Citation Nr: 21066769 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 10-08 664 DATE: November 2, 2021 ORDER Entitlement to an increased rating for a right knee disability, evaluated as 20 percent disabling from January 1, 2009 to November 19, 2010 and from January 1, 2011 to March 28, 2016; 30 percent disabling from May 1, 2017 to June 11, 2021; and 60 percent disabling from June 11, 2021, is denied. FINDINGS OF FACT 1. For the periods beginning January 1, 2009 until November 19, 2010 and January 1, 2011 until March 28, 2016, the Veteran's locked bucket handle medial meniscus tear of the right knee was manifested by no more than moderate recurrent subluxation or lateral instability. 2. For the period from May 1, 2017 to June 11, 2021, the Veteran's right total knee arthroplasty, was manifested by total knee replacement with no evidence of intermediate degrees of residual weakness, pain or limitation of motion and no chronic residuals of severe painful motion in the affected extremity. 3. For the period from June 11, 2021, the Veteran's right total knee arthroplasty was manifested by no more than chronic residuals of severe painful motion or weakness in the affected extremity. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 20 percent for a service-connected right knee disability, characterized as locked bucket handle medial meniscus tear of the right knee, on and after January 1, 2009 until November 19, 2010, and from January 1, 2011 until March 28, 2016 has not been met. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5257. 2. The criteria for entitlement to a rating in excess of 30 percent for right total knee arthroplasty, from May 1, 2017 to June 11, 2021 are not met. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5055. 3. The criteria for entitlement to a rating in excess of 60 percent disabling beginning June 11, 2021 and thereafter for right total knee arthroplasty have not been met. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1995 to August 1999. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge. A copy of the transcript is associated with the evidentiary record. These matters were previously remanded in January 2018 and April 2021 for further development. A remand by the Board imposes a concomitant duty to ensure compliance with the terms of the remand. Where the remand orders are not complied with, the Board itself errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Upon review, the Board finds that with respect to the Veteran's claim for increased ratings for his right knee disability, the remand directives have been complied with. General Rating Principles Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be considered in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the United States Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. Rating Criteria- Right Knee For the period from January 1, 2009 until November 19, 2010 and from January 1, 2011 until March 28, 2016 the Veteran's right knee locked bucket handle medial meniscal tear is evaluated at 20 percent disabling under diagnostic code 5258-5257. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. VA amended the criteria for rating musculoskeletal disabilities effective February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board cannot apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Here, because the periods at issue are prior to the effective date of the amended regulations, the Board will consider the rating criteria for diagnostic code 5257 in effect prior to February 7, 2021. Prior to February 7, 2021, under diagnostic code 5257 a rating of 10 percent is warranted for slight recurrent subluxation or lateral instability. A rating of 20 percent is warranted for moderate recurrent subluxation or lateral instability. A rating of 30 percent is warranted for severe recurrent subluxation or lateral instability. 30 percent is the highest rating under diagnostic code 5257. For the period from May 1, 2017 to June 11, 2021 the Veteran's right knee disability was evaluated with a 30 percent rating under diagnostic code 5055 for total knee arthroplasty. The Veteran's rating was increased to 60 percent, beginning June 11, 2021 and thereafter under diagnostic code 5055. As indicated above, VA amended the criteria for rating musculoskeletal disabilities effective February 7, 2021. Therefore, the Board will evaluate the Veteran's total left knee arthroplasty under the rating criteria for diagnostic code 5055 prior to February 7, 2021 and the amended rating criteria under diagnostic code 5055 beginning February 7, 2021 and thereafter. For the period prior to February 7, 2021 under diagnostic code 5055, a minimum rating of 30 percent is warranted for knee replacement or with intermediate degrees of residual weakness, pain or limitation of motion rated by analogy to diagnostic code 5256, 5261 or 5262; a rating of 60 percent is warranted with chronic residuals consisting of severe painful motion or weakness in the affected extremity; a total disability rating of 100 percent is warranted for one year following implantation of prosthesis. For the period beginning February 7, 2021 and thereafter the minimum rating of 30 percent applies to total knee replacement only with no minimum rating for knee resurfacing. A note to the rating criteria instructs that at the conclusion of the 100 percent evaluation period, resurfacing should be evaluated under diagnostic codes 5256 through 5262. Under diagnostic code 5256 for ankylosis, a rating of 30 percent is warranted if there is evidence of a favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A rating of 40 percent is warranted if there is evidence of extremely unfavorable ankylosis in flexion between 10 degrees and 20 degrees; a rating of 50 percent is warranted if there is evidence of extremely unfavorable amylosis in flexion between 20 and 45 degrees and a rating of 60 percent is warranted if there is evidence of extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more. Prior to February 7, 2021, under diagnostic code 5257 a rating of 10 percent is warranted for slight recurrent subluxation or lateral instability. A rating of 20 percent is warranted for moderate recurrent subluxation or lateral instability. A rating of 30 percent is warranted for severe recurrent subluxation or lateral instability. 