Citation Nr: 21062450 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 13-06 118 DATE: October 7, 2021 ORDER Entitlement to a 10 percent rating, but no more, for lumbar spine degenerative disc disease (DDD) prior to November 10, 2009, is granted. Entitlement to a rating in excess of 10 percent for left ankle disability prior to June 10, 2011, is denied. Entitlement to a rating in excess of 10 percent prior to April 28, 2004, for right ankle disability is denied. Entitlement to a rating in excess of 10 percent for right ankle disability from July 26, 2006, to June 9, 2011, is denied. Entitlement to a rating in excess of 10 percent for right knee strain is denied. REMANDED Entitlement to a rating in excess of 10 percent from April 3, 2015, for lumbar spine DDD is remanded. FINDINGS OF FACT 1. Prior to November 10, 2009, the Veteran's service-connected lumbar spine disability has been manifested by full range of motion (ROM), subjective complaints of pain, and guarding not severe enough to result in abnormal gait or abnormal spinal contour. 2. Prior to June 10, 2011, the Veteran's left ankle disability was not manifested by marked limited motion of the ankle. 3. Prior to April 28, 2004, the Veteran's right ankle disability was not manifested by marked limited motion of the ankle. 4. From July 26, 2006, to June 9, 2011, the Veteran's right ankle disability was not manifested by marked limited motion of the ankle. 5. The Veteran's right knee strain has been manifested primarily by pain and decreased flexion to no less than 110 degrees. CONCLUSIONS OF LAW 1. Prior to November 10, 2009, the criteria for a rating of 10 percent for lumbar spine disability have been more nearly approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5242-5237. 2. Prior to June 10, 2011, the criteria for a rating in excess of 10 percent for left ankle disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.3, 4.59, 4.71a, DC 5271. 3. Prior to April 28, 2004, the criteria for a rating in excess of 10 percent for right ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5271. 4. From July 26, 2006, to June 9, 2011, the criteria for a rating in excess of 10 percent for right ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5271. 5. The criteria for a rating in excess of 10 percent for right knee strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.7, 4.40, 4.45, 4.71a, DC 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1981 to February 1990. In December 2006, April 2010, and December 2011, the Board remanded entitlement to increased ratings for bilateral ankle disability for further development. In March and July 2016 and January 2017, the Board remanded all of the issues on the title page for further development. In a January 2020 decision, the Board denied entitlement to compensable rating for lumbar spine disability prior to November 10, 2009, a rating in excess of 10 percent for lumbar spine disability since April 3, 2015; a rating in excess of 10 percent for right ankle disability prior to April 28, 2004, and from July 26, 2006 to June 9, 2011; a rating in excess of 10 percent for left ankle disability prior to June 10, 2011; and a rating in excess of 10 percent for right knee strain. However, in March 2021, the United States Court of Veteran's Appeals' (Court) issued a Joint motion for Partial Remand (JMPR) and remanded the issues for further development. The Board has held two hearings in this matter, one in August 2016 and the other in February 2018 before different Veterans Law Judges (VLJ) on the issues listed on the title page. The Veteran was advised of his right to a hearing before a third VLJ; however, in August 2018, he waived that right. As noted above, the Veteran testified before a VLJ in February 2018. A transcript of that hearing is of record. The VLJ who conducted that hearing is no longer employed by the Board. In March 2021, the Veteran was notified of this information and informed he could request another Board hearing, pursuant to 38 C.F.R. § 20.707 (noting that a VLJ who conducts a hearing on appeal must participate in any decision made on that appeal). See also 38 U.S.C. § 7107(c). In April 2021, the Veteran stated that he did not wish to appear at another Board hearing. As such, the Board is proceeding with appellate review. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. Disabilities must be reviewed in relation to their history. Where there is a question as to which of two evaluations apply, the Board assigns the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Accordingly, separate ratings may be assigned for separate periods of time based on the facts found, which is a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of the Department of Veterans Affairs to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, 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. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans' Claims 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). 1. Entitlement to a compensable rating for lumbar spine DDD prior to November 10, 2009 The spine is rated under 38 C.F.R. § 4.71a, DCs 5235-5243 according to a General Rating Formula for Disease and Injuries of the Spine (General Formula) unless DC 5243 is evaluated under the Formula for Rating IVDS based on incapacitating episodes. During the pendency the Veteran's appeal, VA amended criteria for rating musculoskeletal disabilities. The new regulation applies to claims received on or after February 7, 2021 or previously filed claims that are pending on February 7, 2021 if the new regulation will render more favorable result for the Veteran. As such, the Board will evaluate the Veteran's disability under both old and new regulations for the entire appeal period and choose the more favorable result. The new regulation revises the rating criteria for DCs 5242 for degenerative arthritis, degenerative disc disease other than IVDS. It notes that the rater should also see either DC 5003 or 5010. Diagnostic Code 5243, IVDS, was also revised. The revision states that 5243 is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign DC 5242 for all other disc diagnoses. Under the old regulation, DC 5003 was assigned to evaluate degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a. Diagnostic Code 5003 is now assigned to evaluate degenerative arthritis (other than post-traumatic). Under both regulations, degenerative arthritis established by X-ray findings will be rated based on 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 DCs, 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. In the absence of limitation of motion, a 20 percent rating is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. The lumbar vertebrae are considered groups of minor joints, rated on a parity with major joints. 38 C.F.R. § 4.45. NOTE (1) states that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. The Board notes that the other DCs remain unchanged. Normal ROM of the thoracolumbar spine is 90 degrees of flexion, and 30 degrees for each of extension, left and right lateral flexion, and left and right rotation. 