Citation Nr: 21069339 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 15-30 929 DATE: November 18, 2021 ORDER Entitlement to a 10 percent rating for pulmonary sarcoidosis to include residuals of recurrent pneumonia is granted. Entitlement to a rating in excess of 10 percent for joint pain, right knee, to include consideration of an extraschedular rating, is denied. Entitlement to a rating in excess of 10 percent for joint paint, left knee, to include consideration of an extraschedular rating, is denied. Entitlement to a separate 10 percent rating for instability, right knee, is granted. Entitlement to a separate 10 percent rating for instability, left knee, is granted. FINDINGS OF FACT 1. The evidence of record indicates that, throughout the appellate period, the Veteran's pulmonary sarcoidosis results in pulmonary function testing (PFT) results were within the range of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent. 2. Throughout the appellate period, the preponderance of the evidence reveals that the Veteran's joint pain, right knee, results in painful flexion to, at worst, 60 degrees. 3. Throughout the appellate period, the preponderance of the evidence reveals that the Veteran's joint pain, left knee, results in painful flexion to, at worst, 80 degrees. 4. The evidence of record indicates that, throughout the appellate period, the Veteran's right knee manifests slight instability. 5. The evidence of record indicates that, throughout the appellate period, the Veteran's left knee manifests slight instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 10 percent rating, but no higher, for pulmonary sarcoidosis to include residuals of recurrent pneumonia have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.96, 4.97, Diagnostic Code (DC) 6846-6600. 2. The criteria for entitlement to a rating in excess of 10 percent for joint pain, right knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 8852-5260. 3. The criteria for entitlement to a rating in excess of 10 percent for joint paint, left knee, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 8852-5260. 4. The criteria for entitlement to a separate 10 percent rating for instability, right knee, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5257. 5. The criteria for entitlement to a separate 10 percent rating for instability, left knee, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1998 to November 2002. The matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in May 2020 for further development by the RO. The case has been returned to the Board for further appellate action. The Board finds that there was substantial compliance with the Board's remand directives of May 2020. See Stegall v. West, 11 Vet. App. 268 (1998). The May 2020 Board remand directed the agency of original jurisdiction (AOJ) to obtain VA examinations for the Veteran's claimed knee and respiratory disabilities. The record shows that in August 2021 the AOJ obtained VA examinations for the Veteran's respiratory and bilateral knee disabilities and that the examination reports contain adequate information to adjudicate the respective claims. Therefore, the Board will proceed to adjudicate the claims. Increased Rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained 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. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 the facts found, a practice known as 'staged ratings.' Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. 38 C.F.R. § 4.27. 1. Entitlement to a 10 percent rating for pulmonary sarcoidosis to include residuals of recurrent pneumonia The Veteran's pulmonary sarcoidosis to include residuals of recurrent pneumonia is rated under DC 6846-6600. 38 C.F.R. § 4.97. DC 6846, for sarcoidosis, provides that a noncompensable rating will be assigned when the evidence of record shows sarcoidosis with chronic hilar adenopathy or stable lung infiltrates without symptoms or physiologic impairment. A 30 percent rating will be assigned upon a showing of sarcoidosis with pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids. A 60 percent rating will be assigned when the evidence of record shows sarcoidosis with pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control. Finally, a 100 percent rating will be assigned when the evidence of record shows sarcoidosis with cor pulmonale or cardiac involvement with congestive heart failure, or progressive pulmonary disease with fever, night sweats, and weight loss despite treatment. 38 C.F.R. § 4.97, DC 6846. Sarcoidosis may be rated based upon the active disease or residuals of chronic bronchitis as set forth in DC 6600, or as extra-pulmonary involvement under the specific body system involved. 