30 percent is the highest rating under diagnostic code 5257. Beginning February 7, 2021 and thereafter, under diagnostic code 5257 a A 30 percent rating is warranted for patellar instability involving recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or walker; or recurrent subluxation or instability involving unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes both an assistive device and brace for ambulation. 30 percent is the highest rating under diagnostic code 5257. Under diagnostic code 5258 for dislocation of semilunar cartilage a rating of 20 percent is warranted if there is evidence of dislocated semilunar cartilage with frequent episode of locking, pain, and effusion into the joint. Under diagnostic code 5259 for removal of semilunar cartilage, a rating of 10 percent is warranted if there is evidence that the affected knee is symptomatic. Under diagnostic code 5261 a rating of 10 percent is warranted for extension limited to 10 degrees; a rating of 20 percent is warranted for extension limited to 15 degrees; a rating of 30 percent is warranted for extension limited to 20 degrees; a rating of 40 percent is warranted for extension limited to 30 degrees and a rating of 50 percent is warranted for extension limited to 45 degrees. Prior to February 7, 2021, under diagnostic code 5262 for impairment of the tibia and fibula a rating of 10 percent is warranted if there is evidence of malunion with slight knee or ankle disability; a rating of 20 percent is warranted if there is evidence of malunion with moderate knee or ankle disability; a rating of 30 percent is warranted if there is evidence of malunion with marked knee or ankle disability and a rating of 40 percent is warranted if there is nonunion of the tibia and fibula with loose motion, requiring a brace. Beginning February 7, 2021 and thereafter, under diagnostic code 5262 a noncompensable rating is warranted for treatment less than 12 consecutive months involving one or both lower extremities. A 10 percent rating is warranted for treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities. A 20 percent rating is warranted for treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotic or other conservative treatment, one lower extremity. A 30 percent rating is warranted for treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. Under diagnostic code 5263 for genu recurvatum, a rating of 10 percent is warranted if there is evidence of acquired, traumatic genu recurvatum with weakness and insecurity in weight-bearing object, objectively demonstrated. Analysis By way of history, the Veteran's right knee disability was initially service connected in a March 2000 rating decision with a rating of 10 percent, effective August 28, 1999 for locked bucket handle medial meniscus tear, under diagnostic code 5258-5257. Relevant here, the Veteran filed a claim for an increased rating for his right knee in February 2009. A June 2009 rating decision granted a temporary evaluation from May 1, 2008 to January 1, 2009 and a 20 percent rating beginning January 1, 2009. The Veteran filed a notice of disagreement in August 2009 and a September 2009 rating decision denied an increase in the Veteran's ratings. Following a December 2009 statement of the case the Veteran appealed to the Board with his timely filed Form 9 in March 2010. In November 2010 the Veteran filed a new claim for a temporary total disability rating based on undergoing right knee surgery in November 2010. A January 2013 rating decision granted a temporary total disability rating from November 2010 to January 1, 2011. The Veteran filed a supplemental claim in October 2013 seeking an increased rating for his right knee (his Board appeal was still pending). A May 2016 rating decision granted a total disability rating for the Veteran's right knee under diagnostic code 5055 based on right total knee arthroplasty, effective March 28, 2016 and a 30 percent rating beginning May 1, 2017. A January 2018 Board decision remanded the Veteran's claim for further development. Upon remand, a June 2021 rating decision increased evaluation for the Veteran's right total knee arthroplasty to 60 percent, effective June 11, 2021. Entitlement to a rating in excess of 20 percent for the period from January 1, 2009 to November 19, 2010 for locked bucket handle medial meniscus tear of the right knee. The Veteran contends that he is entitled to a rating in excess of 20 percent for his locked bucket handle medial meniscus tear of the right knee. In a February 2009 statement in support of claim the Veteran reported worsening of his right knee disability. The Veteran was afforded a VA examination for his right knee in April 2009. Subjectively the Veteran reported intermittent symptoms of the bilateral knees. He reported difficulty in long distance walking and knee stiffness after prolonged sitting and driving and in the morning