38 C.F.R. § 4.71a, Plate II. Under the General Formula, a 10 percent rating is warranted when forward flexion of the thoracolumbar spine was greater than 60 degrees but not greater than 85 degrees; or, when the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, when muscle spasm, guarding, or localized tenderness does not result in an abnormal gait or abnormal spinal contour; or, when there was a vertebral body fracture with loss of 50 percent or more of the height. Under the old IVDS Formula, a 10 percent rating is warranted when there are incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. Under the General Formula, a 20 percent rating is warranted when forward flexion of the thoracolumbar spine was greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, when there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Under the IVDS Formula, a 20 percent rating is warranted when there are incapacitating episodes of IVDS having a total duration of at least two weeks, but less than four weeks during the past 12 months. Under the General Formula, a 40 percent rating contemplates forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Alternatively, under the IVDS Formula, a 40 percent rating contemplates incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Under the General Formula, a 50 percent rating contemplates unfavorable ankylosis of the entire thoracolumbar spine. There is no equivalent rating under the IVDS Formula. Under the IVDS Formula, a 60 percent rating contemplates incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. There is no equivalent rating under the General Formula. Under the General Formula, a 100 percent rating contemplates unfavorable ankylosis of the entire spine. There is no equivalent rating under the IVDS Formula. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain 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 v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). 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 ROM measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Associated objective neurologic abnormalities are evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a (General Formula, Note 1). Analysis The Veteran contends that his disability is more severe than the rating depicts. In October 2009, the Veteran was afforded a VA examination to determine the nature and etiology of his lumbar spine disability. The Veteran stated that there was no specific injury that caused his lumbar spine disability. He described aching more than pain in his lumbar spine. The examiner diagnosed the Veteran with chronic low back strain with DDD. The Veteran did not have lumbar flattening, scoliosis, lordosis, or reverse lordosis. He did not experience spasms, atrophy, guarding, pain with motion, tenderness, or weakness. The Veteran's posture was normal; however, his gait was antalgic, poor propulsion, and his feet splayed outward. The examiner stated that the Veteran did not have muscle spasm, localized tenderness, or guarding severe enough to be responsible for abnormal gait or abnormal spinal contour. Forward flexion was from zero to 120 degrees and extension, left and right lateral flexion and left and right lateral rotation were from zero to 30 degrees. There was no objective evidence of pain on active ROM, no objective evidence of pain following repetitive motion, and no additional limitations after three repetitions of ROM. Lasegue's sign was negative. During ROM testing, the Veteran stated that he experienced pain in his low back, but the examiner found no objective evidence of pain. There were no incapacitating episodes of the spine or flare-ups. The Veteran stated that he was unable to walk more than few yards. In November 2009, the Veteran was seen for his low back pain. The examiner diagnosed the Veteran with chronic axial low back pain. The Veteran stated that the pain was exacerbated with any type of physical activity. He denied bowel or bladder problems. The examiner noted mildly limited lumbar flexion and moderately limited lumbar extension with end-range pain and guarding. During his August 2016 Board hearing, the Veteran stated that he experienced pain in his lumbar spine. When he sat for long periods of times, he experienced a lot of stiffness. He also experienced stiffness from standing for long periods, walking, and climbing up and down stairs. He stated that there had been times where he "almost fell out" because his back area caused his muscles to tighten up to where he could hardly take another step, and he had to sit. In February 2018, the Veteran testified at another Board hearing. He stated that his lumbar spine had been affecting him for quite some time and was getting worse. Due to his disability, he was unable to stand or walk for long periods of time, lift heavy objects, bend down, and pick up an object. The Veteran stated that sitting aggravated his back, i.e., his back would tense up and become tight, so, he had to stand up. If he was standing, he would be unable to bend over and touch his toes. As noted above, in March 2021, the Court remanded the Veteran's claim. The parties agree that the Board erred when it failed to address whether the Veteran's lay statement of aching and pain, his inability to walk more than a few yards, and the 2009 examiner's finding of an abnormal gait supported a finding of an actually painful, unstable, or malaligned joint as contemplated under § 4.59. Upon review of the record, the Board finds that, prior to November 10, 2009, a rating of 10 percent is warranted. Under the general formula, a 10 percent rating is warranted when forward flexion of the thoracolumbar spine was greater than 60 degrees but not greater than 85 degrees; or, when the combined ROM of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees; or, when muscle spasm, guarding, or localized tenderness does not result in an abnormal gait or abnormal spinal contour; or, when there was a vertebral body fracture with loss of 50 percent or more of the height. The Board notes that during the period on appeal, ROM testing performed during the 2009 VA examination revealed no limitation of motion of the thoracolumbar spine or muscle spasm or guarding. However, the November 2009 examiner noted mildly limited lumbar flexion and moderately limited lumbar extension with end-range pain and guarding. Furthermore, VA treatment records show that the Veteran reported symptoms of chronic low back pain. The Board finds that the Veteran is competent to report physical symptoms such as pain because such requires only personal knowledge as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Based on the foregoing, and after resolving all doubt in the Veteran's favor, the Board finds that a 10 percent rating is warranted throughout the appeal period. See 38 C.F.R. § 4.59 (painful joints warrant a minimum compensable rating). The Board finds that a rating in excess of 10 percent is not warranted at any point during the period under review. As noted above, a 20 percent disability rating is assigned when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or with a combined ROM not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. See 38 C.F.R. § 4.71a, DC 5235-5243. Here, at worst, even considering the Veteran's subjective complaints of pain and other symptoms described in DeLuca, his forward flexion was from zero to 120 degrees and combined ROM was 270 degrees. Additionally, he did not have muscle spasm or guarding severe enough to result in an abnormal gait, and there is also no evidence of abnormal spinal contour. See 38 C.F.R. § 4.71a, DC 