Citation Nr: 21005246 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 13-18 623 DATE: January 29, 2021 ORDER Entitlement to a 20 percent staged disability rating, but no higher, prior to September 14, 2019 beginning August 7, 2006, for right knee traumatic arthritis, is granted. Entitlement to staged disability ratings in excess of 30 percent from September 14, 2019 to August 18, 2020, and in excess of 10 percent from August 19, 2020, for service-connected right knee traumatic arthritis, is denied. Entitlement to a 20 percent staged disability rating, but no higher, prior to September 14, 2019 beginning August 7, 2006, for left knee traumatic arthritis, is granted. Entitlement to staged disability ratings in excess of 30 percent from September 14, 2019 to August 18, 2020, and in excess of 10 percent from August 19, 2020, for service-connected left knee traumatic arthritis, is denied. Entitlement to a disability rating in excess of 10 percent for right knee limitation of extension is denied. Entitlement to a disability rating in excess of 30 percent for left knee limitation of extension is denied. Entitlement to a separate disability rating of 10 percent, but no higher, for right knee instability, prior to June 27, 2017, beginning August 7, 2006, is granted. Entitlement to a rating in excess of 10 percent for right knee instability, from June 27, 2017, is denied. Entitlement to a separate disability rating of 10 percent, but no higher, for left knee instability, prior to June 27, 2017, beginning August 7, 2006, is granted. Entitlement to a disability rating in excess of 10 percent for left knee instability, from June 27, 2017, is denied. FINDINGS OF FACT 1. Prior to September 14, 2019, the Veteran’s right knee traumatic arthritis was manifested by pain productive of limitation of motion, with forward flexion no worse than to 35 degrees on weight bearing; and left knee traumatic arthritis was manifested by pain productive of limitation of motion with forward flexion no worse than to 35 degrees on weight bearing. 2. From September 14, 2019 to August 18, 2020, the Veteran’s right knee traumatic arthritis was manifested by pain productive of limitation of motion, with forward flexion no worse than to 10 degrees with consideration of flare ups or repeated use over a period of time; and left knee traumatic arthritis was manifested by pain productive of limitation of motion, with forward flexion no worse than to 15 degrees with consideration of flare ups or repeated use over a period of time. 3. From August 19, 2020 to the present, the Veteran’s right knee traumatic arthritis was manifested by pain productive of limitation of motion, with forward flexion no worse than to 65 degrees with consideration of flare ups or repeated use over a period of time; and left knee traumatic arthritis was manifested by pain production of limitation of motion, with forward flexion no worse than to 70 degrees with consideration of flare ups or repeated use over a period of time. 4. For the entire period on appeal, the Veteran’s right knee disability was manifested by pain productive of limitation of motion, with limitation of extension no worse than to 10 degrees with consideration of flare ups or repeated use over a period of time. 5. For the entire period on appeal, the Veteran’s left knee disability was manifested by pain productive of limitation of motion, with limitation of extension no worse than to 25 degrees with consideration of flare ups or repeated use over a period of time. 6. For the entire period on appeal, the probative evidence of record, including the Veteran’s lay statements, demonstrates slight right knee instability; moderate instability of the right knee is not demonstrated at any time during the appeal period. 7. For the entire period on appeal, the probative evidence of record, including the Veteran’s lay statements, demonstrates slight left knee instability; moderate instability of the left knee is not demonstrated at any time during the appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 20 percent staged disability rating, but no higher, prior to September 14, 2019, for right knee traumatic arthritis, has been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Codes 5010-5260. 2. The criteria for entitlement to a 20 percent staged disability rating, but no higher, prior to September 14, 2019, for left knee traumatic arthritis, has been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Codes 5010-5260. 3. The criteria for entitlement to staged disability ratings in excess of 30 percent from September 14, 2019 to August 18, 2020, and in excess of 10 percent from August 19, 2020, for service-connected right knee traumatic arthritis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Codes 5010-5260. 4. The criteria for entitlement to staged ratings in excess of 30 percent from September 14, 2019 to August 18, 2020, and in excess of 10 percent from August 19, 2020, for service-connected left knee traumatic arthritis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Codes 5010-5260. 5. The criteria for entitlement to a disability rating in excess of 10 percent for right knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Codes 5261. 6. The criteria for entitlement to a disability rating in excess of 30 percent for left knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.59, 4.71a, Diagnostic Codes 5261. 7. The criteria for entitlement to a separate 10 percent disability rating, but no higher, for right knee instability prior to June 27, 2017, beginning August 7, 2006, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 8. The criteria for entitlement to a rating in excess of 10 percent for right knee instability, from June 27, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 9. The criteria for entitlement to a separate 10 percent disability rating, but no higher, for left knee instability prior to June 27, 2017, beginning August 7, 2006, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 10. The criteria for entitlement to a disability rating in excess of 10 percent for left knee instability, from June 27, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1977 to September 1988. