Citation Nr: 21063860 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 14-20 201A DATE: October 18, 2021 ORDER An initial rating in excess of 10 percent for the service-connected right knee degenerative joint disease and knee strain prior to April 19, 2021, is denied. A disability rating in excess of 20 percent for the service-connected right knee degenerative joint disease and knee strain for the period beginning April 19, 2021, is denied. FINDINGS OF FACT 1. Prior to April 19, 2021, the Veteran's right knee degenerative joint disease and knee strain was manifested by limitation of flexion of the knee to at most 100 degrees and normal, nonpainful extension, including consideration of repeated use over time and during flare ups; there is no significant additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. 2. Since April 19, 2021, the Veteran's right knee degenerative joint disease and knee strain has been manifested by limitation of flexion of the knee to at most 80 degrees and limitation of extension of the knee to at most 15 degrees including consideration of repeated use over time and during flare ups; there is no significant additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee degenerative arthritis and knee strain before April 19, 2021 are not 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, Diagnostic Code 5260. 2. The criteria for a rating in excess of 20 percent for right knee degenerative arthritis and knee strain from April 19, 2021 are not 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, Diagnostic Codes 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from May 1972 to August 1973. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, granted service connection for degenerative joint disease of the right knee and assigned a 10 percent disability rating effective January 14, 2013. The Veteran's notice of disagreement (NOD) was received in August 2013. The RO issued the statement of the case (SOC) in April 2014, and the Veteran's VA Form 9, substantive appeal was received in July 2014. In December 2016 and February 2021, the Board remanded the case to the RO for further development and adjudicative action. During the pendency of the appeal, the RO issued a rating decision in July 2021 granting an increased rating for the service-connected right knee degenerative joint disease with knee strain to 20 percent based on limitation of extension, effective from April 19, 2021. The Board notes that the Veteran has an appeal pending pursuant to the Appeals Modernization Act (AMA), which addresses entitlement to a total disability rating based on individual unemployability (TDIU). As the Veteran's AMA appeal follows separate procedural guidelines in addition to the application of regulations specific to the adjudication of AMA claims, a separate decision will be promulgated addressing that claim. Increased Disability Ratings Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). 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; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Furthermore, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 83 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. 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, applying the criteria that is more favorable to the Veteran. The Veteran asserts that his service-connected right knee disability is more disabling than reflected by the currently assigned disability ratings. The Veteran's right knee disability is currently rated as 10 percent disabling prior to April 19, 2021 and as 20 percent disabling thereafter. Prior to April 19, 2021, the Veteran's right knee disability was rated by the RO under Diagnostic Codes 5003-5261. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. The hyphenated codes for the Veteran's right knee degenerative arthritis and knee strain reflect that degenerative arthritis is the service-connected disability under Diagnostic Code 5003 and leg, limitation of flexion of, is the basis of the rating assigned under Diagnostic Code 5261. Since April 19, 2021, the Veteran's right knee disability has been rated by the RO under Diagnostic Code 5261 for limitation of extension. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For purpose of rating a disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides the criteria for limitation of knee flexion of the knee. Under this diagnostic code provision, a 30 percent disability rating is assigned where flexion is limited to 15 degrees; a 20 percent disability rating is assigned where flexion is limited to 30 degrees; a 10 percent disability rating is assigned where flexion is limited to 45 degrees; and a noncompensable disability rating is assigned where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. In addition, Diagnostic Code 5261 governs limitation of extension and provides for a noncompensable disability rating for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for a limitation to 15 degrees, 30 percent for a limitation to 20 degrees, 40 percent for extension limited to 30 degrees, and a maximum of 50 percent for a limitation to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. 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. 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. