Citation Nr: 21066929 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 09-23 337A DATE: November 2, 2021 ORDER Entitlement to increases in the staged (10 percent prior to June 6, 2012 and 30 percent from June 6, 2013) ratings for a left knee disability is denied. FINDINGS OF FACT 1. Before June 6, 2012, the Veteran's left knee disability, status post meniscectomy, with arthritis was manifested by chronic pain, effusion, and limited range of motion (flexion to 90 degrees and extension to 0 degrees, with consideration of limitations due to pain and any weakened movement, excessive fatigability with use, or incoordination including during repeated use over time and flare-ups); there was no ankylosis, evidence of recurrent subluxation or lateral instability, or cartilage impairment manifested by frequent episodes of locking, pain, and effusion into the joint. 2. From June 6, 2013, the Veteran's left knee disability, status post partial knee replacement, gas been manifested by chronic pain, weakness, and limited range of motion (flexion to 120 degrees and extension to 0 degrees, with consideration of limitations due to pain and any weakened movement, excessive fatigability with use, or incoordination including during repeated use over time and flare-ups); there was no severe painful motion or weakness, ankylosis, evidence of recurrent subluxation or lateral instability, or cartilage impairment manifested by frequent episodes of locking, pain, and effusion into the joint. CONCLUSION OF LAW Increases in the staged (10 percent prior to June 6, 2012 and 30 percent from June 6, 2013) ratings for a left knee disability are not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Codes 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSION The appellant is a Veteran who served on active duty from January 1974 to January 1981 and from July 1985 to May 1989, and who also had periods of active duty for training in the National Guard. This case comes to the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of a Department of Veterans Affairs (VA), which denied a rating in excess of 10 percent for a left knee disability with degenerative changes. In October 2012, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development. An August 2013 rating decision granted a temporary total (100 percent) schedular rating for the left knee disability based on surgery necessitating convalescence under 38 C.F.R. § 4.30 from June 6, 2012 through July 2012. A January 2017 Board decision denied a rating in excess of 10 percent prior to June 6, 2012, granted a 100 percent rating from June 6, 2012, to June 6, 2013 (under Code 5055, for partial knee replacement), and granted a 30 percent rating (and no higher) from June 6, 2013. The Veteran appealed the Board's decision, in part, to the United States Court of Appeal for Veterans Claims (CAVC). A June 2017 CAVC Order granted a June 2017 Joint Motion for Partial Remand (JMPR), thereby vacating the Board's decision in part (as to the denial of higher ratings prior to June 6, 2012 and from June 6, 2013) and remanding the matter to the Board for action consistent with the terms of the JMPR. In October 2017, November 2018, and July 2020, the Board remanded the case to the AOJ for additional development. Entitlement to increases in the staged (10 percent prior to June 6, 2012 and 30 percent from June 6, 2013) ratings for a left knee disability Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). For the period considered in this appeal, the Veteran's left knee disability was rated 10 percent before June 6, 2021 under 38 C.F.R. § 4.71a, Code 5010, and 30 percent from June 6, 2013 under 38 C.F.R. § 4.71a, Codes 5010-5055. The issue before the Board is whether he is entitled to higher ratings for the knee disability. Under 38 C.F.R. § 4.71a, Code 5010, arthritis due to trauma, substantiated by X-ray findings, is rated based on degenerative arthritis. Under Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined not added under Code 5003; limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Limitation of flexion of the leg to 60 degrees is rated as 0 percent disabling; flexion limited to 45 degrees is rated as 10 percent disabling; flexion limited to 30 degrees is rated as 20 percent disabling; and flexion limited to 15 degrees is rated as a maximum 30 percent disabling. 38 C.F.R. § 4.71a, Code 5260. Limitation of extension of the leg to 5 degrees is rated as 0 percent disabling; extension limited to 10 degrees is rated as 10 percent disabling; extension limited to 15 degrees is rated as 20 percent disabling; extension limited to 20 degrees is rated as 30 percent disabling; extension limited to 30 degrees is rated as 40 percent disabling; and extension limited to 45 degrees is rated as a maximum 50 percent disabling. 38 C.F.R. § 4.71a, Code 5261. Normal or full range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the CAVC held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Knee replacement (prosthesis) is rated under Code 5055. A 100 percent rating is to be assigned for 1 year following implantation of prosthesis. Following expiration of the 1-year period, a 30 percent rating is the minimum rating to be assigned for residuals. A (maximum) 60 percent rating is warranted for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Codes 5256 (for ankylosis), 5261 (for limitation of extension), or 5262 (for impairment of the tibia and fibula). 