Citation Nr: 21065428 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 18-37 401 DATE: October 26, 2021 ORDER Entitlement to a rating in excess of 20 percent for left knee osteoarthritis is denied. Entitlement to a rating in excess of 10 percent for left knee anterior cruciate ligament (ACL) reconstruction is denied. Entitlement to a separate 10 percent, but no higher, rating from February 25, 2020 for painful limitation of extension of the left knee is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a rating in excess of 10 percent for right knee degenerative changes is denied. Entitlement to a separate 10 percent, but no higher, rating from February 25, 2020 for painful limitation of extension of the right knee is granted, subject to the regulations governing the payment of monetary awards. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's left knee osteoarthritis with ACL reconstruction has been manifested by flexion at most limited to 90 degrees with pain. 2. Throughout the appeal period, the Veteran's left knee osteoarthritis with ACL reconstruction has been manifested by slight lateral instability without a prescription for a brace, cane, crutches, or walker. 3. Throughout the appeal period, the Veteran's right knee degenerative changes has been manifested by flexion at most limited to 90 degrees with pain. 4. Prior to February 25, 2020, the Veteran's bilateral knee disabilities were manifested by full extension without pain. 5. From February 25, 2020, the Veteran's bilateral knee disabilities have been manifested by extension at most limited to 10 degrees with pain. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for left knee osteoarthritis are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5260 (2020). 2. The criteria for a rating in excess of 10 percent for left knee ACL reconstruction are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2020). 3. From February 25, 2020, the criteria for a separate 10 percent, but no higher, rating for painful limitation of extension of the left knee are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5261 (2020). 4. The criteria for a rating in excess of 10 percent for right knee degenerative changes are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5260 (2020). 5. From February 25, 2020, the criteria for a separate 10 percent, but no higher, rating for painful limitation of extension of the right knee are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5261 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Marine Corps from May 1981 to September 2002. These matters are before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The matters currently before the Board were previously before the Board in July 2019 and February 2021 when the Board remanded them for further development. In July 2020, the United States Court of Appeals for Veterans Claims (Court) issued a Joint Motion for Partial Remand (JMPR) regarding the Veteran's reduction in the rating for his left knee ACL reconstruction. The Court partially vacated the Board's August 2019 decision to the extent that it denied restoration of the 10 percent rating for the Veteran's left knee ACL reconstruction. Thereafter, as part of the February 2021 Board remand noted above, the Board remanded the reduction in the rating for his left knee ACL reconstruction to the Agency of Original Jurisdiction (AOJ) for further development consistent with the Court's July 2020 JMPR. In a May 2021 rating decision, the AOJ reinstated the Veteran's 10 percent rating for his left knee ACL reconstruction effective April 13, 2018. As such, the issue of the reduction in the rating for the Veteran's left knee ACL reconstruction is no longer before the Board. Increased Rating Bilateral Knee Disabilities The Veteran and his attorney contend the Veteran is entitled to increased ratings for his bilateral knee disabilities. See VA Form 9, Appeal to Board of Veterans' Appeals, dated July 24, 2018. The AOJ has assigned the Veteran's left knee osteoarthritis a 20 percent rating throughout the appeal period under hyphenated Diagnostic Code 5003-5260 and his left knee ACL reconstruction a 10 percent rating throughout the appeal period under hyphenated Diagnostic Code 5003-5257. The AOJ has assigned the Veteran's right knee disability a 10 percent rating throughout the appeal period under hyphenated Diagnostic Code 5010-5260. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the Veteran's left knee osteoarthritis is rated, by analogy, under the criteria for degenerative arthritis (Diagnostic Code 5003) and limitation of flexion (Diagnostic Code 5260). The hyphenated diagnostic code for the Veteran's left knee ACL reconstruction indicates that the disability is rated, by analogy, under the criteria for degenerative arthritis (Diagnostic Code 5003) and limitation of flexion (Diagnostic Code 5260). The hyphenated diagnostic code for the Veteran's right knee disability indicates that the disability is rated, by analogy, under the criteria for traumatic arthritis (Diagnostic Code 5010) and limitation of flexion (Diagnostic Code 5260). