Citation Nr: 21066567 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 16-12 156 DATE: November 1, 2021 ORDER Entitlement to service connection for a low back disability to include arthritis, intervertebral disc syndrome (IVDS), and lumbosacral strain is granted. Entitlement to service connection for sciatica as secondary to low back disability, is granted. Entitlement to service connection for a right shoulder disability characterized as partial acromioclavicular joint separation of the right shoulder as secondary to bilateral chondromalacia of the knees, is granted. Entitlement to service connection for bilateral foot disability is denied. Entitlement to a rating in excess of 10 percent for chondromalacia of the right knee with subluxing patella based on impaired flexion is denied. Entitlement to a separate 10 percent rating for chondromalacia of the right knee with subluxing patella based on impaired extension from July 29, 2021 is granted. Entitlement to a separate 20 percent rating for chondromalacia of the right knee with subluxing patella based on lateral instability and subluxation from April 4, 2021 is granted. Entitlement to a rating in excess of 10 percent for chondromalacia of the left knee with subluxing patella based on impaired flexion is denied. Entitlement to a separate 10 percent rating for chondromalacia of the left knee with subluxing patella based on impaired extension for the entire appeal period is granted. Entitlement to a separate 10 percent rating for chondromalacia of the left knee with subluxing patella based on lateral instability and subluxation from July 29, 2021 is granted. FINDINGS OF FACT 1. The Veteran's current low back disability, diagnosed as arthritis, IVDS, and lumbosacral strain, is attributable to service. 2. The bilateral radiculopathy of the sciatic nerve is etiologically related to service-connected low back disability. 3. A partial acromioclavicular joint separation of the right shoulder is etiologically related to a fall caused by service-connected bilateral knee disabilities. 4. The Veteran does not have a bilateral foot disability. 5. During the appeal period, the Veteran's right knee disability did not result in impaired flexion to 30 degrees or less. 6. From July 29, 2021, the Veteran's right knee disability resulted in impaired extension, but not beyond 10 degrees. 7. From April 4, 2021, the Veteran's right knee disability resulted in moderate lateral instability and subluxation. 8. During the appeal period, the Veteran's left knee disability did not result in impaired flexion to 30 degrees or less. 9. For the appeal period, the Veteran's left knee disability resulted in impaired extension, but not beyond 10 degrees. 10. From July 29, 2021, the Veteran's left knee disability resulted in slight lateral instability and subluxation. CONCLUSIONS OF LAW 1. The criteria for service connection for low back disability to include arthritis, IVDS, and lumbosacral strain are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for secondary service connection for bilateral radiculopathy of the sciatic nerve are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for secondary service connection for partial acromioclavicular joint separation of the right shoulder are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection on a direct or secondary basis for bilateral foot disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for the assignment of a rating in excess of 10 percent for right knee disability as manifested by impairment of flexion are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 6. The criteria for the assignment of a separate 10 percent rating for right knee as manifested by impaired extension from July 29, 2021 are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5261. 7. The criteria for the assignment of a separate 20 percent rating for right knee as manifested by moderate lateral instability and subluxation from April 4, 2021, are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257. 8. The criteria for the assignment of a rating in excess of 10 percent for left knee disability as manifested by impairment of flexion are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 9. The criteria for the assignment of a separate 10 percent rating for left knee as manifested by impaired extension for the entire appeal period are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5261. 10. The criteria for the assignment of a separate 10 percent rating for left knee as manifested by slight lateral instability and subluxation from July 29, 2021, are met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This matter comes before the Board of Veterans' Appeals on appeal from decisions of the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran appeared and presented testimony at a Board video-conference hearing in November 2019. A transcript of that hearing is of record and has been considered by the Board. The Board remanded this matter to the AOJ in March 2020 for additional development. The case has since been returned to the Board for further appellate review. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the nonservice-connected disease or injury. Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and competent evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). With regard to the matter of establishing service connection for a disability on a secondary basis, the United States Court of Appeals for Veterans Claims (Court) has held that there must be evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a nonservice-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran asserts that both his low back and feet were injured by his inservice duties as a wireman to include the boots he wore for his military occupational specialty (MOS). The Veteran also contends that he has low back and foot disabilities due the altered gait related to his service-connected bilateral knee condition. The service treatment records (STRs) do not reflect treatment or diagnosis of low back, feet, or right shoulder disabilities. Post-service medical records reflect that in April 2003, the Veteran was seen for back myalgia. Thereafter, the Veteran complained of low back pain in August 2000, September 2000, May 2002, June 2002, and January 2003. In October 2002, the Veteran was treated for back pain of two months' duration that he experienced after exercise. He was diagnosed as having a back sprain. In a June 2012 statement, A.W., a friend of the Veteran, indicated that she had witnessed the Veteran falling due to his knee disabilities