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2004 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). As a matter of history, the RO, in the August 2004 rating decision, assigned 10 percent disability ratings, each, for traumatic arthritis of the bilateral knees. In a November 2009 rating decision, the RO granted separate 10 percent disability ratings, each, for limitation of extension of the Veteran’s bilateral knees, effective August 7, 2006. In an August 2017 rating decision, the RO granted the Veteran an increased 30 percent initial disability rating for limitation of extension of the left knee, effective August 7, 2006 pursuant to a June 2017 Board decision; and granted separate 10 percent disability ratings, each, for bilateral knee instability, effective June 27, 2017. In an August 2020 rating decision, the RO assigned an increased staged rating from 10 percent to 30 percent, each, for the Veteran’s service-connected traumatic arthritis of the bilateral knees from September 14, 2019 to August 18, 2020, and staged 10 percent disability ratings, each, for the Veteran’s service-connected effective traumatic arthritis of the bilateral knees from August 19, 2020. As the increases awarded by the RO did not satisfy the appeal in full, the issues remain on appeal and have been characterized as shown on the title page of this decision. See AB v. Brown, 6 Vet. App. 35 (1993). This case was most recently remanded by the Board in May 2018. A review of the record shows that there has been substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The case has been returned to the Board for further review. The Board notes that the issue of entitlement to an increased disability rating to 40 percent, but no higher, for degenerative joint disease of the lumbosacral spine prior to July 22, 2015, was granted in the May 2018 Board decision. Additionally, the Board denied entitlement to a disability rating in excess of 40 percent for a lumbar spine disability at any time during the appeal period in the May 2018 Board decision. Board decisions are final when issued. See 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. Accordingly, the issues are no longer before the Board. The Board further notes that the Veteran submitted additional lay statements in support of his claims that has been associated with the claims file since the RO issued an August 2020 Supplemental Statement of the Case. Under 38 U.S.C. § 7105(e)(1), for substantive appeals received on or after February 2, 2013, a waiver of RO review is not required for new pertinent evidence that is submitted by the appellant or representative, and the Board may proceed with adjudication and consideration of the new evidence in the first instance. The Veteran’s substantive appeal was received after February 2, 2013, in June 2013. Therefore, a waiver of RO review is not required, and the Board may consider the additional lay statements in the first instance. 38 U.S.C. § 7105(e)(1); 38 C.F.R. § 20.1304(c). The Board is cognizant of the ruling of the United States Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, though the Veteran asserts his bilateral knee disabilities impact his ability to work, the Veteran is currently employed full-time, and neither he nor his representative argue that his service-connected bilateral knee disabilities at issue renders him unemployable. Additionally, the record does not otherwise reflect that the Veteran is unemployable on account of his service-connected bilateral knee disabilities. Accordingly, the Board concludes that a claim for a TDIU has not been expressly raised or inferred. Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity.  Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4.  When after careful consideration of all procurable and assembled date, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3.  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).  Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell, 25 Vet. App. at 33, 43.  Even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under §§ 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016).  Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011).  In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.”  In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Entitlement to a staged rating in excess of 10 percent, prior to September 14, 2019, a staged disability rating in excess of 30 percent from September 14, 2019 to August 18, 2020, and a staged disability rating in excess of 10 percent from August 19, 2020, for service-connected right knee traumatic arthritis. Entitlement to a staged rating in excess of 10 percent, prior to September 14, 2019, a staged disability rating in excess of 30 percent from September 14, 2019 to August 18, 2020, and a staged disability rating in excess of 10 percent from August 19, 2020, for service-connected left knee traumatic arthritis. In August 2006, the Veteran submitted a Notice of Disagreement (NOD) seeking higher evaluations for his service-connected traumatic arthritis of his bilateral knees. See August 2006 NOD (Claim). As a prior August 2004 rating decision was final, the Veteran’s NOD is considered a claim for increased ratings for his service-connected traumatic arthritis of his bilateral knees. Id. The Veteran’s increased rating claim was received on August 7, 2006. Therefore, the relevant rating period for consideration on appeal is from August 7, 2005, one year prior to receipt of the claim if an increase is demonstrated therein, through the present. See 38 C.F.R. § 3.400(o)(2). During the pendency of the appeal, the RO, in an August 2020 rating decision, assigned an increased staged rating from 10 percent to 30 percent, each, for the Veteran’s service-connected traumatic arthritis of the bilateral knees from September 14, 2019 to August 18, 2020, and staged 10 percent disability ratings, each, for the Veteran’s service-connected effective traumatic arthritis of the bilateral knees from August 19, 2020. The Veteran’s traumatic arthritis of the bilateral knees is rated under 38 C.F.R. § 4.71a, Diagnostic Codes (DC) 5010-5260. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating, with the first DC representing the underlying condition and the second one representing the residuals. 38 C.F.R. § 4.27. Here, the hyphenated DC indicates that the Veteran’s traumatic arthritis of the bilateral knees was rated based on limitation of flexion. DC 5010 provides that arthritis, due to trauma, substantiated by X-ray findings be rated under DC 5003, degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Under DC 5003, degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code. However, when the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application to be combined, not added, under DC 5003. Under DC 5260, flexion of the leg limited to 60 degrees is rated as noncompensable (0 percent disabling); flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a, DC 5260. Under DC 5256, a higher evaluation of 40 percent disabling is warranted for ankylosis of the knee in flexion between 10 degrees and 20 degrees; a 50 percent evaluation is warranted for ankylosis of the knee in flexion between 20 degrees and 45 degrees; and a 60 percent evaluation is warranted for extremely unfavorable ankylosis of the knee in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, DC 5256. Normal range of motion of knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71a, Plate II. Prior to September 14, 2019 As noted, the Veteran was assigned ratings of 10 percent each for his traumatic arthritis of the bilateral knees prior to September 14, 2019. The Veteran initially asserted that he continued to have consistent pain and discomfort, in pertinent part, to his knees. See August 2006 NOD (Claim). He asserted that his range of motion in all of his joints were severely hindered by arthritis pain. The Veteran also asserted that his knees have increased in their pain to include being “locked” several times a day; getting out of a vehicle puts tremendous stress on his knees; joints are stiff in the morning; and productivity at work has decreased due to continual joint pains. See July 2008 and June 2009 Statements in Support of Claim; September 2009 Correspondence. The record does not contain any VA treatment records as the Veteran was not receiving treatment for his bilateral knees prior to September 14, 2019. The Veteran was initially afforded a VA examination in October 2009. The October 2009 VA examiner noted the Veteran’s reports of constant pain in both knees that are especially bothersome with twisting, prolonged sitting, and prolonged weight bearing. See October 2009 VA examination. The VA examiner noted the Veteran reported flare ups during cold weather, has less weight bearing due to pain, but did not otherwise state a change in range of motion due to flare ups. Upon examination, the Veteran demonstrated flexion to 120 degrees in both knees with no additional loss of range of motion following repetitive use testing. There was no ankylosis or instability found upon examination for either knee. The VA examiner noted there was a left knee meniscus tear; however, there was no locking, effusion, or dislocation upon examination. The VA examiner did not specifically provide any range of motion measurements in during flare ups, or after repeated use over a period of time. The examination does not specify any range of motion measurements in passive motion or with and without weight bearing. In November 2010, the Veteran reported his traumatic arthritis of the bilateral knees worsened in severity. See November 2010 NOD. The Veteran was afforded a second VA examination in May 2013. The May 2013 VA examiner noted the Veteran’s reports of pain in his knees; difficulty with stairs; pain after standing after 5-10 minutes; and ability to walk about 100 yards. See May 2013 VA examination. The Veteran did not report any flare ups. Upon examination the Veteran demonstrated right knee flexion to 110 degrees with pain beginning at 90 degrees; and left knee flexion to 110 degrees with pain beginning at 90 degrees. The Veteran demonstrated right knee flexion to 90 degrees after repetitive use testing; and left knee flexion to 70 degrees after repetitive use testing. The VA examiner noted the Veteran had less movement than normal; excess fatigability; interference with sitting, standing, and weight-bearing; and pain on movement of both knees after repetitive use testing. Both knees demonstrated normal muscle strength. There was no instability, recurrent subluxation/dislocation, or meniscal conditions. The examination does not specify any range of motion measurements in passive motion or with and without weight bearing. In the Veteran’s June 2013 substantive appeal, he contends that the May 2013 VA examination is inadequate and asserted the examination was conducted by a physician’s assistant; did not include all of his lay statements; and that the measurements were incorrect. See June 2013 VA examination. In May 2015, the Board found the Veteran asserted an increase in severity of his bilateral knees disabilities and remanded the issue on appeal for a new examination. The Veteran was afforded a third examination in July 2015. The July 2015 VA examiner noted the Veteran’s reports of experiencing pain every day, and increased limitation of mobility of knees and increased pain during flare ups typically brough on by prolonged standing, walking, or sitting. Upon examination, the Veteran demonstrated right knee flexion to 85 degree, and left knee flexion to 80 degrees with pain on movement and on weight bearing. There was no additional loss of function or range of motion after repetitive use testing. The VA examiner could not say without mere speculation whether pain, fatigability, or incoordination significantly limited functional ability during flare ups or repetitive use over time without observing the Veteran during a flare up or after repetitive use over time. Muscle strength and joint