5235-5243. Therefore, the Board finds that a rating in excess of 10 percent is not warranted. See id. Additionally, the Board finds that a higher rating is not warranted under the IVDS formula. Under the old IVDS formula, the evidence of record must demonstrate incapacitating episodes having a total duration of at least two weeks, but less than four weeks, during the past 12 months. See 38 C.F.R. § 4.71a, DC 5243. Under the new regulation, 5243 is assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root. In this case, the evidence does not show any incapacitating episodes of IVDS requiring prescribed bedrest and treatment by a physician. Additionally, there is no evidence of disc herniation with compression and/or irritation of the adjacent nerve root. Accordingly, a higher rating is not warranted under the IVDS formula. See 38 C.F.R. § 4.71a, IVDS Formula, Note (1). The Board notes that the Veteran has a current diagnosis of lumbar spine DDD, as confirmed by X-ray imaging. As noted above, the 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. As the Veteran has already been assigned rating for lumbar degenerative arthritis to compensate for painful motion, a separate compensable disability cannot be awarded for arthritis. The Board has also considered whether a separate rating is warranted for any associated neurological disorder. However, the record does not show any lower extremity radiculopathy or other neurological abnormalities, such as bowel or bladder problems, associated with the Veteran's thoracolumbar spine. Accordingly, a separate rating for an associated neurological disability is not warranted. In sum, the Board finds that an evaluation of 10 percent, but no more, is warranted for the Veteran's lumbar spine disability prior to November 10, 2009. 2. Entitlement to increased ratings for bilateral ankle disability The Veteran's bilateral ankle disability is rated under 38 C.F.R. § 4.71a, DC 5271. As noted above, during the pendency the Veteran's appeal, VA amended criteria for rating musculoskeletal disabilities. Under both the new and old regulations, a 10 percent rating is assigned for moderate limitation of motion, and a 20 percent rating is assigned for marked limitation of motion. Under the old regulation, the standardized description of joint measurement is provided in Plate II under 38 C.F.R. § 4.71. Normal dorsiflexion of the ankle is from zero to 20 degrees. Normal plantar flexion of the ankle is from zero to 45 degrees. Words such as "moderate" and "marked" are not defined in the VA Schedule of Rating Disabilities. Use of terminology such as severe by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. The VA Adjudication Procedures Manual, M21 shows examples of moderate and marked limitation of motion of the ankle under DC 5271. An example of moderate limitation of ankle motion is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. An example of marked limitation of motion is less than 5 degrees dorsiflexion or less than 10 degrees planar flexion. M21 II.iv.4.A.3l. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under the new regulation, moderate is specifically defined as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion and marked is defined as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. Analysis The Veteran contends that his bilateral ankle disability is more severe than the rating depicts. In April 2001, the Veteran was afforded a VA examination to determine the severity of his ankle disability. The Veteran first injured his ankles when he fainted, fell, and twisted both ankles. He stated that his right ankle was put in a cast, but after the cast was removed, the ankle was still painful. Pain and dysfunction (weakness, fatigability, incoordination) had progressed in severity. The Veteran was unable to walk without pain, "although he worked 12 hours a day as a manufacturing technician." In 1991 he underwent arthroscopy right ankle. The operation failed to relieve his symptoms. He reported bilateral ankle pain of 10/10 pain which he stated kept him awake at night. The examiner confirmed the Veteran's osteochondritis dissecans, medial talar dome, right ankle, status post arthroscopy, abrasion of the talus, and excision of chondral fragment with residual chronic pain and dysfunction and degenerative joint disease (DJD) left ankle, status post injury diagnoses. The Veteran had an antalgic gait and limped on both legs. He was able to hop on either foot, perform heel and toe walk, and squat and rise, but the activities provoked discomfort. While the Veteran was seated on the examining table, the examiner noted full ROM, bilaterally. The examiner noted dorsiflexion to 20 degrees and plantar extension to 45 degrees. The Veteran experienced tenderness and pain on motion and negative drawer signs. There was no deformity. The examiner noted left ankle degenerative changes. In his May 2001 Statement in Support of Claim, the Veteran stated that he had bilateral ankle symptoms to include inflammation, swelling, and pain. He further stated that while standing, it felt like it was bone on bone. He also reported limited motion in both ankles. In July 2001, it was noted that the Veteran received an injection to help with pain. This provided relief for several days. The Veteran reported general weakness in both ankles. In November 2001, the Veteran saw an orthopedic surgeon. The Veteran reported injuring his ankles in service. Since the initial injury, the condition had worsened. The examiner noted that the Veteran had an antalgic gait on the right. The examiner noted previous arthroscopy portals on the Veteran's right ankle which were well healed. There was tenderness to deep palpation at the medial gutter, and he had pain with forced dorsiflexion of his ankle. The examiner stated that both ankles appeared to be painful. The Veteran stated that he had pain at rest and could only ambulate about a block or two before he had to sit. Right ankle dorsiflexion was from zero to 10 degrees and plantar flexion was from zero to 40 degrees. Left ankle dorsiflexion was to 15 degrees and plantar flexion was from zero to 45 degrees. In February 2004, the Veteran saw his private physician regarding right ankle pain. The Veteran described a long history of problems related to his ankles. He stated that he had gradual improvement of the left ankle but has had persistent complaints of pain in the right ankle. He underwent a right ankle arthroscopy in 1991. He noted little real improvement over the years. The Veteran described constant discomfort in the right ankle. He reported increasing pain with prolonged standing and walking. Examination of the right ankle revealed some mild tenderness along the anterior joint line and along the anterior medial aspect of the ankle. There was no tenderness laterally. The examiner noted good ROM of both ankles without any significant limitation. Examination of the left ankle revealed only mild tenderness along the anterior joint. Bilaterally, there was no ligamentous instability. In April 2004, the Veteran was afforded a VA examination to determine the severity of his ankle disability. The examiner confirmed the Veteran's right ankle osteochondritis desiccans superior medial talar dome and left ankle medial talar dome diagnoses. The Veteran stated that his right ankle bothered him daily but varied in