on several occasions. In addition, she related that she witnessed the Veteran having sciatic nerve pain. In August 2012, the Veteran was afforded a VA examination. It was noted that the Veteran had low back pain which radiated down his leg. Degenerative disc disease was diagnosed. The examiner opined that the current low back disability was less likely than not related to service as the service medical record were negative and was also less likely than not related to the bilateral knee disability as there was no evidence to provide a causative relationship. In April 2014, another statement was received from A.W. She stated that she witnessed the fall of the Veteran when his knees gave way when he was carrying some groceries. When he fell, his shoulder slammed into the corner of a building like a football player. He had to be taken for medical treatment and was told that his shoulder was partially separated. She related that he still had only partial use of his right arm. In April 2014, the Veteran was examined by VA. He was diagnosed as having IVDS. The Veteran reported that the low back pain began in 1981 and had continued, and that he had self-treated and had chiropractic care. It was noted that he had radiation of pain down the right side. The examiner opined that the low back disability with the right-sided sciatica was not related to service because there were no records of back pain for 12 years after service and that his back disability was not related to service-connected knee disability because there was no evidence of limping or an antalgic gait. Another VA examination indicated that the Veteran did not have a right shoulder condition which was caused by, a result of, or aggravated by the service-connected right and left knee condition. The examiner further noted that although he had a diagnosis of right shoulder acromioclavicular separation, status post fall, he did not have a current diagnosis. In September 2016, C.R. indicated that he had witnessed the Veteran occasionally fall. A.W. also submitted another statement in which she reiterated her past statement regarding seeing the Veteran fall. As noted, the case was previously before the Board. At that time, the Board noted that the Veteran and his representative indicated that the VA examiner's negative medical opinion as to the Veteran's back disability included an insufficient rationale. They also maintained that a VA examiner found that there was no secondary relationship of the claimed disabilities to the knees because the Veteran does not have an altered gait; however, the Board noted that the Veteran had testified at a Board hearing that he does have an altered gait as documented in the record and shown as being due to his knee disabilities. The Board further noted that that the medical opinions of record did not address aggravation. Thus, the Board remanded this case and additional medical assessment was undertaken. In April 2020, the Veteran was afforded VA examinations. With regard to the low back, which was diagnosed as lumbosacral strain, the examiner indicated that current low back disability is less likely than not incurred in or caused by the claimed in-service injury, event or illness. In addition, the examiner opined that the back disability is less likely than not proximately due to or the result of the service-connected knee condition and is not aggravated beyond its natural progression by service-connected knee condition. With regard to sciatica, that was not noted. With regard to the feet, there was not a diagnosis related to either foot. The examiner opined that the claimed bilateral foot condition is less likely than not incurred in or caused by the claimed in-service injury, event or illness. Also, the claimed foot condition is less likely than not proximately due to or the result of the service-connected knee condition or aggravated thereby. With regard to the right shoulder, a VA examiner examined the Veteran's right shoulder and noted that the Veteran had previously fallen and injured his right shoulder which required surgical repair. However, the examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected knee condition. In September 2020, a private medical opinion was submitted from a physician. The physician noted that the Veteran's claimed that back disease is a result of his service-connected bilateral knee disease. In the physician's medical opinion, the Veteran's lumbar spine disease and lumbar radiculopathy is as likely as not due to his injury to the back while in service and is secondary to his bilateral knee disease. The Veteran has claimed that his back condition was incurred or caused by complaints that began on August 13, 1976, due to his MOS as a wireman and the duties that he performed on a regular basis. He indicated that VA examiners have noted there is indeed a diagnosis of lumbar spinal disease with radiculopathy, but the lower back disease and radiculopathy began thirteen years after discharge thus no nexus is established between the lumbar spinal disease and lumbar radiculopathy to the initial injury. Moreover, it has been argued by the previous examiners there was no gait disturbances from bilateral knee disease thus compensatory injury cannot be established. However, the private physician indicated that these statements are not entirely correct. First, the Veteran has post-traumatic arthritis of the lumbar spine which has progressed to lumbar spinal radiculopathy. Post-traumatic arthritis (PTA) develops after an acute direct trauma to the joints. PTA causes a high percentage of all osteoarthritis cases, and a history of physical trauma may also be found in patients with chronic inflammatory arthritis. Human studies and experimental models have revealed that a series of inflammatory mediators are released in synovial fluid immediately after the joint trauma. These inflammatory markers are responsible for progressively worsening age-appropriate arthritis beyond its natural progression. In the case of the Veteran, although there were no complaints of back disease immediately after discharge, it progressively worsened and became symptomatic years later. Moreover, the Veteran is service-connected for bilateral knee disease. He has suffered years of pain, swelling, and effusion of both knees. Unfortunately, over the years the Veteran had severe symptoms of both knees which has caused compensatory injuries to his spine. The Veteran had severe injuries to his knees which caused him to have an altered gait. This gait caused an imbalanced stress on joint to support the bodies movements. With