38 C.F.R. § 4.97, DC 6846. DC 6600, for chronic bronchitis, provides that FEV-1 of 71 to 80 percent predicted, or the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 71 to 80 percent, or Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO) of 66 to 80 percent predicted warrants a 10 percent rating. A FEV-1 of 56 to 70 percent predicted, or FEV-1/FVC of 56 to 70 percent, or DLCO of 56 to 65 percent predicted warrants a 30 percent rating. A FEV-1 of 40 to 55 percent predicted, FEV-1/FVC of 40 to 55 percent, DLCO of 40 to 55 percent predicted, or maximum oxygen consumption of 15 to 20 ml/kg/min warrants a 60 percent rating. A FEV-1 less than 40 percent of predicted value, FEV-1/FVC less than 40 percent, DLCO less than 40 percent predicted, maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), cor pulmonale (right heart failure), right ventricular hypertrophy, pulmonary hypertension (shown by Echo or cardiac catheterization), episodes of acute respiratory failure, or outpatient oxygen therapy warrants a 100 percent rating. 38 C.F.R. § 4.97, DC 6600. If the DLCO test is not of record, VA is to rate based on alternative criteria as long as the examiner states why the test would not be useful or valid in a particular case. 38 C.F.R. § 4.96. VA is to use post-bronchodilator pulmonary function testing (PFT) results for rating purposes unless the post-bronchodilator results were poorer than the pre-bronchodilator results. Id. When the PFT results are not consistent with clinical findings, VA is still to evaluate based on the PFT results unless the examiner states why they are not a valid indication of respiratory functional impairment in a particular case. Id. Factual background and legal analysis The Veteran underwent a VA examination in May 2013. The Veteran reported sharp, stabbing pains, and dyspnea on exertion with stairs. Regarding treatment, the examiner noted that no oral or parenteral corticosteroid medications; inhaled medications; oral bronchodilators, antibiotics; or outpatient oxygen therapy were required. Sarcoidosis findings included: hilar adenopathy, stable lung infiltrates, and pulmonary involvement. The condition was noted to be at stage two, bihilar lymphadenopathy and reticulonodular infiltrates. Other organ systems were noted to be involved; the Veteran is already service connected for liver dysfunction associated with pulmonary sarcoidosis under DC 7345, and this issue is not before the Board at this time. See also December 2013 rating decision. Regarding bacterial infection findings, the examiner noted fever, night sweats and hemoptysis; bacterial infection was noted to be inactive. No cardiopulmonary complications were noted. No respiratory failure was noted. A contemporaneous chest x-ray showed normal results. PFT results were obtained, and the examiner noted that they reflect the Veteran's current pulmonary function. The examiner noted that the FEV-1 test result most accurately reflects the Veteran's level of disability. While the examiner's notations are somewhat unclear, it appears that pre-bronchodilator results were 89 percent of FVC predicted; 86 percent of FEV-1 predicted; and 78 percent of FEV-1/FVC. Post-bronchodilator results were noted as 4.78 of FVC predicted; and 3.74 percent of FEV-1 predicted. DLCO testing results were noted to be 30.1 or 93 percent. Functional impact was noted to be that the Veteran cannot do any exertional work. A February 2015 private medical treatment record noted a respiratory system review that was negative for cough, chest tightness and wheezing. A physical pulmonary chest exam noted normal effort and breath sounds and no respiratory distress. An April 2015 private medical treatment record noted a respiratory system review that was negative for cough, chest tightness and wheezing. An April 2015 physical pulmonary chest exam noted normal effort and breath sounds and no respiratory distress. A May 2015 private medical treatment record noted normal pulmonary and chest effort. See private medical treatment records received by VA in February 2017. The Veteran underwent a second VA examination in February 2017. The Veteran reported that he experiences shortness of breath at rest, climbing is difficult, and he can only jog one block; he wheezes and coughs, and previously he treated symptoms with inhalant medicines. Regarding treatment, the examiner noted that no oral or parenteral corticosteroid medications; inhaled medications; oral bronchodilators; antibiotics; or outpatient oxygen therapy were required. The condition was noted to be at stage one, bihilar lymphadenopathy. No pulmonary involvement was noted. No ophthalmologic, renal, cardiac, neurologic, or other organ system involvement due to sarcoidosis was noted. No cardiopulmonary complications were noted. No respiratory failure was noted. A contemporaneous chest x-ray showed no active disease in the chest. PFT results were obtained, and the examiner noted that they reflect the Veteran's current pulmonary function. Pre-bronchodilator results were 95 percent of FVC predicted; 86 percent of FEV-1 predicted; and 73 percent of FEV-1/FVC. Post-bronchodilator results were 97 percent of FVC predicted; 90 percent of FEV-1 predicted; and 75 percent of FEV-1/FVC. The examiner noted that the FEV-1 test result most accurately reflects the Veteran's level of disability. DLCO testing was not completed because it was not indicated in the Veteran's particular case. Functional impact was noted to be that shortness of breath limited his walking. The Veteran underwent a third