38 C.F.R. § 4.71a. Other impairment of the knee manifested by recurrent subluxation or lateral instability warrants a 10 percent rating if slight, 20 percent rating if moderate, and a maximum 30 percent rating if severe. 38 C.F.R. § 4.71a, Code 5257. Separate ratings may be assigned for arthritis with limitation of motion of a knee under Codes 5003-5010 and for instability of the knee under Code 5257. VAOPGCPREC 23-97 (July 1, 1997). Separate ratings for each knee joint may also be assigned for both limitation of flexion and limitation of extension. VAOPGCPREC 9-04 (September 17, 2004). Other applicable criteria pertain to cartilage impairment. Semilunar, dislocated cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a 20 percent rating. 38 C.F.R. § 4.71a, Code 5258. Removal of semilunar cartilage that is symptomatic warrants a 10 percent rating. 38 C.F.R. § 4.71a, Code 5259. Consideration of other diagnostic codes for rating knee disability (5256, 5262, 5263) is not warranted here because the Veteran's left knee disability is not shown to have included the pathology or impairment required in the criteria in those Codes (specifically, ankylosis, malunion or nonunion of tibia or fibula with varying degrees of knee disability, or genu recurvatum). 38 C.F.R. § 4.71a. During the pendency of the appeal, the schedular rating criteria for evaluating disabilities of the musculoskeletal system under 38 C.F.R. § 4.71a, including the knee, were amended, effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 (to the extent that it is applicable) and both the old and new rating criteria from February 7, 2021 (to the extent that it is applicable). The pertinent revisions involve changes to Code 5003, 5010, and 5257. Under revised Code 5003, degenerative arthritis, other than post-traumatic, the criteria remain the same. Under revised Code 5010, post-traumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under the affected joint; and if there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Under revised Code 5257, for recurrent subluxation or lateral instability, a 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for sprain, incomplete ligament tear, or repaired ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane, crutch, walker) for ambulation; or, unrepaired or failed repair of complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. A 30 percent (maximum) rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Additionally, under revised Code 5257, for patellar instability, a diagnosed condition involving the patellofemoral complex (consisting of the quadriceps tendon, the patella, and the patellar tendon) with recurrent instability warrants the following: a 10 percent rating (with or without history of surgical repair) where it does not require a prescription from a medical provider for a brace, cane, or walker; a 20 percent rating after surgical repair where it requires a prescription by a medical provider for a brace, cane, or walker; and a 30 percent rating after surgical repair where it requires a prescription by a medical provider for a brace and either a cane or a walker. To qualify as a "surgical repair" for patellar instability, the procedure must involve repair of one or more patellofemoral components that contribute to the underlying instability (e.g., arthroscopy to remove loose bodies and joint aspiration are not qualifying surgical procedures). After applying the governing law to the relevant facts in the record, the Board finds the following: ratings higher than 10 percent before June 6, 2012 and higher than 30 percent from June 6, 2013 for the left knee disability are not warranted. Before June 6, 2012 As the Veteran filed a claim for an increased rating for his left knee in September 2007 (and not June 2007, which the AOJ erroneously believed), the evaluation period for consideration encompasses a one-year "look-back" period beginning in September 2006. 38 C.F.R. § 3.400(o)(2). For this period, the knee was evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Code 5010, for painful limitation of motion to a degree not compensable under Codes 5260 and 5261. (Originally, when service connection was established by an August 1994 rating decision, the left knee disability was evaluated under Codes 5257-5010, apparently by analogy given that there was no subluxation or instability; after a November 2005 rating decision, his knee was "re-coded" under only Code 5010.) Medical records show that previously the Veteran had undergone an abrasion arthroplasty and partial medial meniscectomy in September 2001, and on June 6, 2012, he underwent further knee surgery (a partial knee replacement). Between these surgeries, the Veteran filed his claim for an increased rating. The evidence for the period on appeal (from September 2006 to June 6, 2012) consists of VA and private medical records and the statements and testimony (in August 2012) of the Veteran. He underwent VA