stability testing were normal for both knees. There was no ankylosis in either knee. There were no meniscal conditions. Additionally, the VA examiner remarked that it was not possible to reconcile the Veteran’s prior October 2009 and May 2013 VA examinations regarding range of motion limitations. In June 2017, the Board determined the prior VA examinations were inadequate because they did not include the range of motion testing results required by the Court in Correia, specifically, range of motion testing in active and passive motion, weight bearing, and non-weight-bearing. The Veteran was provided a new examination in June 2017. The June 2017 VA examiner noted the Veteran’s reports of pain in both knees when he gets up in the morning, and difficulty with stairs. Upon examination, the Veteran demonstrated right knee flexion to 110 degrees, and left knee flexion to 90 degrees with pain and weight bearing. The VA examiner noted that the Veteran’s range of motion on weight bearing was right knee flexion to 35 degrees, and left knee flexion to 35 degrees. There was no additional loss of function or range of motion after repetitive use testing. The VA examiner could not say without mere speculation whether pain, fatigability, or incoordination significantly limited functional ability during flare ups or repetitive use over time without observing the Veteran during a flare up or after repetitive use over time. Muscle strength and joint stability testing were normal for both knees. There was no ankylosis in either knee. There were no meniscal conditions or recurrent subluxation. The VA examiner noted a slight level of severity for lateral instability in both knees. In May 2018, the Board determined the June 2017 VA examination was inadequate regarding whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability during flare ups or with repeated use over a period of time and remanded the issues for a new VA examination. The Board also requested the VA examiner to provide an opinion regarding the Veteran’s range of motion throughout the appeal period since August 2005 in active and passive motion, weight-bearing, and non-weight bearing. An August 2020 VA examiner stated that the Veteran’s range of motion throughout the appeal, since August 2005, of the bilateral knees in active motion was 70 degrees to the right and 65 degrees to the left; exhibited similar limitations in passive motion; had significant weight bearing pain in the clinic; and pain in non-weight bearing was noted in his history. See August 2020 VA examination. Based on these findings and resolving any reasonable doubt in favor of the Veteran, the Board finds an increased 20 percent staged disability rating, each, prior to September 14, 2019, for the Veteran’s traumatic arthritis of the bilateral knees, is warranted. In that regard, the Board notes that the June 2017 VA examination is the earliest evidence specifying the degree of functional impairment on weight bearing in terms of range of motion. As noted, the June 2017 VA examiner noted both knees were limited to 35 degrees flexion on weight bearing. See June 2017 VA examiner. The Board has reviewed the evidence to determine if these details may serve to inform the Board’s review with regard to the degree of functional impairment prior to September 14, 2019. Specifically, the October 2009 VA examiner noted the Veteran’s report that he has less weight bearing due to pain but did not provide the degree of functional limitation in terms of range of motion. See October 2009 VA examination. The May 2013 VA examiner noted the Veteran had less movement than normal; excess fatigability; interference with sitting, standing, and weight-bearing; and pain on movement of both knees after repetitive use testing. See May 2013 VA examination. While the evidence is not unequivocally clear, the Board finds that the Veteran’s description of functional impairment is credible and reasonably compatible with the findings of the June 2017 VA examination. Given that the June 2017 VA examination report represents the earliest pertinent estimation of the Veteran’s functional impairment, in terms of limitation of range of motion on weight bearing despite inability to provide a range of motion during flare ups or repeated use over time, the Board views the Veteran’s reports and prior VA examiner’s findings compatible with the June 2017 VA examiner’s description of functional impairment, and creates at least a reasonable doubt as to whether the degree of functional impairment detailed in the June 2017 VA examination was also present during the entire appeal period prior to September 14, 2019. Therefore, resolving reasonable doubt in the Veteran’s favor, the Board finds that the evidence sufficiently supports a finding that the functional impairment shown in the earliest adequately detailed evidence in the June 2017 VA examination has been present throughout the entire appeal period prior to September 14, 2019. As such, the evidence of record supports an increased 20 percent staged disability rating, each, for the Veteran’s traumatic arthritis of the bilateral knees under DC 5010-5260, for the appeal period from August 7, 2006 to September 13, 2019. See 38 C.F.R. § 4.71a, DC 5010-5260. The Board notes that separate ratings are not warranted under DC 5256 as the weight of the competent and probative evidence is against finding ankylosis, prior to September 14, 2019. Consideration was also given to assigning separate disability ratings under DCs 5258 and 5259 prior to September 14, 2019. In that regard, the October 2009 VA examination indicates evidence of a meniscus tear of the Veteran’s left knee only. See October 2009 VA examination. However, the October 2009 VA examiner noted there was no locking or effusion of the left knee. Additionally, despite evidence of locking, pain, and effusion for the Veteran’s bilateral knees, the May 2013, July 2015, and June 2017 VA examinations do not demonstrate dislocated semilunar cartilage or symptomatic removal of semilunar cartilage to warrant separate ratings. Therefore, the Board finds the October 2009 VA examination is inconsistent with the other medical evidence of record and entitled to limited probative weight. Accordingly, separate ratings under DCs 5258 and 5259 are not warranted for the Veteran’s traumatic arthritis of the bilateral knees. See 38 C.F.R. § 4.71a, DCs 5258, 5259. To the extent the Veteran asserts that higher ratings are warranted prior to September 14, 2019, the Board notes the Veteran is credible and competent to report subjective symptoms such as pain. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran is not considered competent to assess the relative severity of his bilateral knee disabilities, as doing so involves medical testing and medical knowledge the Veteran has not been shown to possess. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Consequently, the Board gives more probative weight to the competent medical evidence which includes the June 2017 VA examination that is against the Veteran’s claim for higher ratings than to the Veteran’s lay statements. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). Finally, the Board considered whether the Veteran is entitled to higher ratings due to functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, 8 Vet. App. at 206-07. The objective medical evidence of record is of greater probative value as to the Veteran’s level of impairment than his assertions, given that the testing to ascertain whether a higher rating is warranted is the province of trained and credentialed medical professionals. Even considering the Veteran’s subjective complaints of pain and other symptoms described in DeLuca, limitation of motion of the bilateral knees have not been shown such that higher ratings would be warranted. See Thompson, 815 F.3d at 786. The Board finds that the evidence does not support entitlement to higher ratings for his bilateral knee disabilities on these bases. From September 14, 2019 to August 18, 2020 As noted, the Veteran is currently assigned 30 percent staged disability ratings, each, for service-connected traumatic arthritis of the bilateral knees under DC 5010-5260. The Board finds that the preponderance of the competent evidence does not support the grant of higher staged ratings in excess of 30 percent for the Veteran’s traumatic arthritis of the bilateral knees from September 14, 2019 to August 18, 2020. In that regard, there are no VA treatment records as the Veteran was not receiving treatment for his bilateral knees during the period from September 14, 2019 to August 18, 2020. The Veteran was afforded a VA examination in September 2019. The VA examiner noted the Veteran’s reports of bilateral knee pain especially with extensive walking, standing, and awkward positioning and difficulty with stairs. See September 2019 VA examination. Upon examination, the Veteran demonstrated right knee flexion, at worse, to 10 degrees with consideration of flare ups and repetitive use over time; and left knee flexion, at worse, to 15 degrees with consideration of flare ups and repetitive use over time. Muscle strength and joint stability testing were normal for both knees. There was no ankylosis in either knee. There were no meniscal conditions. The VA examiner noted there was evidence of pain on passive range of motion and on non-weight bearing for both knees. Based on these findings, increased ratings under DC 5010-5260 for limitation of flexion is not warranted. See 38 C.F.R. § 4.71a, DC 5010-5260. 30 percent is the highest rating available for limitation of flexion of the knee. The Board notes that separate ratings are not warranted under DC 5256 as the weight of the competent and probative evidence is against finding ankylosis, from September 14, 2019 to August 18, 2020. Ankylosis is the “immobility and consolidation of a joint due to disease, injury, or surgical procedure,” and is commonly referred to as a “frozen” joint. Dorland's Illustrated Medical Dictionary, 94 (32nd Ed. 2012); see also Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (ankylosis is “stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint,” citing Stedman's Medical Dictionary 87 (25th ed. 1990)). The Veteran has always maintained at least some movement in his knee, and at no time has it ever been found to be frozen or completely immobile. The Board has considered the Veteran’s lay statements, but he has not asserted that he has had ankylosis at any time, and his lay statements regarding pain and difficulty with activity is consistent with the rating assigned. The Board also has considered the Veteran’s pain and its effect on the movement of his knee. See DeLuca, 8 Vet. App. at 206-07. As the Veteran has already been assigned the maximum schedular rating for limitation of motion of flexion for this period, a higher rating is not warranted based on additional limitation of motion due to such factors as pain, pain on motion, weakened movement, incoordination, or excessive fatigability because the maximum limitation of motion, prior to ankylosis (ankylosis means no motion), is established. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Ankylosis is a specific medical finding, and the current medical evidence does demonstrate that the Veteran maintained at least motion in his knee, even if painful. Consideration was also given to assigning separate disability ratings under DCs 5258 and 5259. However, there was no evidence of dislocated semilunar cartilage or removal of symptomatic semilunar cartilage noted on the September 2019 VA examination. Accordingly, separate ratings under DCs 5258 and 5259 are not warranted for the Veteran’s traumatic arthritis of the bilateral knees from September 14, 2019 to August 18, 2020. See 38 C.F.R. § 4.71a, DCs 5258, 5259. Lastly, the Board has considered the effective date of September 14, 2019 that was assigned for the increased ratings of 30 percent. The effective date for an increased rating should be based on the medical evidence showing when the increase in the level of disability actually occurred. See 38 C.F.R. § 3.400(o)(2). Effective dates should not be