VA examination in May 2021. The examiner noted that sarcoidosis symptoms were cough and shortness of breath; no pulmonary involvement was noted. Regarding treatment, the examiner noted that no oral or parenteral corticosteroid medications; inhaled medications; oral bronchodilators; antibiotics; or outpatient oxygen therapy were required. The condition was noted to be at stage one, bihilar lymphadenopathy. No ophthalmologic, renal, cardiac, neurologic, or other organ system involvement due to sarcoidosis was noted. No cardiopulmonary complications were noted. No respiratory failure was noted. A contemporaneous chest X-ray showed normal results. PFT results were obtained and noted to reflect the Veteran's current pulmonary function. Pre-bronchodilator results were 88 percent of FVC predicted; 86 percent of FEV-1 predicted; and 78 percent of FEV-1/FVC. Post-bronchodilator results were 89 percent of FVC predicted; 86 percent of FEV-1 predicted; and 77 percent of FEV-1/FVC. The examiner noted that the FEV-1 test result most accurately reflects the Veteran's level of disability. DLCO testing was note completed because it was not indicated in the Veteran's particular case. Turning to the lay evidence of record, the Veteran stated that his sarcoidosis impacts his lung and heart. He is limited to little or no physical activity. He experiences pain and wheezing. His lungs feel diseased. He is winded using stairs, has mucus building and experiences a sharp pain in his lungs. See August 2012 congressional correspondence. He also stated that he has a constant cough and shortness of breath. His activity levels are affected, and he experiences chest pains. See third party correspondence received by VA in October 2019. On review of the record, the Board finds that, affording the Veteran the benefit of the doubt, the disability picture presented more accurately reflects a 10 percent disability rating, but no higher, for the entire period on appeal. The record shows that the Veteran's PFT values were within the ranges contemplated by the criteria for the minimum 10 percent rating, specifically, within the range of 71 to 80 percent for FEV-1/FVC. Affording the Veteran the benefit of the doubt, the May 2013 VA examination appears to show pre-bronchodilator FEV-1/FVC of 78 percent. The February 2017 VA examination showed pre-bronchodilator FEV-1/FVC of 73 percent and post-bronchodilator FEV-1/FVC of 75 percent. The May 2021 VA examination showed pre-bronchodilator FEV-1/FVC of 78 percent and post-bronchodilator FEV-1/FVC of 77 percent. Therefore, the evidence shows that a rating of 10 percent, but no higher, is warranted throughout the appellate period. The Board does not find that a higher disability rating is warranted. The PFT values do not meet or approximate the rating criteria under the next higher 30 percent rating under DC 6600. With regards to DC 6846, the Board acknowledges the favorable evidence of record; specifically, that pulmonary involvement was noted in the May 2013 VA examination. However, no pulmonary involvement was noted in the Veteran's subsequent February 2017 or May 2021 VA examinations. Therefore, the preponderance of the medical evidence shows that the overall disability picture does not manifest pulmonary involvement such that would warrant the next highest 30 percent rating under DC 6846. Moreover, there was no evidence of other factors, such as cor pulmonale, right ventricular hypertrophy, pulmonary hypertension, episodes of acute respiratory failure, or outpatient oxygen therapy. The Board acknowledges the Veteran's contention that his heart is impacted; however, no cardiovascular complications were noted across all three VA examinations. Thus, higher ratings under DCs 6600 or 6846 are not warranted. The Board has considered whether the Veteran is entitled to a higher disability rating under alternative diagnostic codes. However, the evidence does not show the Veteran suffers from symptoms better represented by another diagnostic code. Moreover, DC 6846 applies directly and specifically to sarcoidosis. Thus, a higher rating under another diagnostic code is not warranted. In assessing the severity of the Veteran's pulmonary sarcoidosis, the Board has considered the Veteran's assertions regarding his symptoms, which he is certainly competent to provide. See Layno v. Brown, 6 Vet. App. 465 (1994); 38 C.F.R. § 3.159(a)(2). However, the criteria needed to support higher ratings requires medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of a higher rating for the Veteran's pulmonary sarcoidosis at any point pertinent to this appeal. In sum, the Board finds that a disability rating of 10 percent, but no higher, is warranted for the Veteran's pulmonary sarcoidosis to include residuals of recurrent pneumonia throughout the appellate period. To the extent that the Veteran contends entitlement to a higher rating, the preponderance of the evidence is against the claim; there is no reasonable doubt to be resolved; and any further increased rating is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular consideration The present appeal includes the matter of whether a higher evaluation on an extraschedular basis is warranted. See August 2021 supplement statement of the case (SSOC). An extraschedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization render the application of the regular schedular standards impracticable. 