). Moreover, in VAOPGCPREC 23-97, VA Office of General Counsel (OGC) opined that it was not pyramiding to assign ratings under DC 5257 (knee instability) and DC 5260/61 based on additional disability. The opinion explained that DC 5257 addressed instability of the knee without reference to limitation of motion, and DC 5003 referenced limitation of motion without instability. Id. at para. 2. In other words, the two DCs addressed different manifestations or symptoms. Right Knee Evidence and Analysis The Veteran was originally granted service connection for his right knee, effective from March 9, 1976, the day after he left active service. In a June 1978 rating decision, the Veteran’s right knee rating was reduced to noncompensable, effective from October 1, 1978; the Veteran did not appeal that decision within one year, and thus it became final. In March 1999, the Veteran filed a claim for an increased rating for his right knee, resulting in an increased rating of 10 percent awarded in a June 1999 rating decision. The Veteran filed a notice of disagreement for that decision in July 1999, and a statement of the case was issued in July 1999, but the Veteran never made a formal substantive appeal to the Board. That rating decision, too, went final without any further appeal. In April 2009, the Veteran filed, inter alia, another claim for his right knee, saying it had worsened. As such, the Board will focus on the disability level of his right knee disability from one year immediately preceding the claim. See 38 U.S.C. § 5110 (b)(2) and 38 C.F.R. § 3.400 (o)(2) (stating that in assessing the present level of disability, the relevant temporal focus is from one year immediately preceding the filing of the increased-rating claim); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran was originally evaluated under Diagnostic Code 5010, traumatic arthritis, and Diagnostic Code 5259, symptomatic removal of semilunar cartilage, for the right knee. After his April 2012 total knee arthroplasty, the Veteran received a temporary total evaluation pursuant to 38 C.F.R. §§ 3.400 & 4.30 for 13 months following the total knee arthroplasty, and then a 30 percent evaluation under Diagnostic Code 5055 for knee replacement, prosthesis, effective from June 1, 2013. 38 C.F.R. § 4.71a. As such, then, the Board will evaluate Diagnostic Codes 5010 and 5259 prior to April 24, 2012 for the Veteran’s right knee disability, and then under Diagnostic Code 5055 from June 1, 2013 forward. The first VA examination in the period on appeal was provided in June 2009, with a follow up in December 2009. The examiner noted the Veteran’s history going back to active service, when the Veteran had a medial meniscectomy of the right knee that was service-connected immediately following active service. This examiner formally diagnosed degenerative joint disease right knee, status post medial meniscectomy. In 1999 and 2001, the Veteran had arthroscopies of the right knee to debride torn cartilage. The examiner noted “giving way,” instability, pain, stiffness, but no episodes of dislocation or subluxation. Some swelling and tenderness were noted. No flare-ups were noted. Degenerative arthritis was noted along the medial joint compartment and patellofemoral space. Crepitus was noted in the patellofemoral area. The meniscus abnormality was noted, but there was no locking, effusion, or dislocation noted. Range of motion was noted for the right knee with zero to 120 degrees extension and flexion. Functional impact was noted as difficulty getting in and out of a car, and traveling on extended trips. The Veteran could only walk about one quarter mile and could only stand for a few minutes at a time before sitting to rest his right knee. The examiner noted, however, that the Veteran still hunts actively and scuba dives on a regular basis. The Veteran received another VA examination for his right knee in July 2013. This examiner noted the Veteran’s history of a medial meniscectomy of the right knee and his recent right knee total arthroplasty, performed in April 2012. Range of motion measurements on the replaced right knee were 130 degrees in flexion to zero degrees extension, and no objective evidence of painful motion was observed. After repetitive use testing, there was no change in flexion but extension was limited to 40 degrees. Muscle strength was five on a scale of five for both knees, and there was no evidence of patellar subluxation or dislocation for the right knee. There were no signs of instability in the replaced right knee. The examiner noted the effects of the joint replacement from April 2012 has having slightly less range of motion. The Veteran received another VA examination for his knees in January 2020. The previous history of the right knee was noted and the examiner observed the right knee had remained the same, though the Veteran complained specifically of arthritis pain in his artificial right knee. Right knee range of motion measurements were 115 degrees of flexion to zero degrees extension, with no change in measurements after repetitive use. Some pain was observed on movement in flexion. There was no evidence of localized tenderness or pain on palpation of the right knee joint or adjacent soft tissue, and there was no objective evidence of crepitus. The Veteran noted no flareups since his knee replacement in April 2012, and while there is general knee pain reported, the examiner estimated this did not alter his range of motion of the right knee. Muscle strength was five on a scale of five and the examiner specifically noted no other symptoms contributing to any right knee disability. No ankylosis was observed and there was no evidence of recurrent subluxation or lateral instability. All instability tests for the right knee were normal. The examiner described the functional impact of the Veteran’s right knee as limiting his tolerance for prolonged weight-bearing, walking more than a quarter mile, climbing stairs, and heavy lifting of loads greater than 50 pounds. The examiner summarized that the Veteran’s right knee replacement seems to have restored much of his right knee function. 