when he wakes up. The Veteran reported that he could not participate in sports or take long walks due in part to his knee pain. He denied any weakness, instability or giving way and denied wearing a brace or other orthotics but noted that he cannot walk or climb stairs without experiencing some pain. The pain was described as sharp, agonizing, severe, continuous throbbing and burning aggravated by lifting, and bending, and constant pressure. The Veteran reported that his pain sometimes improves with lying down and worsens with standing and sitting for long periods of time. The Veteran reported daily flare-ups after excessive ambulation, walking or repeated joint movement. He described flare ups as worsening pain but denied greater limitation of motion and function. Upon examination there was no evidence of abnormal weight bearing, inflammatory arthritis or joint ankylosis. Range of motion included active flexion to 120 degrees against gravity with pain at 120 degrees, passive flexion to 120 degrees with pain at 120 degrees, and flexion to 130 degrees against strong resistance with pain at 130 degrees. There was evidence of pain with active motion, passive motion and after repetitive use. There was no additional loss of motion on repetitive use. The Veteran was able to sit with knee flexed to 90 degrees during the entire exam without obvious discomfort. There was evidence of mild palpable tenderness to the right knee in the medial joint line but no evidence of joint laxity of the knees or ankles and no tenderness or mass in popliteal fossa, no crepitus with maximum flexion of the right knee and no evidence of subluxation, instability or locking. July 2009 VA treatment records note that the Veteran is unable to perform occupations requiring lifting, pushing-pulling more than ten pounds. August 2009 VA treatment records note that the Veteran reported still having a lot of pain, burning and tightness in his hamstring. October 2009 VA treatment records note that the Veteran's right knee continued to demonstrate tenderness to palpation with no significant effusion and well healed surgical scars. The Veteran continued to demonstrate range of motion to 120 degrees with pain, 4/5 hamstring strength with intact sensation, stable varus at 0 and 30 degrees, negative anterior and posterior drawer test, negative Lachman's test, negative McMurray test but the Veteran was unable to pivot shifts 2/2 pain. Ultimately, the preponderance of the probative evidence of record shows that the Veteran has continued to demonstrate flexion to 120 degrees with no evidence of recurrent subluxation, instability, ankylosis or genu recurvatum. The Board has considered the Veteran's lay statements regarding the severity of the Veteran's symptoms and finds that even considering the Veteran's subjective statements a rating in excess of 20 percent is not warranted. The Board has also considered whether higher ratings for the Veteran's right knee disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concluded that such is not warranted. Flexion has been limited to no less than 120 degrees and extension has been limited to no more than 5 degrees. The fact that he may have had pain in range of motion testing does not warrant a higher evaluation. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (discounting the notion that the highest disability ratings are warranted where pain is merely evident as it would lead to potentially absurd results). The evidence shows limitation of motion as described above more closely approximates the evaluation provided by the RO than the higher evaluations sought by the Veteran during the entire period on appeal. The Court has also established that flare-ups must be considered. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Guidance on how to evaluate flare-ups has not been particularly clear. However, the Board finds overall wisdom in Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because there is a regulation addressing stabilization of ratings, the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. VA treatment records note that the Veteran reported having right knee pain resulting in difficulty with climbing stairs, standing for long periods of time, and sitting for long period of time. However, even considering his flare-ups the Veteran has not demonstrated range of motion less than 120 degrees. Further, the VA examination noted no history of recurrent subluxation and no recurrent effusion. The evidence does not substantiate that the Veteran's flare ups warrant a higher rating. For the above reasons, a rating in excess of 20 percent is not warranted for the period from January 1, 2009 to November 19, 2010. As the preponderance of the evidence is against any higher or separate rating, the benefit of the doubt doctrine is not otherwise for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Entitlement to a rating in excess of 20 percent for the period from January 1, 2011 until March 28, 2016 for locked bucket handle medial meniscus tear of the right knee. Similarly, the record does not substantiate entitlement to a rating in excess of 20 percent for the period from January 1, 2011 to March 28, 2016. The Veteran was afforded a new VA examination for his knee in November 2013. The Veteran endorsed flare-ups of pain and reduced motion in both knees. The Veteran reported that he may lose an additional 20 degrees of motion in each knee during a flare up. Range of motion testing demonstrated flexion to 110 degrees with painful motion at 90 degrees, extension to 0 degrees with painful motion at 30 degrees. After repetitive use testing