examinations in October 2007 and December 2011 to assess the nature and severity of his knee disability. His symptom complaints during this period were painful range of motion, swelling, stiffness, and giving way (instability). VA outpatient records in 2007 show that he received injections in the knee joint for osteoarthritis and pain. A July 2007 record notes he wore a knee brace, and on evaluation in July 2007 and December 2007 the knee was non-tender and not swollen. The Veteran thereafter lodged continuing complaints of left knee pain with the VA, especially with prolonged standing and walking, including in December 2007, March 2008, July 2008, June 2009, January 2011, October 2011, and January 2012. He testified at an August 2012 Board hearing that before his June 2012 knee surgery, he regularly received cortisone injections, his range of motion was fairly good but painful (especially with weight-bearing), his knee had given out on him, and his knee would swell up if he stood for long periods (he wore an elastic brace). In applying the limitation-of-motion codes to the evidence, it is clear that the Veteran's greatest left knee limitation of flexion to 90 degrees does not meet the criteria for even a compensable rating under Code 5260. Further, his left knee extension was to 0 degrees, which also fails to satisfy the criteria for a compensable rating under Code 5261. VA outpatient records show range of motion of 0 to 90 degrees on numerous occasions (in December 2007, September 2008, December 2008, October 2009, March and June 2010, May 2011, September 2011, and January 2012) and of 0 to 100 degrees on other occasions (in April 2008, October 2008, January/February 2009, June 2009, January 2010, October 2010, and March 2011). As shown on the VA examination in October 2007, range of motion was 0 to 120 degrees, without evidence of pain or additional limitations on repetitive testing. On VA examination in December 2011, range of motion was 0 to 115 degrees (including after repetitive use testing), with pain beginning at 105 degrees of flexion. Therefore, the Veteran's currently assigned 10 percent rating, which is warranted based on arthritis with painful limitation of motion (where the motion limitation is noncompensable under Codes 5260 and 5261), is appropriate, and a higher rating is not warranted. The Veteran's knee pain is a principal symptom of his left knee disability, but the objective findings as discussed above do not show that pain actually limited knee motion to the extent that he would meet the criteria for either a compensable rating under both Codes 5260 and 5261 or for a 20 percent rating under Code 5261 or 5261. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The VA examiners in 2007 and 2011, collectively, noted the Veteran's complaints such as pain of the knee and, when observed, remarked on how pain (and any fatigue, weakness, lack of endurance, or incoordination) affected range of motion, including on observed repetitive use and during any repetitive use over time and flare-ups. (The Veteran did not endorse flare-ups.) However, the maximum restrictions on flexion and extension still did not meet the criteria for a compensable rating. Thus, the assignment of a disability rating has considered not only the Veteran's demonstrated range of motion on physical examination of the knee, but also his functional loss due to pain (or weakness, fatigability, incoordination, or pain on movement) on repeated use over time and during flare-ups (which were denied). Even with consideration of 38 C.F.R. §§ 4.40 and 4.45 and DeLuca, the record does not present a basis for the assignment of a higher rating for the left knee under the limitation-of-motion codes. Considering the criteria under (old) Code 5257, the evidence does not show that his left knee disability was manifested by recurrent subluxation or lateral instability. The evidence reflects that he wore a knee brace, but there is no evidence of instability (or that the purpose of the brace was for instability). On VA examination in October 2007, the Veteran reported giving way and instability, but the examiner found no instability or patellar abnormality. Similarly, on VA examination in December 2011, instability testing was normal. Other VA records show that on regular clinic visits, testing consistently demonstrated no instability, such as in December 2007 (when he denied any giving way), April 2008, September 2008, October 2008, December 2008, January/February 2009, June 2009, October 2009, January 2010, March and June 2010, January 2011, May 2011, June 2011, and January 2012. A May 2012 private record also noted that his knee was stable on testing. Once, a VA surgeon in October 2011 indicated his knee had "grade I Lachman's," suggesting self-sensed instability. Nonetheless, nearly all knee evaluations throughout the appeal period establish that there was no subluxation or instability of the left knee joint. Thus, a separate 10 percent rating under this code is not warranted. The Board turns to the criteria pertaining to cartilage impairment under Codes 5258 and 5259. The Veteran's left knee disability includes a meniscal tear for which he underwent surgical