Citation Nr: 21063266 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 15-11 281 DATE: October 13, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for right knee osteoarthritis based on limitation of flexion, to include as on an extraschedular basis, is denied. Entitlement to an initial rating in excess of 10 percent for right knee osteoarthritis based on limitation of extension, to include as on an extraschedular basis, is denied. Entitlement to an initial compensable rating for left knee osteoarthritis based on limitation of flexion, to include as on an extraschedular basis, is denied. Entitlement to an initial compensable rating for left knee osteoarthritis based on limitation of extension, to include as on an extraschedular basis, is denied. REMANDED Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's right knee osteoarthritis manifested as flexion limited to, at worst 65 degrees and extension to 5 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups without ankylosis, malunion or nonunion of the tibia and fibula or genu recurvatum. 2. Throughout the period on appeal, the Veteran's left knee osteoarthritis manifested as flexion limited to, at worst 75 degrees and extension to 5 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups without ankylosis, malunion or nonunion of the tibia and fibula or genu recurvatum. 3. Throughout the period on appeal, the Veteran's service-connected right knee and left knee osteoarthritis with limitation of flexion and extension have not been shown to be so exception or unusual, with such related factors as marked interference with employment or repeated hospitalization, to warrant the assignment of higher ratings on an extraschedular basis. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee osteoarthritis based on limitation of flexion, to include as on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.14.14, 4.21, 4.27, 4.71a, Diagnostic Code 5260. 2. The criteria for an initial rating in excess of 10 percent for left knee osteoarthritis based on limitation of flexion, to include as on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.14.14, 4.21, 4.27, 4.71a, Diagnostic Code 5260. 3. The criteria for an initial compensable rating for right knee osteoarthritis based on limitation of extension, to include as on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.14.14, 4.21, 4.27, 4.71a, Diagnostic Code 5260. 4. The criteria for an initial compensable rating for left knee osteoarthritis based on limitation of extension, to include as on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321,4.14.14, 4.21, 4.27, 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1972 to April 1974, and from June 1984 to June 2010, to include service in Southwest Asia. The Veteran has additional periods of service with the Army National Guard. These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Columbia, South Carolina. Jurisdiction of this appeal is currently with the RO in Nashville, Tennessee. This case was most recently before the Board in March 2021, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, the matters were remanded to obtain updated VA treatment records and to conduct a VA examination to determine the current severity of the Veteran's knee disabilities. Updated VA treatment records have been associated with the record and a March 2021 letter requested that the Veteran complete an appropriate authorization form to allow VA to obtain private treatment records on his behalf. In addition, a VA knee examination was conducted in June 2021. The Board therefore finds that there has been substantial compliance with its previous remands. The case has now been returned to the Board for appellate action. The issue of entitlement to a TDIU has been raised by the record and has been added to the appeal. See Rice v. Shinseki, 22 Vet. App. 447, 453, 54 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation); see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (holding that a separate, formal claim is not required in cases where an informal claim for TDIU has been reasonably raised). Increased Rating The Veteran seeks higher ratings for his service-connected right and left knees based on limitation of flexion and extension. Specifically, the Veteran asserts that his knee symptoms are manifested with constant pain, limitation of daily activities, functional impairment with walking, standing, sitting, and squatting, and without instability. See e.g. Decision Review Officer Hearing Testimony Transcript, August 21, 2014. In this regard, the Veteran asserts that the VA examinations afforded were inadequate. See Third Party Correspondence, April 8, 2015. In addition, the Veteran's representative asserts that the Veteran's knee symptoms that impact his life at home, ability to perform daily activities such as yardwork or interacting with his kids, the decrease in quality of life, and interference with work should be given greater consideration for his disability rating as compared to the range of motion measurements. See Appellate Brief, August 19, 2021. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.").] The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). In the instant case, the applicable rating period occurred before the implementation of these revised diagnostic criteria with regard to all evidence submitted after February 7, 2021. Therefore, the February 2021 musculoskeletal criteria apply to aspects of the Veteran's claims on appeal; and the appropriate criteria is discussed below. In addition, the criteria for Diagnostic Codes 5260 and 5261 were not changed in this revision. VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). With regard to extraschedular consideration, the question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). The determination of whether a Veteran is entitled to an extraschedular rating is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); see also 38 C.F.R. § 3.321(b)(1). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare the level of severity and symptomatology of a veteran's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. In such cases, no referral is required. Second, if the schedular evaluation does not contemplate the veteran's level of disability and symptomatology and is, therefore, inadequate, the RO or Board must determine whether the veteran's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." If the first two questions are answered in the affirmative, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. 