intensity. The pain was rated at 7/10. He did not use it repetitively. He used a brace three to four times a week. He reported swollen right ankle almost daily. Due to his right ankle disability, he was unable to stand for more 15 minutes. Regarding his left ankle, the Veteran used a brace on occasions. He reported daily ankle pain and occasional swelling. The pain was rated at 5/10. He did not receive treatment for his bilateral ankle disability. He did not experience flare-ups of either ankle. The Veteran had a well-healed arthroscopic scar on his right ankle. He walked with a slight limp complaining of the right ankle. Both ankles were tender to palpation, medially, laterally, and anteriorly. Manual muscle strength testing was normal, bilaterally. The Veteran did not experience fatiguability. His right ankle active and passive dorsiflexion were from zero to 15 degrees and zero to 20 degrees, respectively. Right ankle active and passive plantar flexion were from zero to 15 degrees and zero to 20 degrees, respectively. Left ankle active and passive dorsiflexion were from zero to 10 degrees and zero to 20 degrees, respectively. Left ankle active and passive plantar flexion were from zero to 35 degrees and zero to 40 degrees, respectively. At the terminal degrees motion for both feet, the Veteran complained of slight pain. The examiner rated the Veteran's functional impairment as moderate. There was no weakness and fatigability and minimal incoordination/limp. The Veteran worked full time as a manufacturer technician which he stated involved a lot of standing and walking. In October 2004 and March 2005, the Veteran was seen for podiatry exams. The examiner confirmed the Veteran's osteoarthritis anterior aspect of right ankle. The Veteran's ROM was within normal limits. The examiner noted crepitus on the anterior right ankle. The Veteran's bilateral ankle dorsiflexion and subtalar joint motion were painful. In July 2006, the Veteran was afforded a VA examination to determine the severity of his ankle disability. At the time of the exam, the Veteran stated that his left and right ankles hurt, daily. Left ankle pain averaged 7/10, and right ankle pain averaged 8/10. He reported no flare-ups of either ankle. But, he reported left ankle pain which increased about once a week, i.e., during prolong standing. He stated that about once a month, his left ankle would swell in the front. About three times a month, his right ankle would swell on the inner, outer, and front sides. He reported pain that increased daily with walking or standing. He treated his ankle with Advil, brace, and, on occasions, ice. He was able to stand for a maximum of two minutes at a time before he had to sit. He did not run or lift over 50 pounds. The examiner confirmed the Veteran's right ankle status post-surgery with osteochondritis dissecans and left ankle DJD. The examiner stated that the Veteran's right ankle functional impairment was slight and minimal in the left. Bilaterally, there was no weakness, fatigability, or incoordination. Bilaterally, and with his braces off, the Veteran's gait was normal. The examiner noted a healed arthroscopy scar on the right. The examiner noted tenderness on the right and left medially, laterally, and anteriorly; however, there was no swelling. Manual muscle strength testing was 5/5 or normal. Right ankle ROM testing revealed active dorsiflexion from zero to 15 degrees and passive from zero to 20 degrees. Plantar flexion was from zero to 45 degrees. There was no complaint of pain. Left ankle ROM testing revealed dorsiflexion to 20 degrees. Active and passive plantar flexion were from zero to 40 and 45 degrees, respectively. There was slight complaint of pain at the terminal degrees. The examiner noted no change with repeat dorsiflexion. The Veteran worked full time as a manufacturing technician. He described it as a sitting job. In March 2007, the Veteran stated that he was prescribed braces to support both ankles and had been wearing them for about five years. He also noted that his podiatrist limited his activities. The Veteran was instructed not to lift more than 20 lbs. or climb ladders and stairs. His prolong standing and ambulation were not to exceed 3 hours of an 8-hour workday. In February 2010, the Veteran was afforded a VA examination to determine the severity of his bilateral ankle disability. The Veteran stated that he hurt both ankles in the military. Since onset, his condition had gotten worse. To treat his condition, he used medication (NSAIDS), braces, and activity limitation. The examiner confirmed the Veteran's chronic left ankle strain and DJD and chronic right ankle strain, residuals of trauma and surgery, and osteochondritis desiccans medial talar dome diagnoses. The examiner noted no joint deformity, episodes of dislocation or subluxation, locking episodes, or effusion. The Veteran experienced giving way, stiffness, instability, pain, weakness, incoordination, and decreased speed of joint motion. Also, the Veteran had severe weekly flare ups that lasted one to two days. The precipitating and alleviating factors for the flare ups included overactivity and prolonged standing or walking. The Veteran stated that resting overnight helped with the pain; however, the pain never really subsided until he was able to rest and apply ice on w/e. Soaking his ankles in warm water also helped. The examiner noted no constitutional or incapacitating symptoms of arthritis. The Veteran was able to walk for 10-15 minutes and walk 1/4 mile. He used a brace as a normal mode of locomotion. At the exam, the Veteran arrived using a walker because he fractured his right femur at work. The Veteran's weight-bearing joint was affected. His gait was antalgic. The examiner noted that the Veteran was recovering from a fractured right femur, and, using a walker, he walked with a pronounced limp on the right. There was no other evidence of abnormal weight bearing. The examiner also noted no loss of a bone or part of a bone, or inflammatory arthritis. In summary, the examiner noted bilateral ankle tenderness; however, no ankle instability, tendon abnormality, or angulation. Bilaterally, ankle dorsiflexion was from zero to 20 degrees and plantar flexion was from zero to 30 degrees. There was no objective evidence of pain with active motion or objective evidence of pain following repetitive motion. The examiner also noted that there were no additional limitations after three repetitions of ROM. The Veteran did not have ankylosis. The Veteran's disability impacted his ability to work. The examiner stated that the Veteran had decreased mobility, problems with lifting and carrying, weakness or fatigue, and decreased strength. The examiner stated that the Veteran would be moderately limited in his mobility due to his bilateral ankle condition. The Veteran was able to walk between 5 or 10 minutes at an easy pace with the opportunity to sit down and take a break. The Veteran was unable to stand for more than a few minutes at a time. He would be able to engage in sedentary employment. In July 2011, the Veteran was afforded a VA examination to determine the severity of his ankle disability. The Veteran stated that he worked as an electrician solderer. He stated, in the past year, he did not lose any time at his work because of his ankles. The Veteran reported using inserts and a