the obvious symptoms of swelling, weakness, and effusion the Veteran had a limp while walking. With an altered gait pattern, this result usually includes a shortened stance phase and a surge during liftoff phase. The result is that with each step the body's center of gravity is shifted toward the affected side during stance phase and to the unaffected during liftoff. This causes increased stress on the other joints on the unaffected side including the midfoot, hip and fact joint of the lumbar spine. Over time, this can lead to accelerated degeneration of those joints or an exacerbation of a pre-existing condition. In the case of the Veteran, he had such a poor outcome of his knees, it is extremely unlikely that his both knees did not have any effect on the spine. Furthermore, no previous examiner has objectively measured the Veteran's gait to rule out gait imbalance. There were no measurements noted to deem no gait malfunction. Lastly, there were numerous discrepancies in lumbar spinal disease compensation and pension examinations. The earliest examiner found profound lower extremity findings and second examiner did not mention any extreme findings of lower extremity radiculopathy. These are grave concerns as continuous image findings on x-ray/magnetic resonance imaging (MRI) show worsening lumbar spinal disease. Thus, later examination findings should have been worse than previous findings. Therefore, examination findings from compensation and pension examiners are not convincing. The examiner noted that with that, it is as likely as not that the lumbar spinal disease and its complications of bilateral lower extremity radiculopathy is as likely as not due to the Veteran's time in service. Moreover, the Veteran's knee disease has had a severe impact on his lumbar spinal disease, and has worsened the low back disease at least as likely as not beyond its natural progression. With regard to the right shoulder, the physician noted that in October 2013, the Veteran fell into a wall and hit his right side and injured his right shoulder. He waited 12 days, but then sought medical attention because the shoulder discomfort was not letting up. He had suffered a partial acromioclavicular joint separation. He had a reconstruction of his acromioclavicular joint to improve his symptoms. He still claims there is pain over the right acromioclavicular joint, discomfort with active overhead reaching and at times, interfering with his activities of daily living (ADLs). It was the physician's medical opinion that the service-connected knees caused him to fall and are responsible for his right shoulder disease. Thus, in the physician's medical opinion, the Veteran's right shoulder disease is at least as likely as not secondary to his service-connected bilateral knee disease. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, the Board remanded the case for additional medical assessment. The April 2020 VA opinion and the September 2020 private opinion were provided by examiners who were aware of the Veteran's medical history, but provided differing opinions. They are both probative. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Low Back The Veteran's current low back disability, diagnosed as arthritis, IVDS, and lumbosacral strain, is etiologically related to service. The VA opinion was negative while the private opinion supported the claim for both direct and secondary service connection. The Board affords the Veteran reasonable doubt and the evidence is in equipoise. Thus, service connection on a direct basis is warranted. As such, secondary service connection need not be addressed. Sciatica The Board finds that the evidence shows that the Veteran has bilateral radiculopathy of the sciatic nerve as secondary to the low back disability. Thus, secondary service connection is warranted for bilateral radiculopathy of the sciatic nerve. Right Shoulder The Board finds that the combined lay and medical evidence shows that the Veteran suffered a post-service fall and injured his right shoulder. Overall, this evidence shows that the Veteran's knees caused the fall which resulted in a right shoulder injury and current disability of the acromioclavicular joint. Thus, secondary service connection is warranted for disability of the acromioclavicular joint. Bilateral Foot The Veteran does not have a bilateral foot disorder. The United States Court of Appeals for Veterans Claims (Court) consistently has held that, under the law, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the Unites States Court of Appeals for the Federal Circuit (Federal Circuit), which has stated, "a Veteran seeking disability benefits must establish... the existence of a disability [and] a connection between the Veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed). In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). More recently, in Saunders v. Wilkie, the Federal Circuit found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." 886 F.3d 1356, 1368 (Fed. Cir. 2018). Thus, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability for VA compensation purposes. It is noted in VA treatment records that the Veteran had past diagnoses of plantar fasciitis and heel spurs, these were not demonstrated during the appeal period. See McCain v. Nicholson, 21 Vet. App. 319 (2007). Likewise, although the Veteran reported to a mental health examiner that he had a history of plantar fasciitis and heel spurs, there is no diagnosis of these disabilities during the appeal period. Notably, on most recent VA examination in April 2020, while the Veteran reported having bilateral foot pain resulting in difficulty with prolonged standing and walking, examination of the feet showed no functional loss and limitation of motion for the left or right lower extremity including the feet and no contributing factors of disability associated with limitation of motion such as pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups, or when the foot was used repeatedly over a period of time. Further, there were no other objective pertinent physical findings, complications, conditions, signs or symptoms and scars. The examiner concluded that there was no bilateral foot diagnosis because there were no findings, signs and/or symptoms to support a diagnosis including no evidence of pain on active or passive motion testing or on weight-bearing and non-weight-bearing testing of either foot. The Veteran's current subjective complaints were not supported by objective findings. Therefore, in the absence of proof of a present disability, there can be no valid claim. Rabideau v. Derwinski, 2 Vet. App. 141, 143- 44 (1992). Therefore, service connection for a bilateral foot disability is not warranted. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim, and it must be denied. Increased Rating for the Knees The service records show that the Veteran was evaluated by a Medical Board in July 1977 and discharged for a bilateral knee disorder. The Medical Board found that the Veteran had tibia vara and patella subluxation which existed prior to enlistment and that no objective signs of aggravation were present. A post-service August 2012 VA examination included an opinion which stated that the Veteran's service entrance examination did not indicate that the Veteran was blow-legged, had subluxing patellae, or chondromalacia. The examiner opined that the Veteran's right knee disability was more likely than not aggravated beyond normal progression in the military as the Veteran was treated numerous times and was discharged for this condition. The examiner did not feel that the chondromalacia of the bilateral knees with subluxing patellae secondary to tibia vara resulted in degenerative joint disease. A September 2012 rating decision granted service connection for chondromalacia of each knee with a subluxing patella secondary to tibia vara, but not degenerative joint disease. The rating decision stated that each knee was assigned a 10 percent rating based on painful motion per 38 C.F.R. § 4.59. The rating sheet listed the Diagnostic Code as 5299-5257, indicating that the Veteran was rated based on lateral instability or subluxation, it appears due to the history of subluxing patella. However, the rating decision clearly indicated that the Veteran was actually rated based on painful motion (painful flexion under Diagnostic Code 5260). The Board notes, as set forth below, that the Veteran can be rated under limitation of motion as well as lateral instability/subluxation codes), if he exhibits symptoms consistent with these codes. The September 2012 decision was not appealed. In April 2014, as previously noted, the Veteran's friend submitted a statement indicating that the Veteran used knee braces, fell due to his knee disability, and currently also ambulated with a cane. The Veteran also indicated that he had bilateral knee pain and trouble with bending and walking. In April 2014, the Veteran was afforded a VA examination. His range of motion of both knees was 0 to 140 degrees with no pain. There was no tenderness or pain to palpation. Muscle strength was normal on both sides. Stability testing was also normal. The Veteran was noted to have a history of patella subluxation or dislocation of both knees, but none currently. X-rays also did not show patellar subluxation. There were no shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. It was noted that the Veteran previously had a right knee meniscectomy. It was noted that the Veteran regularly used knee braces. In a May 2014 rating decision, the AOJ denied an increased rating for the right knee disability, granted service connection for a scar of the right knee, and proposed to decease the Veteran's left knee disability to 0 percent. The rating decision indicated that the right knee chondromalacia disability was evaluated under the diagnostic codes for meniscus impairment and continued at the 10 percent level. Nonetheless, the rating code sheet continued to list the code for lateral instability or subluxation. The Veteran appealed the right knee rating. In an August 2014 rating decision, the AOJ reduced the rating for the left knee to 0 percent effective December 1, 2014. The Veteran appealed that determination. A January 2016 rating decision then restored the 10 percent rating, indicating that the Veteran continued to have painful motion per the evidence below. The rating code sheet then indicated that the Veteran was rated under Diagnostic Code 5260, the code for limited or painful flexion motion. The matter of a higher rating remains under appeal even though the 10 percent rating was restored. In considering the applicability of the diagnostic codes, the Board notes that Diagnostic Codes 5258-9, concerns injury to cartilage of the knee. Under Diagnostic Code 5259, a 10 percent disability rating is warranted for symptomatic removal of the semilunar cartilage. Under Diagnostic Code 5258, a 20 percent disability rating is warranted when there is dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. The VA Office of General Counsel has stated that Diagnostic Code 5259, removal of semilunar cartilage, may result in complications producing loss of motion. As such, limitation of motion is a relevant consideration under Diagnostic Code 5259. The removal of the semilunar cartilage may involve symptomatology caused by tears and displacements of the menisci that may be rated separately from symptoms caused by arthritis. VAOPGCPREC 9-98 (Aug. 14, 1998). At this juncture, the Board notes that in a more recent September 2020 rating decision, the AOJ has assigned a separate rating based on meniscus impairment. That rating decision indicated that a separate evaluation is being granted for the right knee based on the VA regulation which states that "manifestations of a knee disability other than recurrent subluxation and lateral instability, and/or 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261 if a manifestation of the meniscal disability did not result in an elevation of the disability warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and /5261 via application of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 pursuant to Deluca v. Brown, 8 Vet. App. 202 (1995). The separate rating for meniscus impairment is under a separate appellate review process pursuant to the Appeals Modernization Act (AMA). Thus, the Board is not reviewing that matter herein, but rather the other applicable diagnostic codes for rating the knee as addressed below. The Board notes that subsequent to the May 2014 rating decision and prior to the September 2020 rating decision, it appeared that the Veteran's right knee chondromalacia was rated as 10 percent disability, separate from any meniscus condition. VA medical records continued to document complaints of the Veteran of his having bilateral knee pain. Medical records from Palm Beach Sports Medicine & Orthopedic Center PA dated in 2015 documented that the Veteran had pain on motion in both extension and flexion of the left knee, which was from 0 degrees to 110 degrees. The left knee was stable. Motion on the right side was the same, with only pain on flexion. The right knee was also