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Degenerative and/or traumatic arthritis as shown by X-ray studies are rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the United States Court of Appeals for Veterans Claims (Court) rejected VA's argument that § 4.59 requires painful motion, such that the mere presence of joint pain is not sufficient. Id. at 428-29. The Court held that under § 4.59, "the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint," explaining that § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that § 4.59 does not require "objective" evidence but can be satisfied with lay and other non-medical evidence. Id. at 429. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent rating is warranted for cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a separate 10 percent rating may be assigned for the removal of cartilage, semilunar, that is symptomatic. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a 10 percent rating is warranted where flexion is limited to 45 degrees, a 20 percent rating is warranted where flexion is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 10 percent rating is warranted where extension of the knee is limited to 10 degrees, a 20 percent rating is warranted where extension is limited to 15 degrees, a 30 percent rating is warranted where extension is limited to 20 degrees, a 40 percent rating is warranted where extension is limited to 30 degrees, and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a. Normal ranges of motion of the knee are to 0 degrees in extension, and 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (Sept. 17, 2004). The Veteran may also be assigned separate ratings for limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 and for instability under Diagnostic Code 5257. See VAOPGCPREC 23-97 (July 1, 1997). The rating criteria for subluxation and lateral instability under Diagnostic Code 5257 were revised during the course of the Veteran's appeal, effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Under the amended rating criteria for patellar instability under Diagnostic Code 5257, 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 20 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 one of the following: a brace, cane, or walker. A 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. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). Under the amended rating criteria for recurrent subluxation or lateral instability under Diagnostic Code 5257, a 10 percent rating 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 (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for 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; or, 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. A 30 percent rating is warranted 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. Furthermore, the Board notes that the rating criteria for arthritis under Diagnostic Code 5003 were revised during the course of the Veteran's appeal, effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76,453, 76,463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). However, the changes to Diagnostic Code 5003 are in name only in that the amended criteria encompass any degenerative arthritis, other than posttraumatic arthritis. Thus, the amended rating criteria have not affected the Veteran's ratings for his left knee disabilities under Diagnostic Code 5003. The Board also notes that Diagnostic Code 5010 was amended effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76,453, 76,463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5010). The regulatory changes reworded Diagnostic Code 5010 from "Arthritis, due to trauma, substantiated by X-ray findings" to "Post-traumatic arthritis." Prior to the regulatory change, Diagnostic Code 5010 directed that the disability (arthritis due to trauma) be rated as degenerative arthritis under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010. As of February 7, 2021, under the amended criteria, Diagnostic Code 5010 directs that the disability (post-traumatic arthritis) be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are two or more joints affected, each rating is to be combined in accordance with 38 C.F.R. § 4.25. Where a law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted the Secretary of VA to do otherwise and the Secretary did so. See VAOGCPREC 7-2003. Additionally, VA's Office of General Counsel has determined that the amended rating criteria can be applied only for the period from and after the effective date of the regulatory change. The Board can apply only the former regulation to rate the disability for periods preceding the effective date of the regulatory change. However, the former rating criteria may be applied prospectively, beyond the effective date of the new regulation. See VAOPGCPREC 3-2000. Consideration of other diagnostic codes for rating a knee disability (5256, 5262, 5263) is inappropriate in this case as the Veteran's bilateral knee disabilities do not include the pathology required in the criteria for those diagnostic codes (ankylosis, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. Here, the Board will discuss the factual evidence as it relates to the Veteran's bilateral knee disabilities prior to addressing the assigned ratings. The Veteran attended a VA examination in July 2016 for an evaluation of his knees. The Veteran had flexion to 105 degrees without pain bilaterally and full extension