the Veteran demonstrated range of motion to 90 degrees and extension to 0 degrees. The examiner noted additional limitation in range of motion with repetitive use testing. Similarly, the examiner noted that repetitive use resulted in less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, disturbance of locomotion and interference with sitting, standing and weight bearing. The Veteran demonstrated tenderness to palpation but retained 4/5 strength with flexion and extension. Joint stability test was normal and there was no evidence of patellar subluxation or shin splints. The examiner noted the Veteran had a meniscus condition including meniscal tear and frequent episodes of joint pain. The examiner also noted scars measuring less than 6 square inches and the occasional use of a brace. Imaging confirmed degenerative arthritis of the right knee and the examiner noted that as a result of his right knee disability the Veteran is unable to work at a weight bearing job. April 2014 MRI notes mild progression of degenerative changes of the right knee. A June 2014 MRI of the right knee notes postoperative changes of medial meniscus restriction, tear of the posterior horn of the lateral meniscus, articular cartilage defects in the femur, chondromalacia of the patella and extensive tricompartmental degenerative changes with subchondral cysts and osteophytosis. The Veteran was afforded another VA examination in July 2014. Subjectively the Veteran described flare ups of his right knee condition with changes in weather, prolonged weight bearing, and exertional activity. The flare ups result in painful weight bearing for the rest of the day or up to two days. The Veteran reported experiencing further reduced range of motion of approximately 2 degrees during flare ups. Upon examination the Veteran demonstrated forward flexion to 125 degrees with pain at 90 degrees; extension to 0 degrees with pain at 25 degrees. Following repetitive use testing the Veteran demonstrated flexion to 90 degrees and extension to 0 degrees. The Veteran was noted to have functional loss after repetitive use testing. Contributing factors included less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, disturbance of locomotion and interference with sitting. There was evidence of tenderness and pain on palpation, but the Veteran retained 4/5 muscle strength with flexion and extension. Joint stability was normal. There was no evidence of subluxation or shin splints. However, the Veteran was noted to have a meniscal condition with meniscal tear and frequent episodes of locking. Residual signs and symptoms of the meniscal condition included limitation in range of motion and pain with accelerated degenerative changes. The Veteran's scars were less than 6 square inches, and the Veteran continued to require the occasional use of a brace. Ultimately, for the period from January 1, 2011 to March 28, 2016 the record does not establish entitlement to a rating in excess of 20 percent for subluxation and instability. The Veteran demonstrated range of motion no less than 90 degrees, even with pain and functional loss. During his VA examination there was no evidence of instability and the Veteran maintained 4/5 strength in his knee. The Board has also considered whether higher ratings for the Veteran's right knee disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concluded that such is not warranted. Flexion has been limited to no less than 90 degrees and extension has been limited to no more than 5 degrees. The fact that he may have had pain in range of motion testing does not warrant a higher evaluation. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (discounting the notion that the highest disability ratings are warranted where pain is merely evident as it would lead to potentially absurd results). The evidence shows limitation of motion as described above more closely approximates the evaluation provided by the RO than the higher evaluations sought by the Veteran during the entire period on appeal. Additionally, the Board has considered the Veteran's flare-ups. Sharp, 29 Vet. App. 26. Even considering the Veteran's flare-ups and associated pain and reduced range of motion the Veteran's disability does not warrant a higher rating as his symptoms do not result in more than moderate instability. Entitlement to a rating in excess of 30 percent for the period from May 1, 2017 until June 11, 2021 for right total knee arthroplasty. May 2017 VA treatment records note that the Veteran continued to report right knee pain. He also continued to feel weakness. The Veteran was advised that this was normal. The Veteran reported that as a result of his knees he has difficulty going up stairs and reported falling once within the last year. A physical exam noted some tenderness over the joint line and slightly decreased full flexion but 5/5 strength of the lower extremity. May 2017 imaging noted intact total knee components, no fracture or dislocation and no loose bodies. September 2017 VA treatment records note that the Veteran reported that his knee was more stable, but he was experiencing more pain. He also reported that he has to limit his biking and walking to 20 minutes; does half a mile in 20 minutes walking. The Veteran expressed frustration that he often needs to stop exercising within 15 minutes due to pain. In October 2017 the Veteran reported that he no longer uses the gym due to pain and tries to do lower intensity exercises such as walking. Subsequent VA treatment records continue to note symptoms of pain. However, there is no evidence of worsening symptoms or increased instability