115 -16. As noted above, the procedural history of this matter is extensive, and has been before the Board and the Court several times over the past two decades. Most recently, the Board referred the claim to the Director of Compensation Service to in August 2017. The Director of Compensation Service issued a memorandum opinion in November 2019. In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event. It may find that the preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Veteran is in receipt of four separate ratings related to his knees. In this regard, the Veteran is service-connected for left knee osteoarthritis and right knee osteoarthritis based on limitation of flexion and extension, under 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. His left and right knee flexion is currently rated as 10 percent each, under Diagnostic Code 5260-5010, from July 1, 2010; his left and right knee extension is currently rated as noncompensable each, under Diagnostic Code 5010-5261, from June 29, 2016. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Ratings can be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege, that he has shin splints, tibia or fibula impairment, genu recurvatum, or ankylosis of either knee. As such, those diagnostic codes are not for application. Prior to February 7, 2021, Diagnostic Code 5257 evaluated recurrent subluxation or lateral instability of the knee. It provided a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating was warranted for moderate recurrent subluxation or lateral instability. Severe recurrent subluxation or lateral instability warranted a 30 percent rating. The Court recently held that nothing in Diagnostic Code 5257, under the pre-amendment rating criteria, provided 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. English v. Wilkie, 30 Vet. App. 347, 349 (2018). As of February 7, 2021, under the amended criteria, Diagnostic Code 5257 evaluates knee, other impairment of, which may be rated under separate criteria for recurrent subluxation or instability or, alternatively, patellar instability. Under the amended criteria for rating patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker warrants a 20 percent rating. A maximum 30 percent rating 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. Diagnostic Code 5257, Note (1), as amended, defines the patellofemoral complex as consisting of the quadriceps tendon, the patella, and the patellar tendon. Note (2) instructs that 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Turning to the evidence, the Veteran was afforded a general medical VA examination in December 2010. At that time, the examiner diagnosed bilateral knee tendinitis. The Veteran reported his symptoms began in 1974, without specific injury, and has gotten worse. He reported he had not had any problems with his bilateral knees wince he stopped running in 2004; the conditions did not affect his occupation or activities of daily living. He treated by not running and taking pain medication as needed. On physical examination in December 2010, in pertinent part, the Veteran's right knee extended to 180 degrees; his stayed the same on multiple repetitions; there was no pain. His right knee flexion was to, at worst, 100 degrees; there was no pain. He did not have crepitus or instability in his right knee. His left knee flexed to, at worst, 92 degrees, including on repetitions; his extension was to 180 degrees. There was no tenderness to palpation, pain with ranges of motion, and drawer sign and stability testing was negative on the left knee as well. The Veteran was afforded a VA examination in January 2013. At that time, the examiner diagnosed bilateral osteoarthritis, medial meniscus tear of the left knee, and posterior medial popliteal fossa cyst of the right knee. The Veteran reported that he had left knee pain that was near constant and had worsened over time; he stated he will get random, sharp, intermittent pain in his right knee. He endorsed f0us of the knee but he could function through the episodes. Upon physical examination at the January 2013 VA examination, range of motion measurements of the right knee were as follows: flexion was to 90 degrees, with pain at 90 degrees; and extension was to zero degrees without objective evidence of painful motion. Range of motion measurements of the left knee were as follows: flexion was to 80 degrees, with pain at 80 degrees; and extension was to zero degrees without objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions; there was not additional limitation in range of motion of either knee following repetitive-use testing. The Veteran did not have any functional loss and/or functional impairment of the knees; there were no additional contributing factors of disability shown. The Veteran did not have tenderness or pain to palpation on either knee. Muscle strength testing in January 2013 was normal bilaterally; joint stability testing was normal bilaterally; there was no evidence or history of recurrent patellar subluxation or dislocation bilaterally. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran was shown to have a meniscal tear of the left knee and frequent episodes of joint pain of the left knee. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies indicated bilateral degenerative arthritis, without patellar subluxation. The examiner noted the Veteran's knees did not impact his ability to work. The Veteran was afforded a VA examination for his knees in November 2013. At that time, the examiner diagnosed mild osteoarthritis bilaterally. The Veteran denied any complaints related to his bilateral knees, pain, and limitations at that time. He denied flare-ups that impacted the function of his knees. Upon physical examination at the November 2013 VA examination, range of motion measurements of the bilateral knees were as follows: flexion was to 140 degrees or greater each; and extension was to zero degrees each. There was no objective evidence of painful motion bilaterally. The Veteran was able to perform repetitive-use testing with three repetitions; there was not additional limitation in range of motion of either knee following repetitive-use testing. The Veteran did not have any functional loss and/or functional impairment of the knees; there were no additional contributing factors of disability shown. The Veteran did not have tenderness or pain to palpation on either knee. Muscle strength testing in November 2013 was normal bilaterally; joint stability testing was normal bilaterally; there was no evidence or history of recurrent patellar subluxation or dislocation bilaterally. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran has not had any meniscal conditions or surgical procedures for a meniscal condition for either knee. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies indicated bilateral degenerative arthritis. The examiner noted the Veteran's knees did not impact his ability to work. The Veteran was afforded a VA examination in September 2014. At that time, the examiner diagnosed bilateral knee osteoarthritis, left knee medial meniscus tear, and right knee posterior medial popliteal fossa cyst. The Veteran reported pain in both knees; he stated he would get random, sharp, intermittent pain in his right knee. He endorsed flare-ups of the knees that impacted bending and lifting, and worsened pain. Upon physical examination at the September 2014 VA examination, range of motion measurements of the right knee were as follows: flexion was to 90 degrees, with pain at 90 degrees; and extension was to zero degrees, without objective evidence of painful motion. Range of motion measurements of the left knee were as follows: flexion was to 80 degrees, with pain at 80 degrees; and extension was to zero degrees, without objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions; there was not additional limitation in range of motion of either knee following repetitive-use testing. Muscle strength testing in September 2014 was normal bilaterally; joint stability testing was normal bilaterally; there was no evidence or history of recurrent patellar subluxation or dislocation bilaterally. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran was shown to have a meniscal tear of the left knee and frequent episodes of joint pain of the left knee. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies indicated bilateral degenerative arthritis. The examiner noted the Veteran's knees did not impact his ability to work. The examiner remarked the Veteran continued to have occasional pain; there was no change in range of motion with flare-ups but did have increased pain. The Veteran was afforded a VA examination in June 2016. At that time, the examiner diagnosed bilateral knee osteoarthritis. The Veteran reported deep, aching, and sometimes grinding pain in both knees; the pain was worsened by extended walking or stairs. He stated his knees were generally stable over time, and he treated with rest and pain killers. The Veteran denied flare-ups of the knees. He reported functional loss as inability to squat or bend, especially with yardwork; stairs were difficult. Upon physical examination at the June 2016 VA examination, range of motion measurements of the bilateral knees were as follows: flexion was to 135 degrees each; and extension was to 5 degrees each. Pain was noted on flexion bilaterally; there was no objective evidence of localized tenderness or pain on palpation bilaterally; there was no evidence of pain with weight-bearing nor crepitus bilaterally. The examiner noted that range of motion itself contributed toa functional loss because it slowed his walking pace, and contributed to difficulty with stairs and squatting. The Veteran was able to perform repetitive-use testing with three repetitions; there was not additional limitation in range of motion of either knee following repetitive-use testing. In June 2016, the Veteran was not examined immediately after repetitive-use over time; the examination was medically consistent with his statements describing functional loss with repetitive-use over time. Pain and fatigue were shown to contribute to the functional loss bilaterally. The examiner could not describe this in range of motion because there was no additional range of motion loss; however, pain was increased with extended walking, which did restrict the ability to continue. The Veteran was not examined during a flare-up; the examination was neither medically consistent or inconsistent with his statements describing functional loss during a flare-up. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups. The examiner was unable to describe in terms of range of motion because no flare-ups were reported. There were no additional factors contributing to either knee. Muscle strength testing in June 2016 was normal. There was no reduction in muscle strength. The Veteran did not have muscle atrophy. The Veteran did not have ankylosis of either knee. Joint stability testing was normal; there was no history of recurrent subluxation nor lateral instability bilaterally. There was no history of recurrent effusion. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have or ever had meniscus (semilunar cartilage) condition of either knee. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran denied the use of any assistive device as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's knees impacted his ability to work due to poor tolerance for extended walking, especially on stairs; and limited tolerance for jobs that required walking long distances over the course of the day. The examiner remarked that the current history and examination did not indicate there was any substantial change in the underlying disease process. The Veteran was afforded a VA examination in April 2019. At that time, the examiner diagnosed left knee meniscal tear, bilateral osteoarthritis, and bilateral limited extension. The Veteran reported he had constant left knee pain; intermittent right knee pain; and aching pain that was sharp on occasion in the popliteal area of the right side. The Veteran denied any additional medical evaluations in past 4 to 5 years. He stated he previously participated in physical therapy that was ineffective at managing pain, and that it seemed to make his pain