repair in 2001. Thereafter, medical evidence indicates he experienced continual pain in the joint, as well as swelling at times, and he received injections/cortisone shots over much of the appeal period. The VA examiners acknowledged such pain and swelling in light of his diagnosis of osteoarthritis. They did not relate the Veteran's symptoms to his meniscus condition and in fact reported that there were no residuals of meniscal surgery. Rather, the Veteran's currently assigned 10 percent rating was based on limitation of motion of the knee joint (noncompensable under Codes 5260 and 5261), objectively confirmed by findings such as swelling and satisfactory evidence of painful motion, under Code 5010. Thus, it is not shown that his postoperative cartilage disability was symptomatic. Even if his symptoms of pain and swelling could be attributed to a meniscal condition, they would not be deemed separate and distinct from those symptoms evaluated under Codes 5010, 5260, and 5261 for arthritis with painful limitation of motion. This is a significant distinction because the assignment of an additional rating under a different code is prohibited where the symptoms are duplicative or overlapping. See 38 C.F.R. § 4.14 (evaluation of the same manifestation under different diagnoses is to be avoided). The Veteran has limitation of motion, due to pain and swelling, which is noncompensable under Codes 5260 and 5261, and evaluating him separately (with a 10 percent rating) under Code 5259 for symptoms of joint pain and swelling due to cartilage impairment would be duplicative and therefore prohibited. Moreover, granting a higher, or separate, rating of 20 percent under Code 5258 is not warranted because the cartilage was not shown to be dislocated with evidence of frequent episodes of pain, "locking," and effusion into the joint. When assessing a meniscal condition, the examiners noted pain on McMurray testing (indicative of meniscal pathology) and crepitus on range of motion testing. Nevertheless, while there are numerous instances of effusion in the joint, recurrent locking was not observed (Veteran specifically denied it on the 2007 VA examination and a VA clinic visit in December 2007). The Board has considered the Veteran's various symptom complaints, to include weakness, stiffness, swelling, giving way/instability, pain on movement, excess fatigability, and interference with sitting, standing, and weight-bearing (see, e.g., his annotations of the May 2009 statement of the case). The Board acknowledges the Veteran's competence to report, on examinations and treatment, such symptoms and how his knee disability has affected his ability to work and his quality of life. He is competent to describe such symptoms, see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of personal knowledge), but he is not competent to state that they are indicative of subluxation, instability, or meniscal injury, as is contemplated by the relevant rating criteria, or to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of his knee disability has been provided by the medical personnel who examined him during the current appeal and who rendered pertinent opinions in conjunction with the evaluations. The medical findings, as provided in the examination reports and in the clinical treatment records, address the applicable criteria under which the Veteran's disability is rated. The Board finds these records to be more probative than the Veteran's subjective and inadequate (for rating purposes) reports of increased symptomatology. The Board observes further that the Veteran's opinions and observations alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a, with respect to determining the severity of his knee disability. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); see also 38 C.F.R. § 3.159(a)(1) and (2). Determining the severity of the disability is a medical question that must be addressed by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). As discussed above, the Board finds that before June 6, 2012, the preponderance of the evidence is against a rating higher than 10 percent. From June 6, 2013 The Veteran underwent a partial knee replacement surgery (left knee medial compartment arthroplasty with implantation of prosthesis) on June 6, 2012, and his left knee was evaluated 100 percent disabling under Code 5055 beginning on that date and continuing for one year. Following this one-year period, the knee was rated at the minimum (30 percent) rating under Code 5055. The evidence from June 6, 2013 does not support that a rating higher than 30 percent for his left knee residuals was warranted. That is, the left knee residuals are not manifested by severe painful motion or weakness for a maximum 60 percent rating, nor are they manifested by a degree of weakness, pain, or limitation of motion that approximates criteria for a rating between 30 percent and 60 percent. Relative to severe painful motion or weakness, the evidence does not show that his knee residuals are characterized by chronically severe weakness or painful movement. For example, on the December 2013 VA examination, he reported mild pain after being on his feet for most of a 