without pain bilaterally. The examiner attributed the Veteran's decreased flexion bilaterally to his body habitus. The examiner noted that range of motion itself did not contribute to functional loss bilaterally. The Veteran had no pain with weight bearing bilaterally. The Veteran had localized tenderness or pain to palpation to the medial femoral condyle of the left knee. The Veteran had no localized tenderness or pain to palpation on the right knee. The Veteran was able to perform repetitive use testing bilaterally without additional loss of function or range of motion. With repeated use, the examiner noted that pain, weakness, fatigability, and incoordination did not significantly limit functional ability bilaterally. There were no additional factors contributing to disability bilaterally. The Veteran had normal strength bilaterally, no muscle atrophy bilaterally, and no ankylosis bilaterally. The Veteran had no recurrent subluxation, lateral instability, or effusion bilaterally. The examiner noted that the Veteran did not have a meniscal condition in either knee. The Veteran was not noted to use any assistive devices. In terms of the functional impact of the Veteran's knee disabilities, the examiner noted that his bilateral knee disabilities imposed no functional impact. The Veteran reported daily bilateral knee pain with swelling at night and after walking. He reported no locking, catching, or giving away. Furthermore, he reported flare-ups or functional loss. The Veteran attended an additional VA examination in April 2018 where he had left knee flexion to 120 degrees with pain and full extension without pain. With the right knee, the Veteran had flexion to 135 degrees with pain and full extension without pain. The examiner noted that range of motion itself did not contribute to functional loss bilaterally. The examiner noted that the pain with flexion bilaterally did not cause functional loss. The Veteran had no pain with weight bearing bilaterally and no pain to palpation bilaterally. The Veteran was able to perform repetitive use testing bilaterally without additional loss of function or range of motion. With repeated use, the examiner noted that pain, weakness, fatigability, and incoordination did not significantly limit functional ability bilaterally. The examiner noted that an additional factor contributing to disability bilaterally was less movement than normal. The Veteran had normal strength bilaterally, no muscle atrophy bilaterally, and no ankylosis bilaterally. The Veteran had no recurrent subluxation, lateral instability, or effusion bilaterally. The examiner noted that the Veteran did not have a meniscal condition in either knee. The Veteran was not noted to use any assistive devices. In terms of the functional impact of the Veteran's knee disabilities, the examiner noted that his bilateral knee disabilities would prevent work that would require hard physical labor, but work requiring mild physical effort and/or sedentary work would be possible. The Veteran reported bilateral knee pain, with the pain being worse in the left knee. He described the pain in the left knee as a 6/10 at best and 8-9/10 at worst. In the right knee, he described the pain as a 4/10 at best and 7/10 at worst. He reported swelling bilaterally, and he reported popping in his knees every time he gets up. He reported that he treated the pain with rest, elevation, ice, and occasional Aleve. Furthermore, the Veteran reported that his endurance is limited on weight bearing activities, he must take stairs slowly and carefully, he avoids kneeling and squatting, his knees hurt with prolonged stationary positions, he cannot run, and he cannot perform regular exercise. In addition, he reported flare-ups consisting of pain at 8-9/10 in the left knee and 7/10 in the right knee. At a February 25, 2020 VA examination, the Veteran had left knee flexion to 120 degrees with pain and full extension with pain. In a July 2020 addendum, the February 2020 examiner noted that pain began with flexion at 120 degrees. With the right knee, the Veteran had flexion to 115 degrees with pain and full extension with pain. In a July 2020 addendum, the February 2020 VA examiner noted that pain began with flexion at 115 degrees. The examiner noted that range of motion itself did not contribute to functional loss bilaterally. The Veteran had pain with weight bearing bilaterally and objective evidence of crepitus bilaterally. The Veteran had localized tenderness or pain to palpation in the medial and posterior joint in the left knee and in the posterior joint in the right knee. Upon repetitive use, the Veteran's left knee flexion was reduced to 110 degrees. With the right knee, the Veteran was able to perform repetitive use testing without additional loss of function or range of motion. With repeated use, the examiner noted that pain significantly limited functional ability in the form of reduced flexion bilaterally. With repeated use, the examiner noted the Veteran's flexion in his left knee would be to 100 degrees and 105 degrees in the right knee. In July 2020 addendums, the examiner estimated that during flare-ups the Veteran's flexion would be reduced to 90 degrees in the left knee and 95 degrees in the right knee. There were no additional factors