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that, when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate 10 percent ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). As noted above, 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, 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 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 5258, 5259, 5260, and 5261 remain unchanged. Factual Background During a VA examination in February 2013, the Veteran reported on and off pains in both knees, more in the right, accompanied by swelling. He reported flare-ups which he described as difficulty moving knees and walking due to severe pain and swelling. The examiner estimated that the Veteran would have an additional loss of motion of approximately 10 degrees more than repetitive range of motion (ROM) flexion. The VA examiner noted diagnoses of knee strain and degenerative joint disease (DJD) of the right knee. A physical examination revealed initial flexion to 130 degrees with pain beginning at 100 degrees and normal extension without evidence of painful motion. The examiner noted that right knee flexion was limited to 120 degrees and extension remained normal following repetitive use testing. Additional factors contributing to the Veteran's left knee disability were described as less movement than normal, excess fatigability, pain on movement, disturbance of locomotion and interference with sitting, standing and weightbearing. The Veteran's right knee was painful/tender on palpation. Muscle strength testing was normal. Joint stability testing was normal and there was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran did not have a right knee meniscal condition or a surgical procedure for a meniscal condition. There was no ankylosis of the right knee. The Veteran occasionally used a cane for ambulation. Diagnostic testing showed degenerative arthritis of the right knee but no evidence of patellar subluxation. The Veteran submitted a Knee Disability Benefits Questionnaire (DBQ) in February 2013 from a private physician. The Veteran reported constant achy pain. A physical examination revealed flexion to 130 degrees and normal extension. The private physician reported no additional loss of motion after repetitive motion testing. There was no evidence of recurrent patellar subluxation/dislocation, shin splints, meniscal conditions or ankylosis. Joint stability and muscle strength testing were normal. The Veteran occasionally used a cane for ambulation. The Veteran was afforded another VA examination in July 2017. The Veteran reported experiencing constant, sometimes sharp knee pain which he rated as 5-6/10 in severity. He stated that his knees prevent him from hunting, fishing and hiking. He stated that he gets knee pain after walking more than a few hundred yards. He reported taking no medication for his knee disability and stated that, "after 40 years [he] just puts up with it." The Veteran reported flare-ups as described above. A physical examination revealed flexion to 100 degrees and normal extension. There was pain on flexion, but it did not result in or cause functional loss. There was objective evidence of localized tenderness or pain on palpation of the anterior soft tissue along the lateral aspects of the joint line. There was no evidence of crepitus or pain with weight bearing. The examiner noted no additional limitation of motion following repetitive use testing. However, the examiner stated that they were unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time or during flare-ups. The examiner explained that to make such a speculation/guess without sufficient objective evidence-based medical facts or direct observation is contrary to evidence-based practice and outside his scope of professional comportment and expertise. Muscle strength testing was normal. Joint stability testing was normal and there was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran did not have a right knee meniscal condition or a surgical procedure for a meniscal condition and did not have a tibial or fibular impairment. Diagnostic imaging revealed degenerative arthritis affecting the right knee. There was no evidence of pain on passive range of motion testing. There was no pain when the joint was used in non-weight bearing. The Veteran underwent another VA examination in September 2018. The Veteran reported constant bilateral knee pain and denied flare-ups. He reported functional loss or functional impairment in that he has difficulty with stairs and constant pain. Physical examination revealed 105 degrees of flexion and normal extension in the right knee. The range of motion itself contributed to functional loss in that the Veteran reported that the pain is terrible and he has difficulty walking and going up and down stairs. There was pain on flexion, but it did not result in or cause functional loss. There was objective evidence of localized tenderness over the entire joint. There was pain with weight-bearing and no objective evidence of crepitus. There was no additional functional limitation following repetitive use. The examiner noted that the Veteran was not examined immediately after repeated use over time but stated that pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over a period of time. The examiner noted that the examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Additional factors contributing to the Veteran's right knee disability were described as disturbance of locomotion, interference with sitting and interference with standing. Muscle strength testing was within normal limits. There was no atrophy. There was no ankylosis. Joint stability testing was normal for the right knee and there was no history of recurrent effusion, lateral instability or recurrent subluxation. The examiner stated that the Veteran does not currently and has never had a meniscal condition or tibial and/or fibular impairment affecting his right knee. The