mechanically assigned based solely on the date of the VA examination, but should include consideration of all of the facts to determine the date that the increase in disability was ascertainable. Swain v. McDonald, 27 Vet. App. 219, 224 (2015). The Board has reviewed all of the evidence of record, but there is no indication in VA treatment records, the Veteran’s statements, or any other documented evidence that the Veteran’s disability underwent an increase in severity manifesting with a flexion limited in either knee to 15 degrees or less prior to September 14, 2019. The earliest documented evidence that the Veteran’s right and left knee flexion had decreased to such severity was at the September 2019 VA examination. In the absence of any other evidence indicating that the Veteran’s knee disabilities had undergone a worsening prior to September 14, 2019, the Board is unable to assign an earlier effective date for these increases. From August 19, 2020 As noted, the Veteran is currently assigned 10 percent staged disability ratings, each, for service-connected traumatic arthritis of the bilateral knees under DC 5010-5260. The Board finds that the preponderance of the competent evidence does not support the grant of higher staged ratings in excess of 10 percent for the Veteran’s traumatic arthritis of the bilateral knees from August 19, 2020. In that regard, there are no VA treatment records as the Veteran was not receiving treatment for his bilateral knees during the period from August 19, 2020. The Veteran was afforded a VA examination in August 2020. The VA examiner noted the Veteran’s reports of bilateral knee limitation of flexion, daily aching and pain, difficulties with walking, standing, and sitting for long periods of time, and flare ups. See August 2020 VA examination. Upon examination, the Veteran demonstrated right knee flexion, at worse, to 65 degrees with consideration of flare ups and repetitive use over time; and left knee flexion, at worse, to 70 degrees with consideration of flare ups and repetitive use over time. Muscle strength and joint stability testing were normal for both knees. There was no ankylosis in either knee. There were no meniscal conditions. The VA examiner also noted that throughout the appeal period, there was significant observed limitation during active range of motion testing; 70 degrees to the right and 65 degrees to the left with passive range of motion exhibiting similar range of motion limitations; significant pain observed in weight bearing; and pain in non-weight bearing noted in history. Based on these findings, increased ratings under DC 5010-5260 for limitation of flexion is not warranted. See 38 C.F.R. § 4.71a, DC 5010-5260. The current 10 percent staged ratings, each, for the Veteran’s bilateral knee disabilities compensates the Veteran for his limited range of motion and functional loss, including due to pain. 38 C.F.R. §§ 4.440, 4.59; Burton, 25 Vet. App. at 5. The Board notes that separate ratings are not warranted under DC 5256 as the weight of the competent and probative evidence is against finding ankylosis, from August 19, 2020. Consideration was also given to assigning separate disability ratings under DCs 5258 and 5259. However, there was no evidence of dislocated semilunar cartilage or removal of symptomatic semilunar cartilage noted on the August 2020 VA examination. Accordingly, separate ratings under DCs 5258 and 5259 are not warranted for the Veteran’s traumatic arthritis of the bilateral knees from August 19, 2020. See 38 C.F.R. § 4.71a, DCs 5258, 5259. To the extent the Veteran asserts that higher ratings are warranted from August 19, 2020, the Board notes the Veteran is credible and competent to report subjective symptoms such as pain. See Layno, 6 Vet. App. at 469. However, the Veteran is not considered competent to assess the relative severity of his bilateral knee disabilities, as doing so involves medical testing and medical knowledge the Veteran has not been shown to possess. See Kahana, 24 Vet. App. at 435. Consequently, the Board gives more probative weight to the competent medical evidence which includes the August 2020 VA examination that is against the Veteran’s claim for higher ratings than to the Veteran’s lay statements. See Nieves-Rodriguez, 22 Vet. App. at 302. Moreover, the Veteran, nor his representative, has provided any competent evidence to the contrary. Finally, the Board considered whether the Veteran is entitled to higher ratings due to functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, 8 Vet. App. at 206-07. The objective medical evidence of record is of greater probative value as to the Veteran’s level of impairment than his assertions, given that the testing to ascertain whether a higher rating is warranted is the province of trained and credentialed medical professionals. Even considering the Veteran’s subjective complaints of pain and other symptoms described in DeLuca, limitation of motion of the bilateral knees have not been shown such that higher ratings would be warranted. See Thompson, 815 F.3d at 786. The Board finds that the evidence does not support entitlement to higher ratings for his bilateral knee disabilities on these bases. In sum, the Board finds that increased 20 percent staged disability ratings, but not higher, each, for the Veteran’s traumatic arthritis of the bilateral knees is warranted for the appeal period prior to September 14, 2019, beginning August 7, 2006; entitlement to staged disability ratings in excess of 30 percent, each, for traumatic arthritis of the bilateral knees from September 14, 2019 to August 18, 2020, is not warranted; and entitlement to staged disability ratings in excess of 10 percent, each, for traumatic arthritis of the bilateral knees from August 19, 2020, is not warranted. See 38 C.F.R. § 4.71a. DC 5010-5260. In denying any higher ratings, the Board finds that the benefit of the doubt doctrine is inapplicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to a disability rating in excess of 10 percent for right knee limitation of extension. Entitlement to a disability rating in excess of 30 percent for left knee limitation of extension. As noted, in a November 2009 rating decision, the RO granted separate 10 percent disability ratings, each, for limitation of extension of the Veteran’s bilateral knees, effective August 7, 2006, under DC 5261. In an August 2017 rating decision, the RO granted the Veteran an increased 30 percent disability rating for limitation of extension of the left knee, effective August 7, 2006, pursuant to a June 2017 Board decision. As such, the Veteran is currently rated with 10 percent for right knee limitation of extension, and 30 percent disabling for left knee limitation of extension for the entire period on appeal under 38 C.F.R. § 4.71a, DC 5261. Under DC 5261, extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Normal range of motion for extension of the of the knee is to 0 degrees. 