contributing to disability bilaterally. The Veteran had normal strength bilaterally, no muscle atrophy bilaterally, and no ankylosis bilaterally. The Veteran had no recurrent subluxation, lateral instability, or effusion bilaterally. The examiner noted that the Veteran did not have a meniscal condition in either knee. The Veteran was not noted to use any assistive devices. In terms of the functional impact of the Veteran's knee disabilities, the examiner noted that the Veteran would be able to stand or walk for 15 minutes before needing to sit down and rest due to increased bilateral knee pain. At the examination, the Veteran reported constant bilateral knee pain, and he reported using ice and Tylenol for pain relief. The Veteran reported not having flare-ups at the examination. Following the February 2021 Board remand, the Veteran attended an additional VA examination in April 2021 for an evaluation of his bilateral knee disabilities. The Veteran had flexion bilaterally to 115 degrees with pain and extension bilaterally to 10 degrees with pain. The Veteran's passive of range of motion showed the same reductions in flexion and extension bilaterally. The examiner noted that range of motion itself did not contribute to functional loss in the left knee, but pain and instability contributed to functional loss in the right knee. The examiner noted that the Veteran had pain with active motion bilaterally and with passive motion bilaterally. Furthermore, the examiner noted that pain and instability cause functional loss bilaterally. The Veteran had objective evidence of crepitus bilaterally and localized tenderness or pain to palpation bilaterally. The examiner noted that the Veteran had some edema in the left knee. The Veteran was able to perform repetitive use testing bilaterally without additional loss of function or range of motion. Upon repeated use, the examiner noted that pain, fatigability, and weakness cause functional loss in the left knee. The examiner estimated the Veteran's flexion would be to 115 degrees and extension would be to 10 degrees. With the right knee, examiner noted that pain and weakness would cause functional loss with repeated use. The examiner estimated the Veteran's flexion would be to 115 degrees and extension would be to 10 degrees. During flare-ups, the examiner noted that pain, fatigability, and weakness would cause functional loss bilaterally. The examiner estimated that during flare-ups the Veteran's flexion would be to 115 degrees bilaterally and his extension would be to 10 degrees bilaterally. The examiner noted that an additional factor contributing to disability bilaterally was more movement than normal. The Veteran had no muscle atrophy bilaterally and no ankylosis bilaterally. The Veteran had no recurrent subluxation or persistent instability, no ligament tear, and no recurrent patellar instability in the right knee. In the left knee, examiner noted the Veteran had recurrent subluxation or persistent instability and a successful repair of a complete ligament tear. Furthermore, the examiner noted that the Veteran had recurrent patellar instability and surgical repair for the patellar instability. In addition, the examiner noted that the Veteran did not require a prescription for an assistive device or brace for his instability. The examiner noted that the Veteran did not have a meniscal condition in either knee. In terms of the functional impact of the Veteran's knee disabilities, the examiner noted that the Veteran lost 1 to 2 weeks of work time in the last 12 months. Furthermore, the examiner noted that the Veteran is unable to tolerate walking long distances due to increased pain symptoms experienced and his job requires walking and being on his feet for a period of eight hours or more. At the examination, the Veteran reported that his left knee feels unstable with some involuntary pull on the knee with walking. He reported that takes Acetaminophen and Aleve for his knees. He reported flare-ups consisting of throbbing knee pain and swelling bilaterally. He reported that during a flare-up his pain in the left knee is 8/10 and in the right knee it is 7/10. He said the precipitating factors are prolonged walking, prolonged standing, and sleeping without support of the knee with a pillow. Lastly, he reported that the flare-ups are alleviated by staying off his legs and taking medications. In addition to the VA examinations addressed above, a March 2019 VA treatment record reflects that the Veteran reported chronic bilateral knee pain. Furthermore, at the March 2019 VA appointment, the Veteran denied new pain, changes in strength, and joint swelling. Aside from the medical evidence addressed above, the Board acknowledges the Veteran's attorney's February 2017 VA Form 21-4138, Statement in Support of Claim, in which the attorney stated the Veteran's bilateral knee pain is at a three on a one to five scale. Furthermore, the attorney reported that both knees swell and need to be treated with ice regularly. In addition, the attorney noted that the Veteran specifically has to leave work one to two times a week to ice his knees. In a separate February 2017 written statement accompanying the Veteran's Notice of Disagreement, the Veteran's attorney noted that the Veteran had increased pain in