Citation Nr: 21069401 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 16-04 706 DATE: November 18, 2021 ORDER Entitlement to a disability rating for degenerative joint disease of the left knee (left knee disability) in excess of 10 percent, under Diagnostic Code 5260 (painful motion), is denied. Entitlement to a separate rating for left knee disability of 10 percent, and no higher, under Diagnostic Code 5261 (limitation of extension), is granted. Entitlement to a rating for left knee disability of 20 percent, and no higher, under Diagnostic Code 5257 (instability), prior to February 7, 2021, and under Diagnostic Code 5010-5257 (instability), from February 7, 2021 to May 11, 2021, is granted. Entitlement to a rating for left knee disability in excess of 20 percent under Diagnostic Code 5010-5257 (instability), from May 11, 2021, is denied. Entitlement to a separate disability rating for right knee patellar chondromalacia and degenerative arthritis (right knee disability), of 10 percent, and no higher, under Diagnostic Code 5260 (painful motion), prior to May 11, 2021, is granted. Entitlement to a disability rating for right knee disability in excess of 10 percent under Diagnostic Code 5010-5260 (painful motion), from May 11, 2021, is denied. Entitlement to a separate disability rating for right knee disability of 10 percent, and no higher, under Diagnostic Code 5261 (limitation of extension), prior to May 11, 2021, is granted. Entitlement to a disability rating for right knee disability in excess of 10 percent under Diagnostic Code 5010-5261 (limitation of extension), from May 11, 2021, is denied. Entitlement to a disability rating for right knee disability, in excess of 20 percent under Diagnostic Code 5257, except for periods when temporary 100 percent rating was in effect, is denied. Entitlement to an initial compensable disability rating for right knee scars is denied. Entitlement to an initial compensable disability rating for left knee scars is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The competent evidence of record shows that throughout the appeal period, the Veteran's left knee flexion was limited to, at worst, 100 degrees. 2. The competent evidence of record shows that throughout the appeal period, the Veteran's left knee extension was limited to, at worst, 10 degrees. 3. The competent evidence of record shows that the Veteran has moderate left knee instability, has an incomplete tear and requires a prescription for a brace; severe left knee instability and/or sprain, unrepaired or failed repair of complete ligament tear causing persistent instability has not been shown. 4. The competent evidence of record shows that throughout the appeal period, the Veteran's right knee flexion was limited to, at worst, 90 degrees. 5. The competent evidence of record shows that throughout the appeal period, the Veteran's right knee extension was limited to, at worst, 10 degrees. 6. The competent evidence of record shows that the Veteran has moderate right knee instability and requires a prescription for a brace; severe right knee instability and/or sprain, unrepaired or failed repair of complete ligament tear causing persistent instability has not been shown. 7. The competent evidence of record does not show that the Veteran's scars are painful or unstable, deep and nonlinear covering an area or areas of at least 6 square inches (39 sq. cm), superficial and nonlinear covering an area or areas of at least 144 square inches (929 sq. cm.), or any other disabling effects not considered under Diagnostic Codes 7800-7804. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left knee disability have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5260 (2020). 2. The criteria for a separate rating of 10 percent, and no higher, for left knee disability have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5261 (2020). 3. The criteria for a separate rating of 20 percent, and no higher, for left knee disability prior to May 11, 2021, have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5257 (2020); Diagnostic Code 5010-5257 (2021). 4. The criteria for a rating in excess of 20 percent for left knee disability, from May 11, 2021, have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5260 (2020); Diagnostic Code 5010-5257 (2021). 5. The criteria for a separate rating of 10 percent, and no higher, for right knee disability, prior to May 11, 2021, have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5260 (2020); Diagnostic Code 5260 (2021). 6. The criteria for a rating in excess of 10 percent for right knee disability, from May 11, 2021, have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5260 (2020); Diagnostic Code 5260 (2021). 7. The criteria for a separate rating of 10 percent, and no higher, for right knee disability, prior to May 11, 2021, have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5261 (2020); Diagnostic Code 5261 (2021). 8. The criteria for a rating in excess of 10 percent for right knee disability, from May 11, 2021, have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5261 (2020); Diagnostic Code 5261 (2021). 9. The criteria for a rating in excess of 20 percent for right knee disability have not been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.400, 4.59, 4.71a, Diagnostic Code 5257 (2020); Diagnostic Code 5257 (2021). 