stable. MRI revealed meniscus tears on both sides as well as right side partial anterior cruciate ligament (ACL) tear, and partial posterior cruciate ligament (PCL) tear. In August 2016, Dr. J.C. indicated that he had treated the Veteran's bilateral knee conditions (chondromalacia and meniscus tears) with injections and physical therapy. In November 2019, the Veteran testified at a Board hearing. It was argued that the right knee should be increased based on deformity, and the left knee should be awarded a 10 percent rating for painful motion and 10 percent for instability. The Veteran reported that he wore braces on both knees for limitation of motion as well as instability of the knees. He also related that when he received shots in his knees, the knees would swell. He indicated that his knees would lock at night when he would lay down so he put pillows underneath to prevent that from happening. He said his right knee symptoms were worse than the left knee. He indicated that he had physical limitations due to his knees. In April 2020, the Veteran was afforded a VA examination. The Veteran reported difficulty standing and walking and that his knees hurt when he drove for long periods. The Veteran indicated that he had flare-ups of the right knee which occurred 2-3 times per month which were severe. He stated that the right knee flare-ups lasted "about 2 weeks." The right knee flare-ups were precipitated by "lifting, walking too much with objects, moving." The right knee flare-ups were alleviated by "ice, pressure points with a knee strap." Range of motion was from 0 degrees of extension to 130 degrees of flexion. Pain was noted on examination and caused functional loss on flexion. There was no pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was objective evidence of crepitus. On the left side, range of motion was normal from 0 degrees of extension to 140 degrees of extension and was pain free. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. The Veteran was able to perform repetitive testing in both knees. In performing repetitive motion, pain further limited flexion on the right to 120 degrees, and limited flexion on the left to 130 degrees. Muscle strength was normal in both knees with no muscle atrophy. There was no effusion in either knee. There was no instability in either knee. Joint stability tests of both knees were normal. There was no ankylosis. There was no lateral instability or subluxation. There was no recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. It was noted that the Veteran underwent a right knee meniscectomy in 1979. The Veteran constantly used knee braces and a cane. The Veteran could not stand and walk greater than 4 hours in an 8-hour workday. There was no evidence of pain on non-weight bearing testing of the left knee. There was objective evidence of pain on passive range of motion testing of the right knee. There was no evidence of pain on non-weight bearing testing of the right knee. A goniometer was used for all joint range of motion measurements. The Veteran had right knee limitation of motion with painful movement, which was consistent with knee strain and is a progression of this disability. The Veteran also had bilateral knee crepitus which was consistent with bilateral knee chondromalacia. The Board notes that the examination reflects pain on flexion on both the right and left side. On September 21, 2020, Dr. S.B. indicated (in conjunction with his opinion regarding the claimed low back disability) that the Veteran is service-connected for bilateral knee disease. He had suffered years of pain, swelling, and effusion of both knees. Unfortunately, over the years the Veteran had severe symptoms of both knees which had caused compensatory injuries to his spine. The Veteran had severe injuries to his knees which caused him to have an altered gait. This gait caused an imbalanced stress on joint to support the bodies movements. With the obvious symptoms of swelling, weakness, and effusion the Veteran had a limp while walking. With an altered gait pattern, this result usually includes a shortened stance phase and a surge during liftoff phase. The result is that with each step the body's center of gravity is shifted toward the affected side during stance phase and to the unaffected during liftoff. This causes increased stress on the other joints on the unaffected side including the midfoot, hip and fact joint of the lumbar spine. Over time, this can lead to accelerated degeneration of those joints or an exacerbation of a pre-existing condition. Dr. S.B. further stated that in regard to the Veteran's knee disease, the initial discrepancy noted is the diagnosis of both knees. It is a complex disease not just including the surface and surrounding tissue disease, as claimed as chondromalacia. His diagnosis needed an update to include damage to internal structures of ACL/PCL/MCL tears with tricompartmental disease. He had been suffering from these structural tears since enlistment period and had a meniscectomy to correct his internal structure damage to the right knee. Unfortunately, the previous examiner (the VA examiner) did not appropriately document these findings on objective examination when there are clear findings on MRI of both knees to have structural damage. There is clear instability of stabilizing structures of the knees. Thus, the findings from previous examiners are not convincing. It has been proposed the left knee ratings would be decreased to 0 percent on the basis of previous VA examination. The examiner stated that this is not a reliable examination from the VA examiner; thus, proposing a reduction is not convincing. The examiner noted that the Veteran's left knee ratings must, remain at 10 percent as there are given structural damages of the knees as per his MRI that led to instability and subluxation of the knee which was not correctly noted on examination. The Veteran still complained of instability and swelling which requires him to wear a brace at all times. The examiner noted that of importance, one must note repeated internal structure damage which incurred initially in service has a high chance of reoccurring as per literature. It has been shown in literature, patients with a surgically treated meniscal tear have a high rate of recurrent meniscal tear (59 percent at 8 years). Approximately 50 percent of surgically treated patients developed symptomatic lateral compartment osteoarthritis at 8 years from diagnosis. Thus, the claims the Veteran is making are consistent with literature findings with the accelerated progression of his