Veteran did not use any assistive devices as a normal mode of locomotion. The Veteran reported functional impact in the form of pain throughout his knees. There was objective evidence of pain on passive range of motion testing and on non-weightbearing testing of the left knee. The Veteran underwent another VA examination on April 19, 2021. The Veteran reported that his right knee is achy and painful all of the time but not loose or unstable. He reported that his right knee is worsening. He denied flare-ups. The Veteran reported functional loss or functional impairment in that he cannot bend over to pick something up or climb ladders. Physical examination revealed 90 degrees of flexion and 10 degrees of extension in the right knee. The range of motion itself contributed to functional loss in the form of limited standing, walking, lifting, carrying and climbing. There was pain on flexion and extension. There was objective evidence of moderate localized tenderness along the medial and lateral joint lines. There was pain with both active and passive motion of the right knee and objective evidence of crepitus. There was no additional functional limitation following repetitive use. The examiner noted that the Veteran was not examined immediately after repeated use over time and stated that pain, weakness and fatigability significantly limit functional ability with repeated use over a period of time. The examiner estimated that range of motion would be to 80 degrees of flexion and 15 degrees of extension after repeated use over time (i.e., in other words, a loss of 10 degrees of flexion and a loss of 5 degrees of extension following repeated use over time). Additional factors contributing to the Veteran's right knee disability were described as weakened movement. Muscle strength testing revealed right knee strength at 4/5. There was no atrophy. There was no ankylosis. Joint stability testing was normal for the right knee and there was no history of recurrent subluxation or persistent instability, ligament tear (sprain) or patellar instability. The Veteran did not require a prescription of an assistive device for ambulation due to his right knee disability but was prescribed a cane for his left knee disability. The examiner stated that the Veteran does not currently and has never had a meniscal condition or tibial and/or fibular impairment affecting his right knee. The Veteran had a left antalgic gait. The Veteran reported functional impact of his bilateral knee disabilities in the form of limited standing, walking sitting, lifting and carrying. The examiner stated that the Veteran should avoid unprotected heights and has limited ability to traverse uneven ground. The Veteran most recently underwent a VA examination in June 2021. The Veteran reported flare-ups of the right knee which occur daily, are severe, and last 20 minutes. The Veteran stated that flare-ups are precipitated by standing, squatting and walking for more than 10-20 minutes. Flare-ups are alleviated by stopping offending activities, heat/ice applications and slow range of motion movements of leg. The Veteran reported functional loss or impairment in that he experiences pain which is difficult to tolerate when squatting, kneeling, jogging and greater than short durations of standing and walking. The Veteran did not report or have a history of instability or recurrent subluxation of the knee. He also reported a sense of swelling around the right knee at times. Physical examination revealed 90 degrees of flexion and 5 degrees of extension in the right knee. The range of motion itself did not contribute to functional loss. There was pain on both passive and active flexion. There was objective evidence of pain during weight-bearing, on active and passive motion, on rest/non-movement and the pain causes functional loss. There was objective evidence of crepitus and objective evidence of localized tenderness which was moderate in severity. There was no additional functional limitation following repetitive use. The examiner noted that the Veteran was not examined immediately after repeated use over time and stated that pain significantly limits functional ability with repeated use over a period of time. The examiner estimated that range of motion would be to 80 degrees of flexion and 5 degrees of extension after repeated use over time. The examiner noted that the Veteran was not examined during a flare-up and stated that procured evidence from the Veteran do not suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limit functional ability with flare-ups. The examiner found muscle atrophy affecting the bilateral knees. The examiner stated that the right knee muscle atrophy was located 25 cm above the tibial tuberosity and that the left knee was more affected by atrophy than the right. There was no ankylosis. Joint stability testing was normal for the right knee and there was no history of recurrent subluxation or persistent instability, ligament tear (sprain) or patellar instability. The Veteran did not require a prescription of an assistive device for ambulation due to his right knee disability but was prescribed a cane for his left knee disability. The examiner stated that the Veteran does not currently and has never had a meniscal condition or tibial and/or fibular impairment affecting his right knee. VA medical treatment records were reviewed and did not show any symptoms more severe than the findings reported in the VA examinations. Legal Analysis The preponderance of the evidence is against an initial rating in excess of 10 percent for the service-connected right knee