38 C.F.R. § 4.71a, Plate II. The Board finds that the preponderance of the competent evidence does not support the grant of higher disability ratings than 10 percent for the Veteran’s right knee limitation of extension or 30 percent for left knee limitation of extension at any time during the entire period on appeal. In that regard, the Veteran was afforded VA examinations in October 2009, May 2013, July 2015, June 2017, September 2019, and August 2020. In October 2009, the Veteran demonstrated right knee extension limited to 10 degrees, and left knee extension limited to 25 degrees upon examination with painful motion. See October 2009 VA examination. In May 2013, the Veteran demonstrated right knee extension to 10 degrees, and left knee extension to 15 degrees with painful motion. See May 2013 VA examination. The Veteran did not report any flare ups at the May 2013 VA examination. There was no additional limitation of extension upon repetitive use testing for either knee. In July 2015, the Veteran demonstrated right knee extension to 5 degrees, and left knee extension to 5 degrees with pain and in weight bearing upon examination. See July 2015 VA examination. There was no additional loss of function or range of motion after repetitive use testing. The VA examiner could not say without mere speculation whether pain, fatigability, or incoordination significantly limited functional ability during flare ups or repetitive use over time without observing the Veteran during a flare up or after repetitive use over time. In June 2017, the Veteran did not demonstrate any limitation of extension for either knee, including in weight bearing upon examination. See June 2017 VA examination. However, the VA examiner could not say without mere speculation whether pain, fatigability, or incoordination significantly limited functional ability during flare ups or repetitive use over time without observing the Veteran during a flare up or after repetitive use over time. The VA examiner noted pain on passive range of motion and in non-weight bearing for both knees. In September 2019, the Veteran did not demonstrate any limitation of extension of either knee, including with consideration of flare ups and repeated use over a period of time upon examination. See September 2019 VA examination. However, the September 2019 VA examiner also stated that the Veteran had bilateral knee limitation to extension. Therefore, the September 2019 VA examination is inadequate entitled less probative value as it is internally inconsistent regarding the Veteran’s bilateral knee limitation of extension. Finally, in August 2020, the Veteran reported continued bilateral limitation of extension of the knees. See August 2020 VA examination. The Veteran did not demonstrate any limitation of extension of either knee, including with consideration of flare ups and repeated use over a period of time, but pain was noted on examination bilaterally. The VA examiner noted that throughout the appeal, the Veteran demonstrated pain in weight bearing and non-weight bearing. Based on these findings, increased ratings under DC 5261 for limitation of extension for either knee, are not warranted. See 38 C.F.R. § 4.71a, DC 5261. For the Veteran’s right knee, the Veteran demonstrated limitation of extension, at worse, to 10 degrees through the entire period on appeal as shown on the October 2009 VA examination. For the Veteran’s left knee, the Veteran demonstrated limitation of extension, at worse, to 25 degrees through the entire period on appeal. To the extent the Veteran asserts that higher ratings are warranted at any time during the period on appeal, the Board has again considered that he is credible and competent to report subjective symptoms such as pain, but he is not competent to provide medical evidence regarding the degree of limitation of extension, and the Board gives more probative weight to the competent medical evidence which includes the August 2020 VA examination that is against the Veteran’s claim for higher ratings than to the Veteran’s lay statements. See Layno, 6 Vet. App. at 469; Nieves-Rodriguez, 22 Vet. App. at 302. Moreover, the Veteran, nor his representative, has provided any competent medical evidence to the contrary of these findings. Finally, the Board considered whether the Veteran is entitled to higher ratings due to functional impairment under the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca, 8 Vet. App. at 206-07. The objective medical evidence of record is of greater probative value as to the Veteran’s level of impairment than his assertions, given that the testing to ascertain whether a higher rating is warranted is the province of trained and credentialed medical professionals. Even considering the Veteran’s subjective complaints of pain and other symptoms described in DeLuca, limitation of motion of the bilateral knees have not been shown such that higher ratings would be warranted. See Thompson, 815 F.3d at 786. The Board finds that the evidence does not support entitlement to higher ratings for his bilateral knee limitation of extension on these bases. In sum, for the entire period on appeal, the Board finds that entitlement to a disability