of the knee. The Veteran was afforded a VA examination for his knee in May 2019. The examiner noted a diagnosis of degenerative arthritis and right knee replacement. Subjectively the Veteran reported weakness and pain down the right knee. The Veteran reported flare ups with symptoms of decreased mobility one to two times a week lasting three to four days. He rated his pain as a 9/10 on the first day with decreased pain thereafter. The Veteran also reported that he cannot exercise or workout. The Veteran demonstrated flexion to 120 degrees and extension to 10 degrees. No pain was noted on examination. The Veteran was able to perform repetitive use testing with no additional loss of range of motion, however pain, weakness, and lack of endurance were noted to significantly limit functional ability with repeated use over a period of time and with flare ups. The Veteran maintained 4/5 muscle strength with flexion and extension but there was evidence of muscle atrophy of the quadriceps. There was no evidence of ankylosis or recurrent subluxation. The examiner noted no history of lateral instability or recurrent effusion. Right knee joint stability testing was not performed, but the Veteran was noted to have a history of meniscal tear. Ultimately, based on the evidence of record which shows ongoing symptoms of pain and weakness but 4/5 muscle strength and flexion to 120 degrees, no evidence of severe painful motion and no evidence of severe weakness, the preponderance of the probative evidence of record does not establish entitlement to a rating in excess of 30 percent during the period at issue under any applicable diagnostic code. In rendering this decision, the Board has considered all applicable diagnostic codes prior to February 7, 2021 as well as the amended diagnostic codes effective February 7, 2021 and thereafter. The Board has also considered whether higher ratings for the Veteran's right knee disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concluded that such is not warranted. Flexion has been limited to no less than 120 degrees and extension has been limited to no more than 10 degrees. The fact that he may have had pain in range of motion testing does not warrant a higher evaluation. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (discounting the notion that the highest disability ratings are warranted where pain is merely evident as it would lead to potentially absurd results). The evidence shows symptoms as described above more closely approximates the evaluation provided by the RO than the higher evaluations sought by the Veteran during the entire period on appeal. Additionally, the Board has considered the Veteran's flare-ups. Sharp, 29 Vet. App. 26. Even considering the Veteran's flare-ups and associated pain and reduced range of motion the Veteran's disability does not warrant a higher rating as his symptoms do not result in additional loss of range of motion, instability, or greater functional loss. Entitlement to a rating in excess of 30 percent for the period from May 1, 2017 to June 11, 2021 is not warranted. Entitlement to a rating in excess of 60 percent for the period beginning June 11, 2021 and thereafter for right total knee arthroplasty. The Veteran was afforded a VA examination for his right knee in June 2021. The examiner noted degenerative arthritis of the knee and right total knee arthroplasty. Subjectively, the Veteran reported that he continues to suffer from chronic constant pain of the right knee with worsening stiffness with changes of weather, after use of stairs or prolonged weight bearing. He also described morning stiffness. The Veteran did not report flare-ups, but reported functional loss including an inability to run or do cardio. No history of arthropathy or frequent effusion of the knee. The Veteran demonstrated range of motion to 125 degrees and extension to zero degrees. The right knee was noted to have constant pain at 6/10 severity with pain increasing after walking a quarter mile. There was evidence of pain with active motion and pain caused functional loss. There was no objective evidence of crepitus and no objective evidence of pain or tenderness on palpation. The Veteran was able to perform repetitive use testing, with flexion to 115 degrees and extension to zero, pain was noted to cause functional loss. The examiner estimated flexion to 100 degrees immediately after repeated use over time. There was no evidence of muscle atrophy, ankylosis, subluxation or persistent instability but the Veteran was noted to have a history of medial meniscus tear. Ultimately the preponderance of the probative evidence does not establish entitlement to a rating in excess of 60 percent for the Veteran's right knee disability beginning June 11, 2021 and thereafter. While the Veteran continued to report symptoms of pain there is no evidence of instability, subluxation, atrophy or ankylosis and no evidence of range of motion less than 100 degrees. During his exam the Veteran denied flare-ups and the severity, and intensity of the Veteran's symptoms does not more nearly approximate a higher rating under any diagnostic code (including the diagnostic codes as written prior to February 7, 2021 or the amended diagnostic codes effective February 7, 2021 and thereafter). The Board additionally notes that this is the highest rating available under the current diagnostic code utilized post-status knee replacement. (Continued on the next page) Entitlement to a rating in excess of 60 percent is denied. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Wimbish, 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.