worse. He stated he had stiffness in the morning; took Aleve for pain management; and used a heating pain to treat pain. He reported he needed to occasionally use a cane due to the severity of the pain. The Veteran endorsed flare-ups described as walking up or down inclines, uneven surfaces, walking for extended periods, and bending or getting down on his knees. He reported functional loss or functional impairment described as walking, standing, bending or getting down on knees. Upon physical examination at the April 2019 VA examination, range of motion measurements of the bilateral knees were as follows: flexion was to 80 degrees each; and extension was to zero degrees each. The examiner noted that the range of motion itself did not contribute to a functional loss. Pain was noted on flexion and extension bilaterally, and shown to cause a functional loss. There was no evidence of pain with weight-bearing, localized tenderness or pain on palpation, nor objective evidence of crepitus bilaterally. The Veteran was able to perform repetitive-use testing with at least three repetitions, and pain caused additional functional loss or range of motion loss. Range of motion measurements following repetitive-use testing of the right knee was as follows: flexion was to 95 degrees; and extension was to zero degrees. Range of motion measurements following repetitive-use testing of the left knee was as follows: flexion was to 85 degrees; and extension was to zero degrees. The Veteran was not examined immediately after repetitive-use over time; the examination was medically consistent with the Veteran's statements describing functional loss with repetitive-use over time. Pain was shown to significantly limit functional ability with repetitive-use over a period of time bilaterally. The examiner was unable to describe in terms of range of motion because the examination was not performed after functional repetitive-use, however, range of motion deficits due to pain limitation were noted on examination and the examiner noted that pain would likely increase to an unknown degree after repetitive-use. The Veteran was not examined during a flare-up; the examination was medically consistent with the Veteran's statements describing functional loss during flare-ups. Pain was shown to significantly limit functional ability with flare-ups bilaterally. The examiner was unable to describe in terms of range of motion because the examination was not performed during a flare-up, however, range of motion deficits due to pain limitation were noted during examination and the examiner noted that pain would likely increase to an unknown degree during a flare-up. Additional factors contributing to the disability of the right knee included disturbance of locomotion and interference with standing. Additional factors contributing to the disability of the left knee included swelling, disturbance of locomotion, and interference with standing. Muscle strength testing in April 2019 showed active movement against some resistance bilaterally in flexion and extension of both knees; there was a reduction of muscle strength that was entirely due to the claimed conditions. The Veteran reported he had four back surgeries that resulted in weakness and numbness of the left leg and foot. The Veteran did not have muscle atrophy. Ankylosis was not shown on either knee. Joint stability testing was normal. There was no history of recurrent effusion shown. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have or ever had meniscus (semilunar cartilage) condition of either knee. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The examiner endorsed the occasional use of a cane as a normal mode of locomotion due to bilateral knee pain. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies documented bilateral arthritis. The April 2019 VA examiner noted the Veteran's knees impacted his ability to work due to difficulty with work duties that would require getting down onto his knees or extended standing or walking; he was unable to tolerate such activities due to his bilateral knee pain. The examiner remarked there was no objective evidence of pain on passive range of motion testing. There was no objective evidence of pain when the joints were used in non-weight bearing. In a June 2019 VA addendum examination report, the VA examiner noted that the Veteran was not examined immediately after repetitive-use over time; the examination was medically consistent with the Veteran's statements describing functional loss with repetitive-use over time bilaterally. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repetitive-use over a period of time. The examination was not conducted during a flare-up; the examination was medically consistent with the Veteran's statements describing functional loss during flare-ups. Pain, weakness, fatigability or incoordination did not significantly limit functional ability during a flare-up. In a November 2019 VA addendum examination report, the VA examiner noted that pain significantly limited functional ability with flare-ups bilaterally. The examiner could not describe in terms of range of motion because limitation was noted during examination, and pain would likely increase to an unknown degree during a flare-up of the condition. The examiner noted that the Veteran would be unable to perform work duties that would require getting down onto the knees or extended standing or walking due to bilateral knee pain. In an August 2020 VA addendum examination report, the VA examiner noted that the Veteran reported a moderate, constant left knee pain and duration of flare-ups that occurred and precipitated when walking up or down inclines, uneven surfaces, extended walking, and bending or getting down on knees. The VA examiner noted that the Veteran reported a moderate, intermittent right knee pain and duration of flare-ups that occurred and precipitated when walking up or down inclines, uneven surfaces, extended walking, and bending or getting down on knees. Alleviating factors were Aleve and heat. Functional impairment included duties that required getting down onto his knees or extended standing or walking; he was unable to tolerate such activities due to bilateral knee pain. The examiner noted that bilateral knee disability would