rating in excess of 10 percent for the Veteran’s right knee limitation of extension is not warranted; and entitlement to a disability rating in excess of 30 percent, each, for the Veteran’s left knee limitation of extension, is not warranted. See 38 C.F.R. § 4.71a. DC 5261. In denying any higher ratings, the Board finds that the benefit of the doubt doctrine is inapplicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 53. Entitlement to a separate 10 percent rating, but no higher, for right knee instability prior to June 27, 2017, beginning August 7, 2006. Entitlement to a rating in excess of 10 percent for right knee instability from June 27, 2017. Entitlement to a separate 10 percent rating, but no higher, for left knee instability prior to June 27, 2017, beginning August 7, 2006. Entitlement to a disability rating in excess of 10 percent for left knee instability from June 27, 2017. As noted, in an August 2017 rating decision, the RO granted the Veteran granted separate 10 percent disability ratings, each, for bilateral knee instability, effective June 27, 2017. The Veteran’s bilateral knee instability is rated under 38 C.F.R. § 4.71a, DC 5257. Under DC 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability; 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. See 38 C.F.R. § 4.71a, DC 5257. The Board notes that the terms “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.” See 38 C.F.R. § 4.6. The United States Court of Appeals for Veterans Claims recently held that nothing in the DC 5257 provides that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee. See English v. Wilkie, 30 Vet. App. 347, 349 (2018). Turning to the relevant evidence of record, the Veteran’s lay statements indicate that his right and left knee disabilities have been manifested by pain, weakness, giving way, stiffness, fatigability, popping, and locking throughout the entire period of appeal beginning August 7, 2006, the date the Veteran’s claim to entitlement to increased ratings for his service-connected bilateral knee disabilities was received. See October 2009, May 2013, July 2015, June 2017, September 2019, and August 2020 VA examinations; August 2007 Statement in Support of Claim; June 2013 VA Form 9; October 2020 Correspondence. Additionally, an October 2009 VA examiner noted the Veteran had an antalgic gait and poor propulsion but did not find instability of either knee upon examination. See October 2009 VA examination. In May 2013, a VA examiner noted the Veteran had normal stability for both knees upon examination; however, noted the Veteran had less movement than normal, excess fatigability, and interference with prolonged standing, walking, and climbing stairs. See May 2013 VA examination. In July 2015 and June 2017, VA examiners indicated the Veteran had a history for a slight level of severity for lateral instability in both of knees. See July 2015 and June 2017 VA examinations. The July 2015 VA examiner noted the Veteran’s report that he feels instability of both knees, but they do not give out. See July 2015 VA examination. The September 2019 VA examiner noted bilateral instability of station despite the Veteran demonstrating normal joint instability bilaterally upon examination. See September 2019 VA examination. Finally, the August 2020 VA examiner noted the Veteran had normal instability bilaterally upon examination; however, the VA examiner explained that the Veteran had functional instability, such as his knees giving out, but did not have anatomical instability. See August 2020 VA examination. Moreover, the evidence shows that the Veteran has occasionally used a cane for support and stability throughout the rating period on appeal. See June 2013 VA Form 9; January 2014 Correspondence; July 2015, June 2017, and August 2020 VA treatment examinations. Based on the foregoing, the Board finds the Veteran is credible and competent to report subjective symptoms such as experiencing right and left knee weakness, giving way, and locking throughout the entire period on appeal. See Layno, 6 Vet. App. at 469. There is no reason to doubt the credibility of the Veteran’s reports. Thus, credible lay evidence supports that, in addition to pain, the Veteran has experienced right and left knee symptoms more closely approximating slight instability for the entire period on appeal. See English, 30 Vet. App. at 349. Thus, resolving reasonable doubt in the Veteran’s favor, separate 10 percent disability ratings, each, for right and left knee instability, are warranted for the period on appeal prior to June 27, 2017, beginning on August 7, 2006. However, the preponderance of the evidence does not support increased ratings for right and left knee instability in excess of 10 percent at any time during the appeal period. Although there is objective evidence of joint instability in the record, the medical evidence reveals no more than slight lateral instability in the right and left knees. See July 2015 and June 2017 VA examinations. Moreover, his reported symptoms are not consistent with moderate impairment, as he continues to be able to walk independently throughout the appeal period and did not describe symptoms such a history of falls due to instability. In sum, the Board finds that assignment of separate 10 percent disability ratings, but no higher, each, for right and left knee instability is warranted for the appeal period prior to June 27, 2017, beginning August 7, 2006 entitlement to disability ratings in excess of 10 percent, each, for right and left knee instability, are not warranted. See 38 C.F.R. § 4.71a. DC 5257. In denying any higher ratings, the Board finds that the benefit of the doubt doctrine is inapplicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 53. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record for the entire period on appeal. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 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). Mary E. Rude Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. P. Moore, 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.