3. Entitlement to an increased evaluation in excess of 10 percent from March 2, 1999 to April 24, 2012, for right knee arthritis disability For the Veteran’s right knee arthritis under Diagnostic Codes 5010-5259, for the period on appeal March 2, 1999 to April 24, 2012, the Board finds that a 10 percent evaluation, but no higher, is warranted. While the flexion measurements in this period would not warrant a compensable rating for the right knee, a rating of 10 percent is appropriate here 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 right 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. The Board notes the Veteran’s right knee was rated due to Diagnostic Code 5010 for traumatic arthritis and Diagnostic Code 5259, symptomatic removal of semilunar cartilage. However, this rating does not consider the Veteran’s “give way” weakness and instability, which derives from the same original injury to the right knee. VA examinations record symptoms and statements of instability from the Veteran, and they also note the Veteran’s use of a cane to assist in stable ambulation and to reduce falls. The Board finds that the symptomatology of painful motion used for the original right knee disability rating based on arthritis is distinct from the symptomology for the right knee instability. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board thus finds that, in addition to the 10 percent rating assigned for the right knee on the basis of the arthritis and the medial meniscotomy, an additional 10 percent rating under Diagnostic Code 5257 is appropriate from the date of the examination that found for the right knee instability, from June 18, 2009 to April 24, 2012, the date of the right knee replacement. A 10 percent rating for instability is the minimum rating described in Diagnostic Code 5257. 38 C.F.R. § 4.71a. See VAOPGCPREC 9-98 (August 14, 1998) (arthritis & instability). VA General Counsel has 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). VA’s Office of the General Counsel (OGC) opined that it was not pyramiding to assign ratings under DC 5257 (knee instability) and DC 5260/61 based on additional disability. The opinion explained that DC 5257 addressed instability of the knee without reference to limitation of motion, and DC 5060/61 referenced limitation of motion without instability. Id. at para. 2. In other words, the two diagnostic codes addressed different manifestations or symptoms. The Board has considered the findings regarding objective evidence of knee instability versus subjective reporting of instability by the Veteran in this case. See English v. Wilkie, 30 Vet. App. 347, 353 (2018) (holding that the Board cannot categorically favor objective stability test results over lay reports of instability). Here, the Board notes there were reports of instability by VA medical examiners pertinent to this period from June 18, 2009 to the date of his right knee total arthroplasty of April 24, 2012. Id.; see also Tedesco v. Wilkie, 31 Vet. App. 360, 367 (2019). After the right knee arthroplasty of April 2012, no VA examiner found evidence of right knee instability post-replacement. As to the degree of instability, the Board finds that it has been no more than slight in degree for the period in question. Although the Veteran was prescribed a knee brace and he had some pseudo-laxity medially approximated as 2+, the record does not show that the Veteran consistently falls as a result of a buckling knee or that he would consistently fall but for the use of a brace or a cane. Moreover, the degree of instability indicated during testing in June and December 2009 supports a finding of slight instability, but not moderate instability, particularly where, as here, some of the VA examiners found no instability. During this period, there was no subluxation noted. Moreover, the Veteran’s statements regarding his instability were that he had difficulty standing due to pain and feelings that he might fall while standing or walking up and down stairs more closely approximate a slight degree of instability during this period, even though VA orthopedic testing for instability, a drawer test, was negative for the right knee in December 2009. Accordingly, the Board finds that the Veteran’s right knee symptoms include occasional instability for this period. In this regard, the evidence does not show, and the Veteran has not argued that any such instability is more than slight in degree, and this is consistent with the VA examiner’s stability testing and observation of stability-related symptoms during examination. Thus, the Board finds that a separate 10 percent rating is warranted for slight instability of the Veteran’s right knee during this period from the date of the first VA examination that found the instability on June 18, 2009, to April 24, 2012, when the Veteran’s right knee was replaced in a total arthroplasty. The Board considers the other symptoms of painful motion of the Veteran’s right knee are adequately covered by already-assigned Diagnostic Codes of 5010-5259 used in this period. A higher rating of 20 percent under Diagnostic Code 5257 is not warranted unless the Veteran’s right knee instability was characterized as “moderate.” No VA or primary medical examiner or treatment provider had ever characterized the Veteran’s right knee instability as moderate, vice slight, in the appeal period. The Board has considered and found that Diagnostic Codes for limitation of motion, Diagnostic Codes 5260 and 5261, do not provide any additional benefit for the Veteran’s right knee in this period. To warrant the next higher rating above the current 10 percent for painful motion, a 20 percent rating, knee flexion would have to be limited to 30 degrees or less, and/or knee extension would have to be limited to 15 degrees or higher. This has never been shown, even with consideration of additional loss of motion due to pain and swelling during flare-ups. The Board is cognizant that VA examiners have recorded different ranges of motion, but all examiners have noted the consistent pain, pain on motion, and instability of the Veteran’s right knee. Furthermore, the Veteran’s lay statements and testimony before the undersigned Veterans Law Judge are consistent over time and correspond to the medical evaluations and treatment notes in the record. “[O]bjective evidence does not necessarily mean [only] medical evidence.” Petitti v. McDonald, 27 Vet. App. 415, 427 (2015); see Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Veteran is competent to report pain on motion, instability, and limitation of movement. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Moreover, the Board finds him credible, as his reports are internally consistent and there is no evidence to the contrary. Caluza v. Brown, 7 Vet. App. 498 (1995). 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). All potentially applicable diagnostic codes have been considered, and there is no basis to assign an alternative evaluation for the Veteran’s right knee disabilities prior to the April 24, 2012 arthroplasty 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 this appeal period. Any increases in severity were not sufficient for a higher rating beyond the two 10 percent ratings warranted for this period for the reasons discussed above. See Hart, 21 Vet. App. 505. 4. Entitlement to an increased evaluation in excess of 30 percent since April 24, 2012, exclusive of a period of temporary total evaluation, for right knee disability For the Veteran’s right knee, for the period from April 24, 2012, exclusive of periods of temporary total evaluation that expired June 1, 2013, 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. Pursuant to Diagnostic Code 5055, the Veteran’s temporary total evaluation for one year following beginning the first of the month after the month of the total right knee arthroplasty is appropriate. For the right knee replacement in this appeal period, which occurred on April 24, 2012, the RO awarded a temporary total evaluation for one year pursuant to Diagnostic Code 5055 and 38 C.F.R. § 4.30 to June 1, 2013, at which time the Veteran’s evaluation for his right knee reverted to 30 percent. 38 C.F.R. § 4.71a. The Board notes VA examinations in July 2013 and January 2020, both following the right knee total arthroplasty, found intermediate degrees of residual weakness, pain, or limitation of motion, which under Diagnostic Code 5055 meet or approximate the criteria for a 30 percent evaluation. 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 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 in this period from June 1, 2013, 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 pursuant to the medical evidence and Diagnostic Codes 5260 and 5261, 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 issue of the right knee disability, and the level of its 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 the period in question using Diagnostic Code 5055 compared to other possible diagnostic codes, and that the determination of the right 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 the right knee prosthetic replacement is warranted for the period from June 1, 2013, which is when the period of temporary total evaluation expires pursuant to Diagnostic Code 5055 and 38 C.F.R. § 4.30. All potentially applicable diagnostic codes have been considered, and there is no basis to assign an alternative evaluation for the Veteran’s right knee disability 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. TDIU The Board found in this Veteran’s previous appeal before the Board dated April 17, 2018 that a TDIU was inferred as part of that claim pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). That issued was remanded with the remaining issues already described above, and is now again before the Board. A total disability rating may be assigned, where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as the result of service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling; or (2) that the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). For the purpose of establishing one 60 percent disability, or one 40 percent disability in combination, disabilities affecting a single body system are considered as one disability. Id. Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to TDIU is based on an individual’s particular circumstance.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009) (quoting Thun v. Peake, 22 Vet. App. 111, 116 (2008)); see also Todd, 27 Vet. App. at 85-86. Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering veteran’s master degree in education and his part-time work as a tutor). A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether a veteran can find employment. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a veteran’s favor. 38 C.F.R. § 4.3. As noted, consideration may not be given to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. However, when it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant’s favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.10. In discussing the unemployability criteria, the United States Court of Appeals for Veterans Claims (Court) has indicated that, in essence, the unemployability question, that is, the veteran’s ability or inability to engage in substantial gainful activity, has to be looked at in a practical manner, and that the thrust is whether a particular job is realistically within the capabilities, both physical and mental, of the appellant. See Moore v. Derwinski, 1 Vet. App. 83 (1991). The VA General Counsel has concluded that VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities shall be rated as totally disabled, without regard to whether an average person would be rendered unemployable by such circumstances. Thus, the criteria include a subjective standard. It was also held that unemployability is synonymous with the inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91 (1991). As noted above, in determining whether the veteran is entitled to individual unemployability, neither his non-service-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Thus, in deciding the claim, the Board may not favorably consider the effects of the non-service-connected disabilities with respect to their degree of interference with his employability. Indeed, the Court stated that in order for a veteran to prevail on a claim for TDIU, the record must reflect some factor which takes his case outside of the norm. The sole fact that he is unemployed or has difficulty obtaining employment is not enough. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. See Van Hoose v. Brown, supra. If total industrial impairment has not been shown, the VA is not obligated to show that a veteran is incapable of performing specific jobs in considering a claim for a total rating based on individual unemployability. See Gary v. Brown, 7 Vet. App. 229 (1994). Under applicable criteria, VA shall consider all lay and medical evidence of record in a case with respect to benefits under laws administered by VA. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 5. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities Schedular TDIU A total disability rating for individual unemployability may be granted where the schedular rating is less than total and the service-connected disabilities preclude the veteran from obtaining or maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). The Veteran is service-connected for his right knee arthritis disability with a 10 percent rating from March 2, 1999 to April 24, 2012, a separate right knee rating of 10 percent for instability from June 18, 2009 to April 24, 2012, as of this decision, and now a right knee rating of 30 percent for a prosthesis replacement from April 24, 2012 forward. He is also service connected for a right knee scar with a noncompensable evaluation. The total current combined evaluation for compensation is 30 percent from April 24, 2012, excluding a period of temporary total evaluation related to a right knee total arthroplasty in April 2012. Because the Veteran does not have a combined evaluation of at least 70 percent with at least one disability evaluated at 40 percent or higher, or a single service-connected disability that has been rated 60 percent or higher during the period at issue, under the 38 C.F.R. § 4.16(a) criteria outlined above, the Veteran does not meet the schedular criteria for a schedular TDIU rating. Consequently, a TDIU rating on a schedular basis, under 38 C.F.R. § 4.16(a), is not warranted. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Extraschedular TDIU If the above percentage thresholds are not met, the Veteran’s claim may still be referred to the Director, Compensation Service for consideration of an extraschedular rating, when the evidence of record shows that Veteran is “unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities.” 38 C.F.R. § 4.16(b). The Veteran was provided a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, in December 2019. The Veteran completed 12 years of school, graduated from high school, and also one year in college. He was trained as a Navy boatswain and served on ship with duties afloat. Since service, he has worked as a real estate broker and a financial planner, and in his peak earning years noted that he made one hundred thousand dollars a year. The Veteran noted during testimony with the undersigned VLJ in January 2018 that he was working part-time at a camping/hunting megastore in the gun sales but that he did not consider that gainful employment. The Board notes from the January 2020 VA examination for the knees and back about the examiner’s discussion of functional impact. Here, the examiner noted the Veteran could not walk more than one mile or stand in one position for more than 15 minutes, with difficulty climbing stairs or squatting, due to his right knee. The Board also notes a July 2013 VA examination for the Veteran’s right knee that indicated his service-connected disabilities may preclude strenuous labor but would not preclude light or sedentary work. The Board acknowledges that the Veteran’s service-connected disabilities of his right knee and related scar may very well result in some occupational impairment. However, such interference is contemplated in the ratings assigned for those service-connected disabilities, and the weight of the evidence does not demonstrate total occupational impairment from the Veteran’s service-connected disabilities of his right knee and related scar at the current time or at any time in the period on appeal. The evidence of record does not demonstrate that the service-connected disabilities of record alone render the Veteran unemployable. The Board notes and acknowledges the limitations of the Veteran’s other diagnosed conditions, to include lumbar spine pain, left knee arthritis, coronary artery disease, and residuals of diabetes. However, those other disabilities are not service-connected, and are thus not pertinent to the Veteran’s claim for a TDIU. In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Under these circumstances, the Board concludes that extraschedular referral for TDIU is not warranted. Gilbert, supra. Based on the foregoing, the Board finds that referral to the Director of Compensation Service for consideration of TDIU on an extraschedular basis under 38 C.F.R. § 4.16(b) is not warranted because the most credible, competent, and probative evidence of record does not reflect that the Veteran is unable to follow or secure substantially gainful employment due his service-connected disabilities for the entire period on appeal. See also Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Neither the Veteran nor his representative has raised any other issues, 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.