limit the Veteran from obtaining and maintaining a position that required prolonged standing, walking, squatting, bending, or being on his knees; he would be able to function in a sedentary position. The Veteran was afforded a VA examination in June 2021. At that time, the examiner diagnosed left knee meniscal tear, and bilateral osteoarthritis with limited extension. The Veteran reported worsening of knee pain, and worse pain in the left as compared to the right. He denied any knee surgeries. He denied any use of a brace, cane or a crutch. Current symptoms included constant and achy left knee pain that was worse when climbing stairs, getting in and out of a car, and going from sit to stand. Current symptoms of the right knee included constant achy pain. The Veteran used pain medication, rest, and ice as needed as treatments. He endorsed flare-ups of the knees that occurred a couple times a month, lasted one to two days in duration, described as sharp pain in the left knee and achy pain bilaterally, precipitated with yardwork and bending wrong. Alleviating factors included a muscle relaxer. Severity of the flare-ups was described as moderate. The Veteran described functional impairment during flare-ups as limited standing and sitting as much as possible. He reported functional loss as avoiding running, bending carefully, and tried to limit weight-bearing activities with flares of pain. He denied a history of instability or recurrent subluxation of the knee. He denied a history of frequent effusion of the knee. Upon physical examination at the June 2021 VA examination, active range of motion measurements of the right knee were as follows: flexion was to 80 degrees, with pain; and extension was to zero degrees. Range of motion of the right knee contributed to a functional loss due to difficulty getting in and out of a chair. Passive range of motion measurements of the right knee were as follows: flexion was to 105 degrees, with pain; extension was to zero degrees. There was evidence of pain with weight-bearing, nonweight-bearing, active motion, passive motion, and did not result in or cause a functional loss on the right side. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the right knee. Active range of motion measurements of the left knee were as follows; flexion was to 100 degrees, with pain; and extension was to zero degrees. Range of motion of the left knee contributed to a functional loss due to difficulty getting in and out of a chair. Passive range of motion measurements of the left knee were as follows: flexion was to 110 degrees, with pain; and extension was to zero degrees. There was evidence of pain with weight-bearing, nonweight-bearing, active motion, passive motion, and did not result in or cause a functional loss on the left side. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the left knee. At the June 2021 VA examination, the Veteran was able to perform repetitive-use testing with at least three repetitions. There was additional loss of range of motion after three repetitions. Range of motion measurements of the right knee following repetitive-use testing were as follows: flexion was to 75 degrees; and extension was to zero degrees. Range of motion measurements of the left knee following repetitive-use testing were as follows: flexion was to 85 degrees; and extension was to zero degrees. Pain, fatigability, and weakness were shown to cause this functional loss. The Veteran was not examined immediately after repetitive-use over time nor during a flare-up in June 2021. The procured evidence suggested that pain, fatigability, and weakness significantly limited functional ability with repetitive-use over a period of time and during a flare-up bilaterally. Estimated range of motion for the right knee immediately after repetitive-use over time based on information procured showed flexion was to 65 degrees and extension was to zero degrees. Estimated range of motion for the left knee immediately after repetitive-use over time based on information procured showed flexion was to 75 degrees and extension was to zero degrees. Estimated range of motion for the right knee during a flare-up based on information procured showed flexion was to 65 degrees and extension was to zero degrees. Estimated range of motion for the left knee during a flare-up based on information procured showed flexion was to 75 degrees and extension was to zero degrees. There were no additional factors that contributed to the disability in June 2021. The Veteran did not have muscle atrophy bilaterally. Ankylosis was not shown bilaterally. There was no recurrent subluxation or persistent instability. There had not been ligament tear (sprain) of the right side; the Veteran had incomplete or partial ligament tear on the left side. The Veteran did not require a prescription by a medical provider of a cane, walker, crutches, or brace, for ambulation. The Veteran did not have recurrent patellar instability bilaterally. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had meniscal tear of the left knee. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran did not use any assistive devices as normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies showed left knee oblique radial tear of the posterior horn of the medial meniscus; the right knee showed a small non-septated posterior medial popliteal fossa cyst, and was otherwise normal. These results had a direct relationship to the diagnosed left meniscal tear. The examiner noted the Veteran's knees impacted his ability to work due to inability to run; inability to walk prolonged period of time; inability to stand prolonged periods; inability to climb multiple floors of stairs at one time; inability to sit prolonged periods of time; inability to drive prolonged distances; inability to knee; and inability to repeatedly squat. The June 2021 VA examiner found the Veteran did not have knee instability and did not require a prescription for a brace cane or walker. A review of the record shows that the Veteran receives treatment at the VA Medical Center as well as private providers for various disabilities. However, there is no indication from the record that his right and left knee symptoms or range of motion measurements that are manifestly different than those