knee disease and his current outcome. In regard to the right knee, it warrants a higher rating to 20 percent as there is clear structural damage which has been noted on his MRI. As per guidelines higher percentage is warranted when frequent locking and/or joint effusion is noted of the knee. The right knee MRI shows not only chondromalacia, but findings of tricompartmental disease with internal, structure damage leading to instability and indeed findings of locking of his knee joint. Furthermore, the Veteran does claim he has pain, instability, and locking of his right knee which warrants a higher rating. The examiner noted that the Veteran states if he lifts anything greater than 20 pounds it would cause severe swelling and pain for days. He currently wears braces on both knees. In this examiner's medical opinion, the Veteran's right knee needed an increased rating to 20 percent given his findings of frequent locking and swelling, with an updated diagnosis of tricompartmental disease with ACL/MCL/PCL degeneration, as these new findings are secondary to the initial service-connected right knee disease. His right knee disease had progressed beyond its natural progression from his initial service-connected tricompartmental disease. Moreover, the Veteran had been noted to be service-connected as having tibia vara of his right knee, and this deformity is a high risk for meniscal tears. Not only was the Veteran affected from inservice meniscal tear which likely deteriorated over time, but a deformity risk of tibia vara had worsened his meniscal tear beyond its natural progression. At this juncture, the Board again notes that a rating based on the meniscus condition is not before the Board at this time and is under a separate AMA appeal. As noted above, the reduction was restored. Otherwise, the Veteran's bilateral knee disabilities will be rated herein based on the symptoms related to his service-connected knee disabilities. The Board accords probative value to the statements of this physician, but there are no specific objective findings on physical examination showing the current limited or painful motion of each knee and/or lateral instability ot subluxation since an examination was not performed. Thus, the objective findings on the physical examinations are more probative as to current findings. On April 4, 2021, the Veteran was afforded another VA examination. The Veteran reported he was wearing knee braces and had intermittent pains. The Veteran reported currently or worsening of his pain. He used a TENS unit for pain relief, and also got injections for his knee pains. The Veteran reported he had difficulty in walking and standing long periods of time and climbing down stairs. The Veteran reported that flare-ups of the right knee occurred twice a week and were severe, and lasted 30 to 50 minutes. They were precipitated by activity and relived with rest. He did not have instability or recurrent subluxation of the knees or effusion. Range of motion testing on the right was 0 degrees of extension to 110 degrees of flexion. Passive and active range of motion were the same with pain on active motion. On the left, range of motion testing was 0 degrees of extension to 130 degrees of flexion with pain on both extension and flexion. The pain was on active motion. Passive and active range of motion were the same. There was crepitus on the right with severe objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no crepitus on the left with moderate objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive testing. In both knees, pain, weakness, lack of endurance, or incoordination significantly limited functional ability with repeated use over time, but motion remained the same. On the right, during flare-ups, pain, weakness, lack of endurance, or incoordination significantly limited functional ability, but motion remained the same. On both sides, the Veteran had disturbance of locomotion, interference with sitting, and swelling. There was no muscle atrophy. There was no ankylosis of either knee. On the right, the examiner noted recurrent subluxation or persistent instability, which was not present on the left. The examiner indicated that there had not been a complete or partial/incomplete ligament tear in either knee and there was no prescribed (by a medical provider) of an ambulatory device. There was also no recurrent patellar instability on either side. There were no shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. The Veteran had a meniscal tear of both knees and a history of meniscus surgery on the right side. The examiner noted that a goniometer was used for all joint range of motion measurements. There was moderate recurrent subluxation of the right knee and a history of moderate lateral instability of the right knee. The right knee joint stability testing could not be performed because of pain. There was no lateral instability of the left knee. There were no findings of joint instability of the left knee. The left knee anterior instability test result was normal. The left knee posterior instability test result was normal. The left knee medial instability test result was normal. The left knee lateral instability test result was normal. There were no findings of chronic exertional compartment syndrome of the right lower extremity. There were no findings of chronic exertional compartment syndrome of the left lower extremity. On July 29, 2021, the Veteran was afforded another examination. He reported additional physical restrictions as well as mild to moderate edema. Range of motion testing on the right revealed extension to 10 degrees to flexion of 105 degrees with pain on flexion. Range of motion testing on the left revealed extension to 5 degrees to flexion of 140 degrees with pain on extension and flexion. Active motion was the same. On the right, there was pain on weight-bearing, nonweight-bearing, and on active motion which caused difficulty walking, severe inability to carry heavy objects, severe, no yard work, difficulty with stairs, and trouble getting in and out of cars. On the left, there was pain on weight-bearing, nonweight-bearing, on passive motion, and on active motion which caused difficulty walking, severe inability to carry heavy objects, no yard work, difficulty with stairs, and trouble getting in and out of cars. There was crepitus on the right, but no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was crepitus on the right, with objective evidence of localized tenderness on palpation on the medial and lateral joint line with a severity of 4/10. The Veteran was able