38 C.F.R. § 3.321(b)(1). Ordinarily, there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Turning to the first step of the extraschedular analysis, the Veteran has not argued, and the record does not otherwise show, that his respiratory condition results in any symptoms other than shortness of breath that affects activity. Limitation of activity is a practical effect of a respiratory condition that has been clinically observed and measured in the evidence of record and that is expressly contemplated by the rating criteria. Likewise, any impact on his heart is expressly contemplated by the rating criteria. The Veteran is not entitled to additional separate disability ratings where the symptoms for the conditions in question overlap or are duplicative. See 38 C.F.R. §§ 4.14 (prohibiting evaluation of the same manifestation under various diagnoses). In conclusion, the Board finds that the available schedular evaluation is adequate to fully compensate the Veteran. In the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19. Therefore, remand for referral for extraschedular consideration is not warranted. 2. Entitlement to a rating in excess of 10 percent for joint pain, right knee 3. Entitlement to a rating in excess of 10 percent for joint paint, left knee 4. Entitlement to a separate 10 percent rating for instability, right knee 5. Entitlement to a separate 10 percent rating for instability, left knee The Veteran's joint pain, right and left knees, is rated under DC 8852-5260. 38 C.F.R. § 4.71a. Here, DC 8852 corresponds with an undiagnosed disability associated with service with Southwest Asia. Under DC 5256, knee ankylosis, a favorable angle in full extension, or in slight flexion between 0 and 10 degrees warrants a 30 percent disability rating; in flexion between 10 and 20 degrees warrants a 40 percent rating; in flexion between 20 and 45 degrees warrants a 50 percent rating; and extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more, warrants a 60 percent rating. 38 C.F.R. § 4.71a, DC 5256. Under DC 5257, where there is recurrent subluxation, lateral instability, or other impairment of a knee, a 10 percent evaluation may be assigned where the disability is slight, a 20 percent evaluation will be assigned for moderate disability, and a 30 percent for severe disability. 38 C.F.R. § 4.71a, DC 5257. The Board observes that the words "slight," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Use of terminology by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Pursuant to DC 5258, a 20 percent evaluation, the highest and only rating available under that schedular provision, may be assigned where there is evidence of dislocated cartilage, with frequent episodes of "locking," pain, and effusion into the knee joint. 38 C.F.R. § 4.71a, DC 5258. Under DC 5259, symptomatic residuals of removal of a semilunar cartilage warrants a maximum rating of 10 percent. 38 C.F.R. § 4.71a, DC 5259. The diagnostic codes pertaining to limited motion of the knee are DCs 5260 and 5261. Limited flexion of the knee is rated under DC 5260, which assigns a noncompensable rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and a 30 percent rating when limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Limited extension of the knee is rated under DC 5261, which assigns a noncompensable rating when extension is limited to 5 degrees; a 10 percent rating when limited to 10 degrees; a 20 percent rating when limited to 15 degrees; a 30 percent rating when limited to 20 degrees; a 40 percent rating when limited to 30 degrees; and a 50 percent rating when limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. VA's General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). Separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Under DC 5262, impairment of the tibia and fibula with malunion, a slight knee or ankle disability warrants a 10 percent rating; a moderate knee or ankle disability warrants a 20 percent rating; and a marked knee or ankle disability warrants a 30 percent rating. A maximum 40 percent rating is warranted when there is nonunion and loose motion requiring a brace. 38 C.F.R. § 4.71a, DC 5262. Under DC 5263, acquired genu recurvatum with weakness and instability in weight-bearing objectively demonstrated warrants a maximum 10 percent rating. 38 C.F.R. § 4.71a, DC 5263. Diseased joints may be manifested by crepitation on motion in the tendons or ligaments, or within join structures. 38 C.F.R. § 4.40. Pain, swelling, locking and crepitus may be compensated under the DCs for limited motion, i.e., DCs 5260 and 5261. Lyles v. Shulkin, No. 16-0994, slip op. at 14 (U.S. Vet. App. Nov. 29, 2017) (acknowledging popping and grinding as symptoms of crepitus and that to the extent that crepitus or locking cause disturbance of locomotion, sitting, standing, and weight-bearing they are contemplated under § 4.45(f)). The Board notes that this version of DCs 5257 and 5262 was amended effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). The amended versions of these DCs may not be applied prior to the effective date of February 7, 2021. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003 (Nov. 19, 2003). However, the Board finds it may still apply the prior version of these DCs to the entire period on appeal, as the Board is not prohibited from applying a prior regulation in effect during the pendency of a claim to the period on or after the effective date of the new version of the regulation. Thus, the Board finds that it may still apply the prior version of 38 C.F.R. § 4.71a, DCs 5257 and 5262 to the period on or after February 7, 2021, which is the effective date of the amended criteria, if this would afford a more favorable outcome. As explained below, the highest available rating is being granted pursuant to the old regulations. Factual background and legal analysis On review of the record, the Board finds that the evidence weighs against a rating in excess of the currently assigned 10 percent ratings for joint pain of the right and left knees. The May 2013 VA examination shows initial range of motion testing results to be 0 to 110 degrees of the right knee and 0 to 115 degrees of the left knee; these values were shown to be same upon repetitive use testing. The functional impact was noted to be the incapacity to undertake prolonged sitting, driving, bending, standing or walking. The February 2017 VA examination shows initial range of motion testing results to be 0 to 140 degrees for both knees; repetitive use testing was not performed because it was too painful to do so. The functional impact was noted to be that prolonged standing or walking increased the Veteran's pain. The October 2020 VA examination shows initial range of motion testing results to be 0 to 60 degrees of the right knee and 0 to 80 degrees of the left knee; the values were shown to be the same upon repetitive use testing and were estimated to be the same with repeated use over time and upon flare-ups. No difference was shown between active or passive range of motion. The functional impact was noted to be pain and weakness in both knees with activity. The May 2021 VA examination shows initial range of motion testing results to be 0 to 132 degrees of the right knee and 0 to 134 degrees of the left knee; no additional loss of function or range of motion was noted upon repetitive use testing. As for repeated use over time and upon flare-ups, the examiner noted that no procured evidence to include the Veteran's statements suggested an additional limitation of functional ability. No difference was shown between active or passive range of motion. The functional impact was noted to involve prolonged walking and running and staying in one position for too long. Turning to the lay evidence of record, during the May 2013 VA examination, the Veteran reported that his knees give out and are stiff, painful and weak, particularly with bending. He reported wearing braces. He reported flares a few times per month with overuse or bending; these last a few days and he avoids weight-bearing. See May 2013 VA examination. During the February 2017 VA examination, the Veteran reported that prolonged standing and walking worsened the pain, and overuse leads to him not being able to bend or straighten knees. He wears special shoes with inserts and braces. He reported no flare-ups. See February 2017 VA examination. Furthermore, in September 2019, the Veteran stated that both knees had worsened, and he experienced instability and more pain. He had particular difficulty using stairs and driving at length. He had an altered gait, which caused a caused limp. He also used braces to help with instability whenever he left home. See third party correspondence received by VA in October 2019. During the October 2020 VA examination, the Veteran reported pain, weakness, cracking and popping, which he treated with NSAIDs. He reported flare-ups with walking or using stairs. See October 2020 VA examination. During the May 2021 VA examination, the Veteran reported cracking and popping, which he treated with ibuprofen as needed. He reported flare ups as occurring several times per month, lasting less than one day, causing increased pain, which were triggered by overuse and alleviated by rest and medication; the severity was noted as moderate, and functional impact upon a flare-up was noted to be pain with walking and using stairs. The Board does not find that higher disability ratings for the Veteran's joint pain, right and left knees, under DC 5260 are warranted. Throughout the appellate period, the Veteran reported symptoms to include pain, stiffness, and weakness, and difficulty with activities such as prolonged sitting, driving, bending, standing or walking. Yet contemporaneous range of motion testing did not show greater range of motion values that would warrant the next higher rating under DC 5260. The VA examination reports cited above do not show that the Veteran's flexion was limited to or approximated the 30 