reported at above-mentioned examinations. I. Analysis Right and Left Knees Based on the foregoing, the Board finds an initial rating in excess of 10 percent is not warranted for the right or left knee based on limitation of flexion; nor is a compensable rating warranted for the right or left knee based on limitation of extension. In this regard, throughout the period on appeal, right knee flexion was limited to, at worst, 65 degrees at his June 2021 VA examination, and his right knee extension was limited to, at worst, 5 degrees at his June 2016 VA examination. The Veteran's left knee flexion was limited to, at worst, 75 degrees at his June 2021 VA examination, and his left knee extension was limited to, at worst, 5 degrees at his June 2016 VA examination. Even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, the Board finds that he is not entitled to an initial rating in excess of 10 percent under Diagnostic Code 5260 nor a compensable rating under Diagnostic Code 5261. Specifically, as demonstrated during the VA examinations of record, the Veteran had pain on motion but there is no indication that such resulted in additional functional loss, to include a greater loss of flexion or extension. The Board finds that they do not more nearly approximate flexion that is limited to 30 degrees of either knee at any time during the period on appeal. See DeLuca, supra; Mitchell, supra. Therefore, the Veteran is not entitled to an initial rating in excess of 10 percent in either knee under Diagnostic Code 5260. Moreover, the Veteran was not shown to have extension limited to 10 degrees of either knee at any time during the period on appeal. Id. Therefore, the Veteran is not entitled to an initial compensable rating in either knee under Diagnostic Code 5261. The Board also notes that, while the Veteran reported having flare-ups during his November 2013, April 2019, and June 2021 VA examinations, the examiner did not estimate the degree of any additional loss in range of motion during flare-ups, and found that the pain, weakness, fatigability or incoordination did not significantly limit functional ability during flare-ups. The Board notes that at the June 2021 VA examination, the examiner estimated range of motion for the right knee to 65 degrees of flexion and the left knee to 75 degrees of flexion, and extension to zero degree bilateral even in contemplation of the information procured. Additionally, in the VA examination reports of record, physical activity, such as repetitive use testing, revealed no additional loss of function. Therefore, the Board finds no prejudice to the Veteran in this regard, as the findings noted in the VA examination reports likely represent the functional loss experienced by the Veteran during flare-ups, i.e., after physical activity. Therefore, an initial rating higher than 10 percent is not warranted based upon limitation of motion under Diagnostic Code 5260 based on limitation of flexion of either knee; and an initial compensable rating is not warranted based upon limitation of motion under Diagnostic Code 5261 based on limitation of extension of either knee. With regards to instability or subluxation, the Board finds that a higher or separate rating is not warranted for either knee at any time during the period on appeal. In this regard, the Veteran has not been shown to have instability or subluxation at any time. Rather, the VA examination reports consistently show the Veteran's knee stability to be normal. Additionally, the Veteran denied having symptoms of instability throughout the period on appeal. Additionally, physical objective examination of the Veteran did not reveal subluxation nor history of instability of the either knee. Therefore, a higher or separate rating based on instability or subluxation for either knee is not warranted. Next, the Board has also analyzed the currently assigned separate 10 percent ratings under Diagnostic Code 5260, and the noncompensable ratings under Diagnostic Code 5261, and whether the Veteran could be assigned 10 percent ratings under Diagnostic Code 5261 for pain. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). The Board finds that assigning such 10 percent ratings for pain under Diagnostic Code 5261 would violate the rule against pyramiding. In this regard, Diagnostic Codes 5260 and 5261 contemplate pain, limitation of motion, weakness, fatigability, and the like. The evaluation of the same disability or the same manifestations under various diagnoses is prohibited. 38 C.F.R. § 4.14; Lyles v. Shulkin, supra. Moreover, the Board notes that that every symptom contemplated by Diagnostic Code 5260 (limitation of flexion) is not distinct nor separate, and the same symptoms are also contemplated in the criteria for a rating under Diagnostic Code 5261, which contemplates limitation of extension. Therefore, a higher 10 percent rating based on pain based on limitation of extension is not permissible in this instance, and amounts to impermissible pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994); VAOPGCPREC 9-2004. The Board also notes that the preponderance of the evidence does not reflect that the Veteran's right and left knees were manifested by ankylosis, recurrent subluxation, malunion and nonunion of the tibia or fibula, or genu recurvatum. Therefore, Diagnostic Codes 5256, 5259, 5262, and 5263 are not for application in this case. Moreover, as the Veteran has retained motion in his knees throughout the period on appeal, by definition he does not have ankylosis. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). Here, the Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court's holdings in Correia and Sharp. See Correia v. McDonald, supra, and Sharp v. Shulkin, supra. The Board initially notes that both of the Veteran's knees have been awarded service connection and that there is therefore no opposite undamaged joint to test. In this case, the December 2010, January 2013, November 2013, September 2014, and June 2016 VA examinations were conducted prior to Correia and Sharp and provides only partial information as described above. The April 2019 and June 2021 VA examinations measured active and passive range of motion and range of motion on repetitive use testing as well as range of motion on weight-bearing and nonweight-bearing; the effect of pain on range of motion is described above. The Board also notes that active range of motion testing usually results in further limitation than passive range of motion testing. See Massie v. Shinseki, 25 Vet. App. 123, 131 (2011); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). With regards to flare-ups, the Veteran only endorsed experiencing such flare-ups at his November 2013, April 2019 and June 2021 VA examinations. Sharp v. Shulkin, supra. His reports of additional functional loss associated with the flare-ups as described above. Therefore, the December 2010, January 2013, November 2013, September 2014, and June 2016 VA examinations are adequate for adjudication purposes. In reaching its conclusions, the Board acknowledges the Veteran's belief that his right and left knee flexion and extension are more severe than is reflected by the currently assigned disability ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, supra. Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than his reports regarding the severity of his right and/or left knee symptoms. The Board has considered whether staged rating under Hart, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence is against the assignment of initial ratings higher than 10 percent for right and left knee osteoarthritis based on limitation of flexion, and against the assignment of an initial compensable rating for right and left knee osteoarthritis based on limitation of extension. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. II. Extraschedular Analysis With respect to the first prong in Thun, the evidence in this case does not show such an exceptional or unusual disability picture that the available schedular rating for service-connected right and left knees based on limitation of flexion or extension, is inadequate. The Veteran himself did not claim that his service-connected right and left knee flexion and extension were exceptional or unusual; he simply requested higher ratings, to include unemployability (TDIU). In this regard, the Veteran asserted that his right and left knee symptoms resulted in pain, difficulty with ambulation, difficulty with driving, interference with daily tasks, decrease in quality of life, interference with his ability to work, and the use of pain medication. Moreover, the Veteran's representative argues that impact of his knee symptoms on his daily life and employment should be taken more into consideration than range of motion measurements and/or range of motion limitations of flexion and extension, and that the schedular criteria do not indicate that such impact is contemplated by the currently assigned rating. See Appellate Brief, August 19, 2021. Furthermore, his representative asserts that the evidence shows marked interference with employment because of the severity of his symptoms. Id. Based on the foregoing, to include the lay and medical evidence of record, the Board finds that the symptoms related to the Veteran's service-connected right and left knee osteoarthritis, with limitation of flexion and extension, manifested in limited range of motion, pain, difficulty walking, walking in an unsteady manner, interference with activities of daily activities, interference with bending, and pain medication for management of symptoms. A review of all of the schedular diagnostic code ratings currently assigned to the right and left knees indicate that these symptoms are adequately addressed by the schedular rating criteria. While Diagnostic Codes 5260 and 5261 do not specifically list all the Veteran's symptoms, the Veteran's reported symptoms are reasonably similar to pain, stiffness, and limitation of motion, which are listed under Diagnostic Codes 5260 and 5261. Additionally, for all musculoskeletal disabilities, the Rating Schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance that affects stability, standing and weight-bearing. 38 C.F.R. §§ 4.40, 4.45; Mitchell, 25 Vet. App. 32, 37 (2011). For disabilities of the joints in particular, the Rating Schedule specifically contemplates factors such as weakened movement, excess fatigability, pain on movement, disturbance of locomotion and interference with sitting, standing, and weight bearing. 38 C.F.R. §§ 4.45, 4.59; Mitchell, 25 Vet. App. at 37. In summary, the schedular criteria for musculoskeletal disabilities contemplate a wide variety of manifestations of functional loss. The Board finds that the rating criteria and the provisions of 38 C.F.R. § 4.40, 4.45, and 4.59 reasonably describe the Veteran's disability level and symptomatology, the disability picture is contemplated by the rating schedule, and the assigned schedular rating is adequate. Because the Rating Schedule was purposely designed to compensate for such functional effects of the Veteran's disabilities in all spheres of his daily life, including at work and at home, and given the variety of ways in which the Rating Schedule contemplates functional loss for musculoskeletal disabilities, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. Therefore, the arguments of the Veteran's representative, even in contemplation of the Veteran's assertions and the statements of record, are without merit. The fact that a particular symptom or manifestation may not be mentioned in the rating criteria does not in itself show an exceptional or unusual disability picture. In this regard, all schedular criteria are meant to consider the average impairment in earning capacity resulting from service-connected disabilities. See 38 C.F.R. § 4.1. The basis of the schedular criteria is one's ability to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Viewed in this light, although a particular diagnostic code may provide for evaluations of a disability in terms of objective clinical data rather than in terms of symptoms, as is the case with musculoskeletal disorders, the purpose of the schedular ratings is to provide compensation for the symptoms and functional impairment caused by the disability in question, particularly with regard to how they affect earning capacity. See 38 C.F.R. §§ 4.1, 4.10, 4.21. Moreover, the Veteran's service connected right and left knees were found to be manifested by limitation of motion due to pain and no ankylosis. The