cane. He took Naprosyn and Percocet for pain and arthritis control. In 1991, he had arthroscopy surgery on his right ankle. He stated that his right ankle was worse than his left; however, in the past year, his left ankle was increasing in discomfort. He described the pain in his ankles as 6-7/10 and 24 hours a day, 7 days per week. He stated if he stood for over 15 minutes or walked more than a block, he had to sit. When he sat, his ankles felt like they were on fire, and he was repetitively moving the ankles to get them more comfortable. He also reported hearing noises in his ankles. The examiner diagnosed the Veteran with degenerative arthritis of the talotibial joint, bilaterally. On Physical exam, the examiner stated that the Veteran walked slowly and limped down the hall. When he stood erect, there was marked bilateral pronation of each foot with the os calcis going into valgus. The examiner asked the Veteran to stand on his heels as well as his toes. The Veteran was barely able to start each direction but essentially was not able to do perform the exercises because of pain. Regarding ROM testing, the examiner found that the Veteran's dorsiflexion was from zero to illegible stopping because of pain but not further lost by pain, fatigue, weakness, lack of endurance, or incoordination. Plantar flexion barely came out to 25 degrees bilaterally, stopping because of pain and stiffness. Manual stability testing revealed no abnormal laxity. However, there was acute pain to palpation over the anterior talofibular ligament of each ankle, but there was no thickness or pain to palpation in the peroneus brevis tendons. The Veteran was also instructed to sit at the edge of a table and actively move each ankle around just against gravity without weightbearing. The examiner noted bilateral palpable crepitation. Additionally, the examiner noted bilateral limitation in dorsiflexion as well as plantar flexion. The examiner described the limitation as moderate. During his August 2016 Board hearing, the Veteran stated that his right ankle was worse than his left; however, he experienced the same issues on both ankles. He reported stiffness in his ankles. He further stated that it was a lot of bone on bone which made it very slow for him to get around. He reported using inserts in both shoes for ankle support as well as feet support. He also iced his feet and ankles. a. Entitlement to a rating in excess of 10 percent for left ankle disability prior to June 10, 2011 In March 2021, the Court issued a JMPR and remanded the issue for further development. The parties to the JMPR agreed that the Board did not address why the limitation of the left ankle to half of the normal ROM examination did not reflect marked limitation of motion for purposes of a 20 percent rating under DC 5271. The parties stated that the Board's failure to address relevant evidence as to the severity of the Veteran's left ankle disability required remand to assess whether a 20 percent rating is warranted under DC 5271. The Board notes that the 2010 VA examiner noted that the Veteran experienced instability. However, the examiner also stated that the Veteran did not experience recurrent subluxation and/or instability. Additionally, the other VA examiners all noted that the Veteran did not experience instability. Therefore, the Board finds that the preponderance of the evidence does not reflect recurrent subluxation of the left ankle throughout the period of time on appeal. Based on the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran's left ankle disability. As noted above, for both the old and new regulations, a 20 percent rating is warranted for marked limitation of motion which is defined as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. In this case, and at worse, the Veteran's plantar flexion was to 25 degrees and dorsiflexion was to 10 degrees. The Board notes that during the July 2011 VA examination, the Veteran's dorsiflexion ROM was illegible. However, the 2004, 2010, and 2011 VA examiners described the Veteran's functional impairment or limitation as moderate. Therefore, based on the evidence of record, the Board finds that the criteria for a disability rating in excess of 10 percent under DC 5271 is not met. The Board recognizes that under DeLuca, VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the DCs. "Functional loss" may occur as a result of weakness or pain on motion. Here, the evidence shows that pain has been a constant and predominant symptom. There was also reported weakened movement, giving way, stiffness, pain, weakness, incoordination, and decreased speed of joint motion. However, even considering the Veteran's pain and functional loss, the Veteran was able to, in 2001, worked 12-hour days as a manufacturing technician, and in 2004, he was able to stand and walk a lot at his job. Additionally, in 2011, he stated, in the prior year, he did not lose any time at his work because of his ankles. Therefore, given the extent of ankle motion, the Board finds that, even after taking his reported pain, giving way, stiffness, pain, weakness, incoordination, and decreased speed of joint motion into full consideration, the Veteran's disability picture does not warrant a higher rating based on limitation of flexion. See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5271. The Board has also considered whether an increased disability rating may be assigned under alternative DCs pertaining to disability of the ankle. Diagnostic Codes 5270 and 5272 apply to disabilities involving diagnosis of ankylosis. Diagnostic Code 5273 applies to calcis or astragalus and DC 5274 applies to astragalectomy. As these conditions are not shown or alleged, DCs 5270, 5272, 5273, and 5274 do not apply in this matter. Additionally, the examiner noted that the Veteran did not have scars related to his left ankle disability. Therefore, separate ratings under DC 7800-7805 are not warranted. The Board has considered the Veteran and his representative's statements regarding the severity of the Veteran's left ankle disability. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners' opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiners' findings and the other evidence of record. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). In sum, the preponderance of the evidence is against the claim for a rating in excess of 10 percent for the Veteran's left ankle disability. As such, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). b. Entitlement to a rating in excess of 10 percent prior to April 28, 2004 and from July 26, 2006 to June 9, 2011 for right ankle disability The parties to the JMPR agreed that the Board failed to address relevant evidence as to the severity of the Veteran's right ankle disability prior to April 28, 2004, and from July 26, 2006, to June 9, 2011. The parties agreed that a remand was required to assess whether 20 percent ratings are warranted under DC 5271. Based on the evidence of record, the Board finds that prior to April 28, 2004, and from July 26, 2006, to June 9, 2011, ratings in excess of 10 percent are not warranted for the Veteran's right ankle disability. As noted above, for both the old and new regulations, a 20 percent rating is warranted for marked limitation of motion which is defined as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. At worse, the