degrees necessary to warrant the next higher 20 percent rating. At worst, the Veteran's right and left knee flexion was shown to be 60 and 80 degrees, respectively. See October 2020 VA examination. Therefore, higher ratings under DC 5260 are not warranted. The Board has considered whether the Veteran is entitled to a separate disability rating under alternative diagnostic codes. The Board finds that separate 10 percent ratings for instability of the right and left knees are warranted. Throughout the appellate period, the Veteran reported symptoms to include instability, giving way, and the use of braces. The Board does not find that a higher disability rating is warranted. Joint stability testing results were normal, and no evidence or history of recurrent patellar subluxation/dislocation was noted. See VA examinations dated May 2013, February 2017, October 2020, and May 2021. The overall disability picture, when considering the lay and medical evidence of record, more closely approximates a slight level of instability. See English v. Wilkie, 30 Vet. App. 347 (2018). Thus, the evidence of record supports additional 10 percent ratings, but no higher, for instability of the right and left knee under DC 5257. The amended version of DC 5257, effective February 7, 2021, would not afford the Veteran greater relief. See 85 Fed. Reg. 76453 (Nov. 30, 2020). No examiner has indicated the presence of a sprain or ligament tear; or patellar instability, a diagnosed condition, such that would warrant the next higher rating under the amended DC 5257. The Board further finds additional ratings for the Veteran's right and left knee disabilities are not indicated. A rating under DC 5256 is not warranted as there is no evidence of ankylosis or functional ankylosis. A rating under DCs 5258 or 5259 is not warranted because there is no evidence of any meniscal condition. There is no evidence that the Veteran's range of motion in extension was limited to 10 degrees or more to warrant a compensable rating under DC 5261. Additionally, there is no evidence of genu recurvatum to warrant a rating under DC 5263. Regarding the presence of a tibia or fibula impairment under DC 5262, the Board notes that the October 2020 VA examination indicated that the Veteran has a diagnosis of shin splints that is a progression of the knee disability due to chronic pain with progressive use. The Board advises the Veteran that if he wishes to file a claim of secondary service connection for this condition, he should do so using VA's standard claim forms. The Board has considered the Veteran's lay statements regarding the functional impact of his knee conditions, as set out above. The Veteran is competent to report his own observations with regard to the severity of his disability, including reports of pain and decreased mobility. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, his statements are consistent with the evidence of record and the rating assigned. The occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed and measured in the evidence of record. To the extent that the Veteran believes that a higher rating is warranted, this belief is outweighed by the remaining evidence of record, as summarized above. In sum, the Board finds that disability ratings in excess of the currently assigned 10 percent ratings are not warranted for the Veteran's right and left knee joint pain. The Board also finds that disability ratings of 10 percent, but no higher, throughout the appellate period are warranted for the Veteran's right and left knee instability. To the extent that the Veteran contends entitlement to higher ratings, the preponderance of the evidence is against the claim; there is no reasonable doubt to be resolved; and any further increased rating is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular consideration The present appeal includes the matter of whether a higher evaluation on an extraschedular basis is warranted. See August 2021 SSOC. An extraschedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization render the application of the regular schedular standards impracticable. 38 C.F.R. § 3.321(b)(1). Ordinarily, there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Turning to the first step of the extraschedular analysis, the Veteran has not argued, and the record does not otherwise show, that his claimed symptoms result in any symptoms other than limitation of motion or instability, which are expressly contemplated by the rating criteria. The Veteran is not entitled to additional separate disability ratings where the symptoms for the conditions in question overlap or are duplicative. See 38 C.F.R. §§ 4.14 (prohibiting evaluation of the same manifestation under various diagnoses). (Continued on the next page) In conclusion, the Board finds that the available schedular evaluation is adequate to fully compensate the Veteran. In the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19. Therefore, remand for referral for extraschedular consideration is not warranted. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Minaya, 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.