disability prior to April 19, 2021. The initial 10 percent disability rating prior to April 19, 2021 was assigned based on x-ray evidence of degenerative arthritis along with noncompensable limitation of flexion. As noted above, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003 for degenerative arthritis. In order to meet the criteria for the next higher 20 percent disability rating under Diagnostic Code 5260, there would have to at least be an indication of flexion limited to 30 degrees. This is clearly not the case as, prior to April 19, 2021, flexion in the Veteran's right knee has consistently been shown to be no less than 100 degrees even when considering functional loss due to flare-ups and repeated use over time. Given the range of motion findings and the lack of significant functional loss, frequency, and severity with flareups, or other motion including repetitive motion, it cannot be said that range of motion would more nearly approximate flexion limited to 30 degrees as required for a 20 percent rating under DC 5260 prior to April 19, 2021. The Board also notes that the Veteran's extension was normal and nonpainful prior to April 19, 2021; therefore, a separate rating under 5261 is not warranted, even if considering the April 2019 examiner's estimation that flare-ups and repeated use over time throughout that period would result in a 5-degree loss of extension. Similarly, the preponderance of the evidence is against a rating in excess of 20 percent for the service-connected right knee disability for the period on appeal beginning April 19, 2021. In order to meet the criteria for the next higher 30 percent disability rating under either DC 5260 or DC 5261, there would have to at least be an indication of flexion limited to 15 degrees or extension limited to 20 degrees. This is clearly not the case as flexion in the Veteran's right knee has consistently been shown to be no less than 80 degrees and extension in the Veteran's right knee has consistently been shown to be no less than 15 degrees, even when considering functional loss due to flare-ups and repeated use over time. Given the range of motion findings and the lack of significant additional functional loss, frequency, and severity with flareups, or other motion including repetitive motion, it cannot be said that range of motion would more nearly approximate flexion limited to 15 degrees or extension limited to 20 degrees as required for a 30 percent rating under DC 5260 and DC 5261 respectively, prior to April 19, 2021. As to the Veteran's limitation of flexion of the right knee, since April 19, 2021, there is no basis for a separate rating based on limitation of flexion. VAOPGCPREC 9-2004 (2004) (separate ratings may be assigned under DCs 5260 and 5261, where there is compensable limitation of flexion and extension). As noted above, the Veteran's right knee degenerative arthritis and knee strain was assigned a 20 percent disability rating based on limitation of extension for the period on appeal beginning April 19, 2021. However, throughout the entire period on appeal, ROM testing did not reflect flexion limited to 45 degrees. As the record does not show that there was compensable limitation of both flexion and extension, a separate rating for flexion for the period on appeal beginning April 19, 2021 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. However, given the extent of right knee motion, there is no evidence of a disability picture that is commensurate to a limitation of flexion or extension 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 the 10 percent disability rating assigned under DC 5260 prior to April 19, 2021 already contemplates an otherwise non-compensable degree of limitation of motion verified by objective evidence of symptoms such as painful motion. The Board acknowledges the Veteran's contention that the April 2021 and June 2021 VA examinations were inadequate because the examiner did not find that pain, weakness, fatigability or incoordination significantly limited functional ability during a flare-up. However, the Veteran affirmatively denied experiencing flare-ups during the April 2021 VA examination and while the Veteran reported flare-ups during the June 2021 VA examination, the examination report makes clear that the examiner considered the Veteran's procured and reported statements regarding the severity, frequency, precipitating and alleviating factors of his right knee flare-ups and concluded that pain, weakness, fatigability and/or incoordination do not significantly limit functional ability during such flare-ups. 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. Regarding DC 5257, 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 reported instability and buckling in his left knee, he has consistently denied experiencing instability, looseness or buckling in his right knee. See e.g. April 2021 VA examination. Moreover, all VA examiners noted that the Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion in the right knee and joint stability testing for the right knee has been normal throughout the period on appeal. 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 in the right knee 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 an initial rating in excess of 10 percent for the Veteran's right knee disability prior to April 19, 2021 and against a rating in excess of 20 percent for the Veteran's right knee disability thereafter. 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). MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Modesto, Victor 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.