to perform repetitive-use testing on both sides with at least three repetitions with no additional loss of motion. Pain further reduced flexion on the right to 95 degrees. There was no additional loss of motion on the left. It was noted that the Veteran was having a flare-up on the right side during the examination. The flare-up did not otherwise limit motion on the right, but the examiner noted that a flare-up did further limit flexion on the left to 130 degrees. On the right, the Veteran had interference with standing, disturbance of locomotion, less movement than normal, instability of station, interference with sitting, and swelling. On the left, the Veteran had interference with standing, disturbance of locomotion, less movement than normal, interference with sitting, and swelling. The Veteran had difficulty with standing, walking, and sitting on the right and left, and also an antalgic gait on the left. There was no muscle atrophy on either side. There was no ankylosis on either side. The examiner indicated that there had not been a complete or partial/incomplete ligament tear in either knee. There were prescribed ambulatory devices. There was recurrent subluxation or persistent instability on both sides. There was recurrent patellar instability on both sides which required braces. There had not been surgical repair for the patellar instability. There were no shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. The Veteran had a meniscal tear and a history of meniscus surgery on the right side. The Veteran constantly used braces and a cane. The knee disabilities impacted work. Passive range of motion of the right knee was not performed as it was medically contraindicated as it may cause the Veteran severe pain or the risk of further injury. It was not medically advisable to conduct passive range of motion testing because it may cause the secondary to pain. With regard to joint stability, on the right side, there was slight recurrent subluxation of the right knee as well as slight lateral instability of the right knee. Stability testing on the left was performed. There was slight recurrent subluxation of the left knee and slight recurrent patellar dislocation of the left knee. There was no lateral instability of the left knee. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 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. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In deciding the Veteran's higher rating claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. 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. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca. The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. 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. The Court previously indicated that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). However, the Court recently suggested that the plain language of 38 C.F.R. § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joint or periarticular pathology that are painful, whether or not evaluated under a diagnostic code predicated on range of motion measurements. See Correia v. McDonald, 28 Vet. App. 158 (2016); Southall-Norman v McDonald, 28 Vet. App. 346 (2016). In Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017), the Court noted that the VA Clinician's Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from a Veteran. The Board notes that recent VA examinations were adequate per Correia and Sharp. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that 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. 85 Fed. Reg. 76453 (Nov. 30, 2020). The amendments apply to claims, such as the Veteran's, that were pending before VA as of that date, with the provision that the more favorable of the old and new criteria are to be applied. If application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation. 38 U.S.C. § 5110 (g). Prior to the effective date of the change in the regulation, the Board can apply only the original version of the regulation. Prior to February 7, 2021, Diagnostic Code 5010 provided that the rating for arthritis due to trauma was determined under the criteria pertaining to degenerative arthritis, Diagnostic Code 5003, which rated based on limited motion. 38 C.F.R. § 4.71a. Since February 7, 2021, Diagnostic Code 5010 provides that post-traumatic arthritis shall be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. The Veteran is not rated based on a diagnosis of arthritis. Regarding the diagnostic codes pertaining to the knees, 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), instability and 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). Under Diagnostic Code 5262, malunion impairment of the tibia or fibula with a slight knee or ankle disability will be assigned a 10 percent rating, moderate knee or ankle disability will be assigned a 20 percent disability rating, marked knee or ankle disability will be assigned a 30 percent disability rating, and non-union of the tibia and fibula with loose motion, requiring a brace, will be assigned a 40 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5262. In this case, the applicable diagnostic codes for the Veteran's knee disabilities based on diagnoses and symptoms are 5257, 5260, and 5261. As repeatedly noted, meniscus impairment is not addressed in this decision. Under the former version of the rating schedule, under Diagnostic Code 5257, a 10 percent rating is warranted for impairment of the knee with slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for impairment of the knee with moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for impairment of the knee with severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under the amended criteria, Diagnostic Code 5257 provides for recurrent subluxation or instability with a 30 percent rating that is 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, a 20 percent rating that is (a) 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) an 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, and a 10 percent rating for a 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. Revised Diagnostic Code 5257 also provides for patellar instability with a 30 percent rating 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, a 20 percent rating 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, and a 10 percent rating 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. Note (1) of the rating provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon, and Note 2 states 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). The February 2021 amendments did not affect Diagnostic Codes 5260, limitation of flexion, or 5261, limitation of extension. 