Veteran's plantar flexion was to 15 degrees and dorsiflexion to 10 degrees. Additionally, the VA examiners rated the Veteran's functional impairment or limitation due to his disability as moderate. Therefore, the Board finds that, prior to April 28, 2004, and from July 26, 2006, to June 9, 2011, the criteria for a disability rating in excess of 10 percent under DC 5271 is not met. The Board recognizes that, under DeLuca, VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the DCs. "Functional loss" may occur as a result of weakness or pain on motion. Here, the evidence shows that pain has been a constant and predominant symptom. There was also reported weakness, fatigability, and incoordination. However, as noted above, in 2001, the Veteran was able to work 12 hours a day as a manufacturing technician, and in 2004, he was able to stand and walk a lot at his job. In 2011, he stated, in the past year, he did not lose any time at his work because of his ankles. Additionally, given the extent of ankle motion, the Board finds that, even after taking his reported pain, weakness, fatigability, and incoordination into full consideration, the Veteran's disability picture does not warrant a higher rating based on limitation of flexion. See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5271. The Board has also considered whether an increased disability rating may be assigned under alternative DCs pertaining to disability of the ankle. However, the Board notes that ankylosis, calcis or astragalus, and astragalectomy are not shown or alleged; therefore, DCs 5270, 5272, 5773, and 5274 do not apply in this matter. Additionally, the VA examiner noted that the Veteran had a healed scar associated with his right ankle disability. However, there is no evidence that the scar was painful or unstable, have a total area equal to or greater than 39 square cm (6 square inches) or is located on the head, face or neck. Therefore, separate ratings under DC 7800-7805 are not warranted. The Board has considered the Veteran and his representative's statements regarding the severity of the Veteran's right ankle disability. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners' opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiners' findings and the other evidence of record. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). In sum, the preponderance of the evidence is against the claim for a rating in excess of 10 percent for the Veteran's right ankle disability. As such, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). 3. Entitlement to a rating in excess of 10 percent for right knee disability The Veteran's right knee disability is rated under DC 5260. During the pendency of the Veteran's appeal, VA amended the criteria for rating musculoskeletal disabilities. The new regulation revises the rating criteria for DC 5257. Under the new regulation, a 30 percent is warranted for recurrent subluxation or instability for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation along with one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation warrants a 20 percent rating. Sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation warrants a 10 percent rating. Regarding patellar instability, a 20 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker. A 30 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Under the old regulation, moderate recurrent subluxation or lateral instability warrants a 20 percent rating, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. 38 C.F.R. § 4.71a. The words "slight," "moderate," and "severe" as used in the various DCs are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. The Board notes that DCs 5268, 5269, 5260, and 5261 remain unchanged. Under DC 5260, limitation of flexion, flexion limited to 30 degrees warrants a 20 percent rating and flexion limited to 15 degrees warrants a 30 percent rating. See 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, limitation of extension, extension limited to 15 degrees warrants a 20 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 30 degrees warrants a 40 percent rating; and extension limited to 45 degrees warrants a 50 percent rating. See 38 C.F.R. § 4.71a, DC 5261. Under Diagnostic Code 5258, a 20 percent rating is assigned for a knee with dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. DC 5259 provides a 10 percent evaluation for symptomatic removal of semilunar cartilage. Id. The normal ROM of the knee is 0 degrees of extension and 140 degrees of flexion. See 38 C.F.R. § 4.7, Plate II. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain 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 v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). 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 non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Analysis The Veteran contends that his right knee disability is more severe than the rating depicts. In February 2013, the Veteran telephoned the Phoenix VAMC and reported that his knees buckled every time he walked. He also reported extreme pain. In March 2013, the Veteran saw his private physician. The examiner confirmed the Veteran's bilateral knee osteoarthritis diagnosis. The Veteran reported right knee pain over the distal quadriceps region and anterior thigh. The examiner noted, bilaterally, active/passive flexion was to 140 degrees and extension to zero degrees. In August 2013, the Veteran was afforded a VA examination to determine the severity of his right knee disability. The Veteran stated that he experienced sharp pain in the right knee area. The examiner diagnosed the Veteran with right knee DJD. The Veteran stated that flare-ups did not impact the function of his knee. Bilaterally, forward flexion was from zero to 140 degrees and extension was from 140 to zero degrees. There was no objective evidence of painful motion of right knee extension. There was no objective evidence of painful motion of left knee flexion or extension. The Veteran was able to perform repetitive-use testing with three repetitions. There was no additional limitation in ROM after three repetitions. The Veteran did not have any functional loss and/or functional impairment of the knee. He did not experience tenderness or pain to palpation for joint line or soft tissues of either knee. Muscle strength and stability testing were normal. There was no evidence or history of recurrent patellar subluxation/dislocation. He did not now have or had ever had any meniscal conditions or surgical procedures for a meniscal condition or shin splints, (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. Additionally, the Veteran did not have joint replacement and other surgical procedures. There were no other pertinent physical findings, complications, conditions, signs, scars, and/or symptoms related to his condition. The Veteran did not use any assistive device as a normal mode of locomotion. The Veteran's disability did not have an impact on his ability to work. In October 2014, the Veteran was seen for right knee pain. The examiner confirmed the Veteran's right knee arthralgia and post-operative changes within the distal femoral shaft, visualized portions diagnoses. The Veteran's right knee was positive for crepitus. He did not have right knee swelling/effusion, erythema, or warmth. The Veteran had full active and passive ROM. Muscle