record reflects that, on occasion, the Veteran used a cane to assist him with ambulation. However, the use of this assistive device alone does not render the service-connected disability unique or unusual or the schedular criteria inadequate. Although the Veteran and his representative argue that the Veteran's right and left knees have worsened since service, the representative did not explain how the Veteran's schedular rating did not adequately compensate for this worsening. The use of an assistive device is not unexpected when a person experiences significant joint pain. While acknowledging the Veteran's reports of symptoms including functional loss due to bilateral knee pain, the use of assistive devices for ambulation, pain during flare ups, reliance on medication, the inability to drive, the Board finds that the Veteran's bilateral knee symptoms were not productive of significant occupational impairment, and such symptoms are adequately reflected by the currently assigned schedular ratings. The Board notes that the record establishes that the Veteran's difficulties included ambulation, bending, squatting, sitting and walking prolonged periods, and inability to get onto his knees, and that he used multiple assistive devices, to include a cane. While the use of an assistive device, such as a cane, is not specifically listed in the rating criteria for evaluating the Veteran's right and left knees prior to February 7, 2021, the assistive devices are provided to alleviate the presence of symptoms and/or functional limitations caused by an individual's disability. For instance, a cane is provided to normalize an abnormal gait that may be limited by instability in the joint, pain, weakness, or decreased endurance. Furthermore, the use of an assistive device is not a symptom of the Veteran's knees; rather, it is utilized as a result of such symptoms. In this regard, the Veteran uses an assistive device due to pain, but such is a symptom that is specifically contemplated by the schedular rating criteria. Specifically, as previously discussed, pain is contemplated as it causes functional loss, to include limitation of motion as contemplated by Diagnostic Cods 5260 and 5261. The same is true with limitations as to sitting, squatting, bending, walking, climbing, or standing. The Veteran has such difficulties because of an increase in pain. As such, even though the Veteran does use assistive devices, and has trouble with walking and standing, the schedular rating criteria reasonably describe his symptomatology. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see e.g. Spellers v. Wilkie, 30 Vet. App. 211 (2018). The Veteran has also described additional symptoms, such as difficulty performing yardwork, playing with his kids, and an inability to perform household chores. However, the Board notes that the type of movement required to perform yardwork, play, or drive (i.e., the ability to bend or weight bear on the knees, to perform yardwork or household chores) is largely determined by the knees' ability to flex and weight-bear, which is exactly what is measured under the schedular rating. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Likewise, to the extent that household chores and exercise involve any type of knee motion such functional impairment is contemplated under the schedular rating. Id. Activities that involve prolonged standing, sitting, walking, or bending, or functional impairment manifested by symptoms such as weakness, fatigability, and incoordination are also contemplated under the regulations. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). In addition, the pain elicited by such movements is contemplated in the schedular rating. See 38 C.F.R. § 4.59. As the Veteran's symptomology is contemplated by the schedular criteria, extraschedular consideration is not warranted. The Board acknowledges that there is some evidence of interference with the Veteran's employment, to include contentions that his physical limitations and pain interfere with his ability to perform occupational tasks. However, after a review of the evidence, there is simply no probative evidence of "marked" interference of the sort contemplated under 38 C.F.R. § 3.321(b), nor indeed is there evidence of other factors such as frequent periods of hospitalization or other compelling factors which brings this case within the realm of exceptional disability due to Veteran's bilateral knee symptomatology. This argument is therefore without merit. In sum, the evidence of record does not establish that the Veterans right and left knee osteoarthritis with limitation of flexion and extension has produced symptoms not contemplated by the rating criteria, as applied to his schedular ratings under Diagnostic Cods 5260 and 5261. The Board therefore finds that this is not an exceptional case where the criteria in VA's Rating Schedule are inadequate. 38 C.F.R. § 3.321(b)(1). Accordingly, the available schedular evaluations are adequate to rate these disabilities. In the absence of this threshold finding, the Board need not conduct the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19. In conclusion, the Board finds that the schedular criteria are adequate to rate the Veteran's right and left knee osteoarthritis with limitation of flexion and extension. The preponderance of the evidence is against assigning higher ratings on an extraschedular basis. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND Entitlement to a TDIU The Veteran and his representative has asserted that the Veteran's right and left knee osteoarthritis results in an inability to obtain and/or maintain employment. See Appellate Brief, August 19, 2021. The Veteran's current employment status is unknown. It appears that the Veteran's claim for a TDIU further development, as the Veteran's employment status and/or history are not associated with the claims file. Such information is necessary to determine whether the Veteran is entitled to a TDIU. On remand, such evidence should be obtained. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). (Continued on the next page) 2. Request that the Veteran complete a VA Form 21-8940 to provide his complete income history for each year beginning in 2010. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.