10-12-hour day, and denied increased muscle fatigue and could ascend/descend inclines without pain (the examiner assessed him with minimal fatigue and minimal difficulty due to pain following surgery). On the August 2018 VA examination, the Veteran reported sharp stabbing pain when walking, dull pain when weather was bad, and flare-ups of moderate severity once a week. Pain was noted on examination on range of motion and muscle strength was 5/5 (normal). The Veteran did not use an assistive device. The examiner concluded that there was a residual of painful motion particularly during increased activity or a change in weather, but that the knee impairment was at a moderate (not severe) degree. On the October 2019 VA examination, the Veteran reported that it seemed his left knee just kept getting worse, but there was no pain noted on the examination, and muscle strength was 5/5. On the August 2021 VA examination, the Veteran reported he had pain in both knees on a daily basis (he did not characterize the pain as severe) and difficulty ambulating or standing for extended periods of time. Yet, there was no pain noted on range of motion, and there was no muscle atrophy observed. Fatigability and lack of endurance (but not weakness) were factors noted to cause functional loss with repeated use of the knee over time, yet he did not use any assistive devices (as would be expected if there was severe painful motion or weakness). Private treatment records (from Wake Forest Baptist Medical Center) are consistent with the depiction of the left knee disability on VA examinations. A July 2013 evaluation of the knee showed it was "excellent" with range of motion (flexion) accomplished with very little difficulty. In October 2013, the Veteran denied knee pain. In October 2014, it was noted the Veteran's knee was doing well; he denied any knee pain and was able to walk without any difficulty. On an October 2015 clinic visit, the Veteran's knee was not giving him any trouble. In January 2018, the Veteran denied any trouble with his knee, reporting that his pain was significantly decreased as compared to the pre-operative period (before June 2012). VA outpatient treatment records briefly note complaints of pain or stiffness in the knees (along with other joints) in July 2019 and June 2020. In light of the foregoing evidence, the Board finds that the Veteran's left knee disability is not manifested by chronic postoperative residuals that approximate severe weakness or severe painful movement. In applying the limitation-of-motion codes to the evidence, it is clear that the Veteran's left knee limitations of flexion and extension do not meet the criteria for even a compensable rating under Codes 5260 or 5261. At no time, for example, was it shown on VA examinations in December 2013, August 2018, October 2019, and August 2021 that his left knee had limitation of flexion that approximated 45 degrees or limitation of extension that approximated 10 degrees. His knee range of motion was the following: 0 to 120 degrees in 2013; 0 to 140 degrees in 2018; 0 to 125 degrees in 2019; and 0 to 140 degrees in 2021. For his knee to warrant a rating higher than 30 percent under a code based on limitation of motion, the knee would need to exhibit extremely unfavorable ankylosis (under Code 5256), which is clearly not shown by the evidence or indicated by any VA examiner. Otherwise, there would have to be extension limited to 30 degrees, or some combination of limitation of extension and flexion where the ratings under Codes 5260 and 5261, when combined (under 38 C.F.R. § 4.25), would exceed 30 percent. Here, the Veteran's knee limitations simply do not approximate the criteria for a higher rating under those Codes. The Veteran's left knee pain is a principal symptom of his knee disability, but the objective findings as discussed above do not show that pain actually limited knee motion to the extent that he would meet the criteria for a rating in excess of 30 percent under Codes 5260 and/or 5261. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The VA examiners in 2013, 2018, 2019, and 2021, collectively, noted the Veteran's various complaints such as pain of the knee and, when observed, remarked on how pain (and any fatigue, weakness, lack of endurance, or incoordination) affected range of motion, including on observed repetitive use and during any repetitive use over time and flare-ups. None of the findings remotely suggested knee limitation of motion that would satisfy criteria for a 40 percent (or higher) rating. For example, the 2019 VA examiner noted the Veteran's report of an increase in pain during flare-ups without a change in his range of motion. The parties to the JMPR of June 2017 noted deficiencies in the 2013 VA examinations (pursuant to 38 C.F.R. § 4.59 and Correia v. McDonald, 28 Vet. App. 158 (2016)), and the Board remanded the case in October 2017, November 2018, and July 2020 to address them. On examination in August 2021, by an examiner different from those who previously conducted an examination, the Veteran's range of motion was found to be normal (0 to 140 degrees) in all aspects, including on flare-ups (which were denied) and on repeated