strength testing was normal, i.e., 5/5. In February 2015, the Veteran was seen for pain consult. The examiner noted that the Veteran had chronic knee pain that was aching and related to degenerative changes. The examiner stated that the Veteran's peripheral joint ROM was full and pain free without obvious instability or laxity in all four extremities. In May 2015, the Veteran was afforded a VA examination to determine the severity of his right knee disability. The Veteran reported constant pain in his right knee. The examiner diagnosed the Veteran with right knee strain. The Veteran reported no flare-ups of the knee. However, he reported having functional loss or functional impairment, i.e., he stated that his knee bothered him a lot, and it was hard to walk and stand. The Veteran's right knee flexion and extension were normal, i.e., from zero to 140 degrees and 140 to zero degrees. Pain was noted on flexion but did not result in or cause functional loss. There was no evidence of pain with weight bearing or objective evidence of crepitus. The examiner noted objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no additional functional loss or ROM after three repetitions. The Veteran was examined immediately after repetitive use over time. The examiner stated that because there was no objective exam after repeated use over a period of time, he was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. There were no additional contributing factors of disability. Bilaterally, muscle strength testing was normal with no reduction in muscle strength and no muscle atrophy. The Veteran did not have ankylosis or recurrent effusion. Additionally, he did not have a history of recurrent subluxation, instability, or recurrent effusion. The examiner stated that joint stability testing was performed; however, there was no joint instability, i.e., the Veteran's stability testing was normal. The Veteran did not now have or had ever had a meniscus condition or recurrent patellar dislocation, "shin splints", stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have any other pertinent physical findings, complications, conditions, signs, scars, or symptoms related to his right knee condition. He did not use any assistive device as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Due to pain with mobility limitation, the Veteran's condition impacted his ability to perform any type of occupational task. During his August 2016 Board hearing, the Veteran stated that his right knee was almost unbearable. He reported having had fluid drained from his knee. He also reported getting injections every six months and taking pain medications for pain. In July 2018, the Veteran was afforded a VA examination to determine the severity of his right knee disability. The Veteran stated that his right knee disability had worsened since the last exam. The examiner confirmed the Veteran's right knee osteoarthritis diagnosis. The Veteran did not report flare-ups of the knee. Forward flexion was from 110 to zero degrees and extension from zero to 110 degrees. The ROM itself contributed to functional loss, to include limiting the Veteran's ability to walk, stand, kneel, and squat. Regarding the right knee, the examiner noted pain on flexion at rest/non-movement, evidence of right knee pain with weight bearing, and objective evidence of crepitus. However, there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The examiner noted evidence of left knee pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the TTP lateral joint line. There was no objective evidence of crepitus. Bilaterally, the Veteran was able to perform repetitive use testing with at least three repetitions. The examiner noted no additional functional loss or ROM after three repetitions. The Veteran was examined immediately after repetitive use over time. Pain significantly limited functional ability with repeated use over a period of time. However, the examiner was unable to describe in terms of ROM; but, the examiner noted that the pain limited the Veteran's ability to walk, stand, kneel, and squat. Muscle strength testing was normal with no reduction in muscle strength and no muscle atrophy. The Veteran did not have ankylosis. Additionally, he did not have a history recurrent subluxation, lateral instability, or recurrent effusion. The examiner stated that joint stability testing was performed; however, there was no joint instability. The Veteran's stability testing was normal. He did not now have or had ever had a meniscus condition or a recurrent patellar dislocation, "shin splints", stress fractures, chronic exertional compartment syndrome or any other tibial, and/or fibular impairment. In May 2018, the Veteran had total left knee joint replacement with residuals that included intermediate degrees of residual weakness, pain or limitation of motion. The Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to his right knee disability. The examiner noted a left knee scar; however, there was no objective evidence that the scar was painful, unstable, have a total area equal to or greater than 39 square cm (6 square inches) or were located on the head, face or neck. The Veteran used a cane on a regular basis as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The Veteran's right knee disability impacted his ability to perform any type of occupational task. The examiner stated that pain was noted on active and passive motion with and without weight bearing (WB). As noted above, the Court issued a JMPR and remanded the Veteran's issue for further development. The parties to the JMPR agreed that the Board erred when it failed to address whether the July 11, 2018 VA examination was compliant with the requirements set forth in Correia. The parties stated that although the examiner generally noted the ROM findings, he did not reflect if the Veteran was tested for pain on both active and passive motion nor did he state whether he was unable to conduct the required testing or conclude that the required testing was not necessary. Additionally, the parties stated that the Veteran complained that his knees would buckle which limited his ability to walk and stand, and he used a knee brace to assist with walking; however, the Board did not address whether a separate rating under DC 5257 is warranted. Regarding the parties contention that the VA examiner did not reflect if the Veteran was tested for pain on both active and passive motion, the Board notes that the July 2018 VA examiner did indicate that the Veteran experienced "pain on active and passive motion with and without WB." Additionally, the examiner noted pain on flexion at rest/non-movement and evidence of right knee pain with weight bearing. The Board also notes that the Veteran was able to perform repetitive use testing with at least three repetitions, and there was no additional functional loss or ROM after three repetitions. As the examiner did indicate that the Veteran was tested on both passive and active motion and with and without weightbearing, and given the extent of the Veteran's right knee ROM, i.e., after being testing on pain on active and passive motion with and without WB, the Board finds that there is no prejudice to the Veteran in relying on the examination. Based on the evidence of record, the Board finds that a rating in excess of 10 percent for the