38 C.F.R. § 4.71a. The normal range of motion of the knee is from 0 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). The Board observes that former regulation 38 C.F.R. § 19.9 (b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the agency of original jurisdiction. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9 (b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904 (d)(2), the Board will proceed to adjudicate the Veteran's claim. The Board notes that the April 2014 VA examination did not show any knee disability, but this is inconsistent with the other evidence of record including contemporaneous VA treatment records documenting complaints of pain. The Veteran's complaints of pain were credible. Also, the record clearly shows a progression in his knee disabilities over time. As such, the Board will base the ratings primarily on the other evidence of record. Prior to February 7, 2021, the right knee disability resulted in painful and limited motion on flexion; however, flexion was not limited to 30 degrees or less, even considering pain and other pertinent factors as well as the Court directives outlined above. There was no impairment of extension. Accordingly, the right knee disability warranted a 10 percent rating based on impaired flexion, a higher rating was not warranted, nor was a compensable rating warranted for impaired extension. Although the Veteran reported having instability, instability was not objectively demonstrated on stability testing when he was examined which diminishes the credibility of such report. Likewise, while the Veteran had a history of a subluxing patella, he did not demonstrate any subluxation or dislocation when he was examined. The Board places weight on the objective evidence as the various tests were developed to specifically measure instability and were administered by specially trained and educated medical professionals. Additionally, the collective evidence from this period from VA examinations consistently document normal stability testing and no lateral instability. Accordingly, a separate rating based on lateral instability or subluxation is not warranted. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Prior to February 7, 2021, the left knee disability resulted in painful and limited motion on flexion; however, flexion was not limited to 30 degrees or less, even considering pain and other pertinent factors so a higher rating is not warranted. With regard to extension, extension was not limited. The medical evidence documented painful extension on and off. In affording the Veteran the benefit of the doubt, the Board finds that a separate rating is warranted for painful extension of the left knee. For the same reason as for the right knee as outlined above, a separate rating based on lateral instability or subluxation is not warranted. From February 7, 2021, the right knee disability resulted in painful and limited motion on flexion; however, flexion was not limited to 30 degrees or less, even considering pain and other pertinent factors as well as the Court directives outlined above. The July 29, 2021 examination reflected that the Veteran had painful and limited extension to 10 degrees, but no impairment beyond that point. Thus, a separate 10 percent rating, but no higher, is warranted based on impaired extension from July 29, 2021. From February 7, 2021, the left knee disability resulted in painful and limited motion on flexion; however, flexion was not limited to 30 degrees or less, even considering pain and other pertinent factors and Court directives. The Veteran continued to have painful extension warranting a separate 10 percent rating which was also limited on the July 2021 examination, but only to 5 degrees, so a rating higher than 10 percent is not warranted. After February 7, 2021, the April 4, 2021 examination showed that the Veteran had moderate lateral instability/subluxation on the right side. The July 2021 examination showed a slight level of disability, but the Board notes this was only three months later and accepts the higher moderate level as representative of the Veteran's lateral instability/subluxation on the right side. Under the former version of the rating schedule, that disability warrants a separate 20 percent rating. In order for a higher rating to be warranted under the amended code, the right knee would need to demonstrate that the Veteran had an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribed ambulatory device or 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. The VA examiner indicated that there had not been a complete or partial/incomplete ligament tear or surgical repair for patellar instability. Accordingly, a higher rating under the amended criteria is not met. With regard to the left knee, the Veteran initially demonstrated lateral instability or subluxation on the July 29, 2021 examination, which was slight, warranting a separate 10 percent rating under the former version of the rating code. The Veteran's left knee disability does not warrant a higher 20 percent rating under the amended code, because the left knee disability does not result in a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability; an unrepaired or failed repair of complete ligament tear causing persistent instability; or patellofemoral complex with recurrent instability after surgical repair. Accordingly, a separate 10 percent rating, but no higher, is warranted under the older version of the rating schedule from July 29, 2021. There is no basis for a compensable rating under any other applicable code addressed in the current decision herein. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, for the right knee, a preponderance of the evidence is against a rating higher than 10 percent based on impaired flexion. The evidence supports a separate 10 percent rating based on painful and limited extension from July 29, 2021. The evidence supports a separate 20 percent rating based on lateral instability and subluxation from April 4, 2021. For the left knee, a preponderance of the evidence is against a rating higher than 10 percent based on painful flexion. The evidence supports a separate 10 percent rating based on painful extension for the entire appeal period. The evidence supports a separate 10 percent rating based on lateral instability and subluxation from July 29, 2021. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Connolly, 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.