use over time (for which the examiner provided an estimate). Thus, the assignment of a disability rating has considered not only the Veteran's demonstrated range of motion on physical examination of the knee, but also his functional loss due to pain (or weakness, fatigability, incoordination, or pain on movement) on repeated use over time and during flare-ups. Even with consideration of 38 C.F.R. §§ 4.40 and 4.45 and DeLuca, the record does not present a basis for the assignment of a higher rating for the left knee under the limitation of motion codes. The current evaluation of the Veteran's left knee disability under Codes 5010-5055 does not specifically contemplate residual manifestations of either instability or cartilage impairment. Further, the criteria for each such Code (5257, 5258, and 5259) do not provide a rating in excess of 30 percent. Given the potential for multiple, separate ratings that may combine for a rating higher than 30 percent, such criteria will be considered. In reviewing the criteria under old and revised Code 5257, the evidence does not show that the Veteran's left knee disability was manifested by recurrent subluxation or lateral instability. With the exception of the VA examiner in August 2018, who determined there was slight medial and lateral instability on testing, his knee joint was stable. The Veteran did not complain of instability on VA examinations in 2013, 2019, and 2021, nor was any knee instability noted. The examiners also noted that he did not use any assistive devices for ambulation. The single finding of slight instability on the 2018 VA examination was an isolated finding. Thus, on longitudinal review, the Veteran would not warrant a compensable rating under old Code 5257. Regarding the revised criteria, there was no evidence of a sprain or ligamentous tear causing persistent instability, or a diagnosed condition involving the patellofemoral complex. Thus, a separate 10 percent rating under this code (both old and revised) is not warranted. In reviewing the criteria pertaining to cartilage impairment under Codes 5258 and 5259, the Veteran's knee history includes a meniscectomy. The VA examiners found no residual meniscal symptoms, with one exception. The August 2018 examiner's concluding remarks indicated there was dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion in the joint, but such findings were not explicitly documented earlier in the report (in the section relating to meniscal conditions). Moreover, other medical records do not reflect that he experienced frequent episodes of locking, pain, and effusion. As the examiner's concluding remarks in this regard are internally inconsistent and inconsistent with other evidence, they are suspect and unreliable. In any case, the Veteran is already assigned the (minimum) rating of 30 percent under Code 5055, which is based on residual weakness, pain, and limitation of motion, and it would be pyramiding to assign an additional rating based on pain under Code 5258 or 5259. The assignment of an additional rating under a different code is prohibited where the symptoms are duplicative or overlapping. See 38 C.F.R. § 4.14. Therefore, the Board finds that a separate rating under Code 5258 or 5259 is not appropriate given the facts in this case. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Board also notes that VA examiners in 2019 and 2021 found objective evidence of crepitus, in connection with range of motion testing. This audible sound is a sign indicating the rubbing together of the dry synovial surfaces of joints (see Dorland's Illustrated Medical Dictionary 429 (32nd ed. 2012)). It is not shown to be a disabling symptom or even a residual of the meniscectomy. The Board has considered the Veteran's complaints, primarily regarding knee pain. Although he is competent to describe such symptoms, see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of personal knowledge), he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of his knee disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered opinions in consideration of his complaints of pain and in conjunction with the evaluations. The medical findings, as provided in the examination reports and in the clinical treatment records, address the applicable criteria under which the Veteran's disability is rated. The Board finds these records to be more probative than the Veteran's allegation that his knee symptoms are sufficiently disabling to afford him a rating higher than 30 percent. The Board observes further that the Veteran's opinions and observations alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a, with respect to determining the severity of his knee disability. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); see also 38 C.F.R. § 3.159(a)(1) and (2). Determining the severity of the disability is a medical question that must be addressed by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). As discussed above, the competent medical evidence of record does not support a rating higher than currently assigned. George R. Senyk Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debbie Breitbeil, 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.