Veteran's right knee disability is not warranted. There is no evidence that the Veteran has had limitation of right knee flexion to 30 degrees or less or limitation of extension to 15 degrees or more. The record shows that, at worse, his right knee flexion was to no less than 110 degrees. As such, the criteria for a disability rating in excess of 10 percent under DC 5260 are not met. The Board also notes that the Veteran's extension was normal; therefore, a separate rating under 5261 is not warranted. The Board recognizes that, under DeLuca v. Brown, 8 Vet. App. 202 (1995), VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the DCs. "Functional loss" may occur as a result of weakness or pain on motion. Here, the evidence shows that pain has been a constant and predominant symptom. The Board notes that the July 2018 VA examiner noted evidence of pain on active and passive motion with and without weight bearing. Pain was noted on flexion and caused functional loss. However, given the extent of right knee motion, there is no evidence of a disability picture that is commensurate to a limitation of flexion to the extent necessary to establish entitlement to a higher disability rating, even after taking his reported pain into full consideration. See DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5260 and 5261. In this regard, the Board emphasizes that a 10 percent disability rating under DC 5260 already contemplates an otherwise non-compensable degree of limitation of motion verified by objective evidence of symptoms such as painful motion. Further, the Board has considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The other criteria for rating knee disabilities are provided under DCs 5256 (ankylosis), 5258 (dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint), 5259 (cartilage, semilunar, removal of, symptomatic), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum or traumatic genu recurvatum). The evidence does not show that the Veteran's right knee disability manifestations have included ankylosis, a meniscus condition, shin splints, or genu recurvatum. Therefore, the Board finds that separate or higher ratings under DCs 5256, 5258, 5259, 5262, and 5263 are not warranted. The Board also notes that the parties to the JMPR stated that the Board did not address whether a separate rating under DC 5257 (recurrent subluxation or lateral instability) was warranted. The parties noted that in February 2013, the Veteran stated that he wore knee braces to assist with walking, and in October 2015, he reported his knees were "buckling" whenever he walked. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). As noted above, under the old regulation, slight recurrent subluxation or lateral instability warrants a 10 percent rating, moderate recurrent subluxation or lateral instability warrants a 20 percent rating, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. 38 C.F.R. § 4.71a. The Board notes that although the Veteran noted that his knees buckled, and he needed a brace for walking and support, the VA examiners noted that the Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. They also stated that they performed joint stability testing. However, there was no joint instability, i.e., the Veteran's stability testing was normal. As such, the Board finds that a separate rating is not warranted under the old regulation. Regarding the new regulation, a 10 percent is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. The evidence does not demonstrate right knee sprain, incomplete ligament tear, or complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device. Additionally, the evidence does not demonstrate that the Veteran has a patellofemoral complex with recurrent instability that required a prescription from a medical provider for a brace, cane, or walker. Therefore, the Board finds that a separate rating is not warranted under the new regulation. The Board also notes that the Veteran did not have scars related to his right knee disability. Therefore, separate ratings under DC 7800-7805 are not warranted. The Board has considered the Veteran and his representative's statements regarding the severity of the Veteran's right knee disability. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the VA examiners' opinions on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions by themselves are outweighed by the VA examiners' findings and the other evidence of record. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). In sum, the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's right knee disability. As such, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). REASONS FOR REMAND In March 2021, the Court issued a JMPR and remanded the issue of entitlement to a rating in excess of 10 percent for lumbar spine disability from April 3, 2015 for further development. The parties to the JMPR agreed that the Board erred when it failed to satisfy its duty to assist as the December 5, 2018, VA examination was inadequate for rating purposes. The parties stated that in the December 2018 VA examination, the Veteran reported flare-ups of the low back. He stated that during a flare-up, he would miss one day of work on average each month. The VA examiner found that the Veteran had pain that significantly limited his functional ability with flare-ups, but he was unable to describe the additional functional loss in terms of ROM. As rationale for this opinion, the examiner found that the Veteran was "unable to work due to increased pain and stiffness." The examiner did not explain why he was unable to describe additional functional loss in terms of ROM or provide an estimate. Considering the Court's findings, the agency of original jurisdiction (AOJ) should obtain an addendum opinion from the December 2018 VA examiner to ascertain why the examiner was unable to describe additional functional loss in terms of ROM or provide an estimate. The matter is REMANDED for the following action: 1. Obtain and associate all outstanding VA and private treatment records with the claims file. 2. Obtain an addendum opinion from the December 2018 VA examiner or an appropriate clinician. The complete record, to include a copy of this remand and the claims folder, must be made available to and reviewed by the examiner in conjunction with the examination. The examination report must include a notation that this record review took place. The examiner is asked to describe the Veteran's additional functional loss in terms of ROM or provide an estimate. If the examiner is unable to describe additional functional loss in terms of ROM or provide an estimate, the examiner must include a discussion of any specific facts that cannot be determined specifically whether the inability to provide an opinion without speculation reflects "the limitation of knowledge in the medical community at large," as opposed to a limitation of the individual examiner (lack of expertise, insufficient information, or unprocured testing). 3. Then, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, furnish the Veteran and his representative a Supplemental Statement of the Case and afford them the opportunity to respond before the file is returned to the Board for further consideration. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Tara-Deen 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.