his knees and "functionally lost use in his knees." In addition, the Board notes the attorney's July 2018 Third Party Correspondence in which the attorney noted that the Veteran reported having to leave work one to two times per week due to his left knee instability. Lastly, the Board acknowledges the attorney's contention in his September 2020 Third Party Correspondence that the February 2020 VA examination regarding flare-ups was inconsistent. However, the Veteran was afforded an additional VA examination in April 2021 that complies with Sharp v. Shulkin, 29 Vet. App. 26 (2017). Regarding the Veteran's 20 percent rating for left knee osteoarthritis under Diagnostic Code 5003-5260, there is no competent and credible evidence that the Veteran has had flexion in his left knee that has been less than 30 degrees, even when considering additional factors of pain, fatigue, weakness, lack of endurance, and swelling. The medical evidence addressed above illustrates that the Veteran's left knee flexion was at most limited to 90 degrees. See July 2020 Addendum. As such, the Board concludes that even when considering additional contributing factors of pain, fatigue, weakness, lack of endurance, and swelling, the evidence does not more nearly approximate flexion limited to less than 30 degrees. Therefore, a preponderance of the evidence is against a rating in excess of 20 percent based on limitation of flexion at any point during the appeal period. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Regarding the Veteran's 10 percent rating for his left knee ACL reconstruction under Diagnostic Code 5003-5257, the medical evidence of record illustrates that there has been no point during the appeal period where the Veteran has had moderate recurrent subluxation or lateral instability, the requirement for a higher 20 percent rating under the former rating criteria of Diagnostic Code 5257. The July 2016, April 2018, and February 2020 VA examinations reflect no recurrent subluxation or lateral instability and normal strength. The April 2021 VA examination reflects recurrent subluxation or persistent instability. Furthermore, the Board acknowledges the July 2018 attorney's written statement that reflects that the Veteran had left knee instability that required him to leave work one to two times per week. In addition, the attorney indicated that such evidence indicates at least intermittent slight instability. The Veteran also reported at his April 2021 VA examination that his left knee felt unstable with some involuntary pull on the knee with walking. However, the Veteran did not report any instability at the prior VA examinations. The Veteran is competent, however, to report the symptoms of instability, as the manifestations are readily observable to even a lay person, and the Board finds the Veteran's reports to be credible. See English v. Wilkie, 30 Vet. App. 347 (2018). However, the Veteran's reports of instability and the competent medical evidence at the April 2021 VA examination reflect no more than slight instability of the knee throughout the appeal period. As there is no evidence of moderate lateral instability or recurrent subluxation throughout the appeal period, a rating in excess of 10 percent is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5257 former rating criteria. As is noted above, VA amended the rating criteria for Diagnostic Code 5257, effective February 7, 2021. However, even when considering the amended rating criteria, a rating in excess of 10 percent for the Veteran's left knee ACL repair under Diagnostic Code 5257 is not warranted under the amended rating criteria from February 7, 2021. Regarding the Veteran's 10 percent rating for his left knee lateral instability, a 20 percent rating requires that a medical provider prescribes a brace and/or a cane, crutches, or walker for ambulation. The medical evidence does not reflect, and the Veteran has not contended, that, he has been prescribed a brace and/or a cane, crutches, or a walker for ambulation at any point throughout the appeal period, including during the applicable period since February 7, 2021, the date the amended rating criteria took effect. Thus, as the record does not reflect a prescription from a medical provider for an assistive device for the left knee, a higher rating under the amended rating criteria is not warranted for the Veteran's left knee. Regarding the Veteran's 10 percent rating for his right knee degenerative changes under Diagnostic Code 5010-5260, there is no competent and credible evidence that the Veteran has had flexion in his left knee that has been less than 45 degrees, even when considering additional factors of pain, fatigue, weakness, lack of endurance, and swelling. The medical evidence addressed above illustrates that the Veteran's right knee flexion was at most limited to 95 degrees. See July 2020 Addendum. As such, the Board concludes that even when considering additional contributing factors of pain, fatigue, weakness, lack of endurance, and swelling, the evidence does not more nearly approximate flexion limited to less than 45 degrees. Therefore, a preponderance of the evidence is against a rating in excess of 10 percent based on limitation of flexion at any point during the appeal period. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board has considered whether the Veteran is entitled to a separate compensable rating for limitation of extension of his left and right knees under Diagnostic Code 5261. The Board concludes the evidence more nearly approximates a finding that the Veteran is entitled to a 10 percent, but no higher, rating for an actually painful left and right knee joint on extension from February 25, 2020 under Diagnostic Code 5261 given the evidence of an actually painful left and right knee joint on extension. The February 2020 VA examination report reflects that the Veteran had full extension with pain in the left and right knees and the April 2021 VA examination report reflects that the Veteran had extension to 10 degrees with pain bilaterally. Therefore, based on the competent and credible medical evidence of showing pain with extension bilaterally, the Board concludes a 10 percent, but no higher, rating for an actually painful left and right knee joint on extension beginning February 25, 2020 is warranted. A rating in excess of 10 percent is not warranted at any point because the Veteran has had no point where his extension in either knee has been limited to more than 10 degrees, even when considering additional factors of pain, fatigue, and weakness. Therefore, the evidence warrants a separate 10 percent, but no higher, rating for each knee based on painful extension pursuant to 38 C.F.R. § 4.59 beginning February 25, 2020. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A compensable rating prior to February 25, 2020 under Diagnostic Code 5261 is not warranted for either knee as the July 2016 and April 2018 VA examination reports reflect no pain with extension. Furthermore, the Veteran's reports of knee pain prior to February 25, 2020 do not specifically illustrate the Veteran had an actually painful left and right knee joint on extension. In evaluating the Veteran's increased rating claims for his left and right knees, the Board must address the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59. The Board recognizes the Veteran's statements that his bilateral knee conditions cause pain and swelling. Furthermore, he reported his bilateral knee disabilities cause difficulties with navigating stairs, squatting, being in prolonged positions, running, and performing any regular exercise. However, even when considering the reported functional loss, the Veteran's disability picture for his left knee did not more nearly approximate flexion limited to 15 degrees throughout the appeal period, extension limited to 15 degrees from February 25, 2020, or moderate lateral instability throughout the appeal period. Regarding his right knee, even when considering the reported functional loss, the Veteran's disability picture did not more nearly approximate flexion limited to 30 degrees throughout the appeal period or extension limited to 15 degrees from February 25, 2020. The Board has considered whether the Veteran is entitled to a separate rating for his right knee under Diagnostic Code 5257 for recurrent subluxation or lateral instability. However, the Veteran has not alleged that he has subluxation or instability in his right knee at any point during the appeal period. Furthermore, the medical evidence of record throughout the appeal period shows no subluxation or instability. Thus, a separate rating under Diagnostic Code 5257 is not warranted for the right knee at any point during the appeal period. The Board has also considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5258 or Diagnostic Code 5259 for a left knee semilunar cartilage condition as the Veteran underwent left knee surgery during his service. However, the March 1995 surgery was for ACL and posterior cruciate ligament (PCL) tears. Thus, as the VA examinations addressed above reflect, the Veteran does not have a left knee semilunar condition. A separate rating under Diagnostic Code 5258 or 5259 is not warranted for the right knee as the record does not contain evidence that the Veteran has a right knee semilunar condition. In sum, the Board finds the criteria for a rating in excess of 20 percent for the Veteran's left knee osteoarthritis under Diagnostic Code 5003-5260 have not been met. The Board finds that the criteria for a rating in excess of 10 percent for the Veteran's left knee ACL reconstruction under Diagnostic Code 5003-5257 have not been met. The Board finds that the Veteran is entitled to a separate 10 percent, but no higher, rating for painful limitation of extension of the left knee under Diagnostic Code 5261 beginning February 25, 2020. The Veteran is not entitled to any further separate ratings for the left knee. Regarding the right knee, the Board finds the criteria for a rating in excess of 10 percent for the Veteran's right knee degenerative changes under Diagnostic Code 5010-5260 have not been met. The Board finds that the Veteran is entitled to a separate 10 percent, but no higher, rating for painful limitation of extension of the right knee under Diagnostic Code 5261 beginning February 25, 2020. The Veteran is not entitled to any further separate ratings for the right knee. M. Mills Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Breitbach, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.