10. The criteria for an initial compensable disability rating for scars have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code, 7805 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1976 to January 1984. These matters come before the Board of Veterans' Appeals (Board) from April 2012, March 2015, and July 2020 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). By way of history, in the April 2012 decision, the agency of original jurisdiction (AOJ) awarded service connection for degenerative joint disease of the left knee and assigned an initial 10 percent disability rating, from April 13, 2011. In the March 2015 decision, the AOJ awarded a temporary 100 percent disability rating for right knee patellar chondromalacia and degenerative arthritis due to surgical or other treatment requiring convalescence, from December 19, 2014 through February 28, 2015. A 20 percent disability rating was assigned, from March 1, 2015. In January 2020, the Board expanded the appeal to include the inferred issue of entitlement to a TDIU, as part and parcel of the higher rating matters on appeal. See Harper v. Wilkie, 30 Vet. App. 345 (2018); Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board remanded the TDIU issue, as well as the issues of entitlement to higher ratings for the service-connected left and right knee disabilities, for further development. In the July 2020 rating decision, as part of the Veteran's claim for a higher disability rating for his bilateral knee disabilities, the AOJ awarded separate non-compensable disability ratings for the left and right knee, effective May 6, 2015. The Veteran testified before a Veterans Law Judge (VLJ) at an October 2019 hearing and a transcript of the hearing is associated with his claims file. The VLJ who conducted the hearing is no longer employed at the Board and is unable to participate in any further adjudication. In January 2021, the Board sent the Veteran a letter which informed him that the VLJ who conducted the October 2019 hearing was no longer employed at the Board and asked him to indicate whether he wanted to attend a new hearing. The Veteran responded later in January 2021 that he did not wish to have a new Board hearing. In a March 2021 decision, the Board remanded these issues for additional development, which has been substantially completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). As for characterization of the issues on appeal, as the Veteran was awarded a 100 percent rating from April 16, 2011 to August 1, 2011 and from December 19, 2014 through February 28, 2015 for his service-connected right knee disability under 38 C.F.R. § 4.30. The rating for this disability during this period will not be addressed herein by the Board. Cf. AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating Legal Criteria Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must consider the extent to which a veteran may have additional functional impairment beyond the limitation of motion objectively demonstrated, such as when the symptoms are most prevalent due to the extent of the pain and painful motion, weakness, premature or excess fatigability, and incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The rating schedule is intended to recognize actually painful, unstable, or malaligned joints due to healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to cases of painful motion in which there is a finding of arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Case law and VA guidelines anticipate that VA examiners will use information procured from relevant sources, including lay statements, to estimate additional functional loss during flare-ups of musculoskeletal disability. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation. See 38 C.F.R. §§ 3.951, 3.957. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 49. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Increased Disability Ratings Knee Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5003 (degenerative arthritis), DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). A recent CAVC decision highlighted that separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (DC 5260), limitation of extension (DC 5261), lateral instability or recurrent subluxation (DC 5257), and meniscal conditions (DCs 5258, 5259). See Lyles v. Shinseki, 29 Vet. App. 107 (2017). Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that when limitation of motion is noncompensable under the appropriate code or codes, a rating of 10 percent may be applied to each major joint or group of minor joints affected by limitation of motion. Such limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. If there is no limitation of motion, a 10 percent rating will be assigned where there is x-ray evidence of involvement of two or more major joints or minor joint groups, and a 20 percent rating will be assigned where there is such involvement along with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. Under Diagnostic Code 5256, a 30 percent rating is assigned for ankylosis of a knee with favorable ankle in full extension, or in slight flexion between zero and ten degrees and a 40 percent rating is assigned for ankylosis of a knee in flexion between 10 degrees and 20 degrees. A 50 percent rating is assigned for ankylosis of a knee between 20 degrees and 45 degrees and maximum 60 percent rating is assigned for extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more. Consideration must be given to whether a veteran is functionally ankylosed. Cf. Chavis v. McDonough, __ F.3d __, No. 18-2928 (Fed. Cir. April 16, 2021). Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Diagnostic Code 5257 provides that an evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability. An evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Words such as "mild," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "severe" by medical examiners, 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 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. The Board does note, for reference and illustrative purposes, that the definition for "mild" includes not very severe. Webster's II New College Dictionary at 694 (1995). In addition, a synonym for "mild" is "slight" and definitions for "slight" include small in size, degree, or amount. Id. at 1038. The definitions for "moderate" include of average or medium quantity, quality, or extent. Id. at 704. Finally, definitions for "severe" include extremely intense. Id. at 1012. It is also noted that the term "moderately severe" indicates impairment that is considered more than "moderate" but not to the extent as to be considered "severe." Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of semilunar cartilage. Diagnostic Code 5260 provides a noncompensable rating for limitation of flexion to 60 degrees, a 10 percent rating for limitation of flexion to 45 degrees, a 20 percent rating for limitation of flexion to 30 degrees, and a 30 percent rating for limitation of flexion to 15 degrees. Diagnostic Code 5261 provides a noncompensable rating for limitation of extension to 5 degrees, a 10 percent rating for limitation of extension to 10 degrees, a 20 percent rating for limitation of extension to 15 degrees, a 30 percent rating for limitation of extension to 20 degrees, a 40 percent rating for limitation of extension to 30 degrees, and a 50 percent rating for limitation of extension to 45 degrees. Diagnostic Code 5262 provides that impairment of the tibia and fibula characterized by malunion with slight knee or ankle warrants a 10 percent rating; characterized by malunion with a moderate knee or ankle disability warrants a 20 percent rating; and characterized by malunion with marked knee warrants a 30 percent rating. Impairment of the tibia and fibula manifested by nonunion with loose motion and requiring a brace warrants a maximum 40 percent rating. Diagnostic Code 5263 provides that genu recurvatum warrants a 10 percent rating. The Board notes that the criteria concerning the rating of knee disabilities under Diagnostic Code 5257 was amended during the pendency of this appeal, effective from February 7, 2021. Specifically, the amendment changed the criteria for compensable ratings. 85 Fed. Reg. 76463 (Nov. 30, 2020) (eff. Feb. 7, 2020). When a regulation changes during the pendency of a claim, the version most favorable to the Veteran applies. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overruling in part Karnas v. Derwinski, 1 Vet. App. 308 (1991)). However, the amended version cannot be applied prior to its effective date. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; see also Green v. Brown, 10 Vet. App. 111 (1997). Under the amended Diagnostic Code 5257, for recurrent subluxation or instability a 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Diagnostic Code 5257 also provides that for a patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. The Board also notes that the criteria concerning the rating of knee disabilities under Diagnostic Code 5262 was amended during the pendency of this appeal, effective from February 7, 2021. Under the amended version of Diagnostic Code 5262, a 40 percent rating is assigned for nonunion of the tibia and fibula with loose motion, requiring a brace. 85 Fed. Reg. at 76463. The amended Diagnostic Code 5262 instructs that malunion of the tibia and fibula is to be rated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Id. The amended Diagnostic Code 5262 also applies to medial tibial stress syndrome (MTSS), or shin splints, for which it provides the following ratings: a 30 percent rating is assigned for MTSS of both lower extremities, and a 20 percent rating for MTSS of one lower extremity, requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment; a 10 percent rating is assigned for MTSS of one or both lower extremities requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment; a 0 percent rating is assigned for MTSS of one or both lower extremities when there has been treatment for less than 12 consecutive months. Id. Increased Disability Ratings Scars In evaluating scars, the Board notes that during the appeal period, changes were made to certain Diagnostic Codes under 38 C.F.R. § 4.118. Effective August 13, 2018, VA amended its regulations governing skin disabilities. VA's intent is that the 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. For applications filed on or after the effective date, only the new criteria will be applied. 83 Fed. Reg. 32592 (July 13, 2018). As the Veteran filed his claim before the August 13, 2018 effective date, the Board will consider whether either the old or new rating criteria is more favorable to the Veteran. Under the old rating criteria, Diagnostic Code 7805 provided that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 under an appropriate Diagnostic Code. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2017). The Board notes that this diagnostic code is largely unchanged under the new amendments apart from the replacement of the phrase "(including linear scars)" with "and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804." 38 C.F.R. § 4.118, Diagnostic Code 7805 (August 13, 2018). Diagnostic Code 7800 (which was unchanged by the 2018 amendments), contemplates scars of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800. Under Diagnostic Code 7800, for disfigurement of the head, face, or neck, a 10 percent disability rating is warranted for scarring with one characteristic of disfigurement. A 30 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or two or three of the characteristics of disfigurement. A 50 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or four or five characteristics of disfigurement. An 80 percent disability rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or six or more characteristics of disfigurement. 38 C.F.R. § 4.118. The eight characteristics of disfigurement for the purposes of rating under 38 C.F.R. § 4.118 are: scar of 5 in. or more (13 or more centimeters (cm.)) in length; scar at least 1/4 in. (0.6 cm.) wide at its widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 sq. in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 sq. in. (39 sq. cm.); and skin indurated and inflexible in an area exceeding 6 sq. in. (39 sq. cm.). Id., Note (1). The pre-amended Diagnostic Code 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. 38 C.F.R. § 4.118, Diagnostic Code 7801 (2017). In contrast, the amended Diagnostic Code 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 (August 13, 2018). Both the old and new criteria provide that a 10 percent rating is awarded when the area of the scar(s) covers at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). A 20 percent rating is warranted when the area of the scar(s) covers at least 12 square inches (77 square centimeters) but less than 72 square inches (456 square centimeters). A 30 percent rating is warranted when the area of the scar(s) covers at least 72 square inches (456 square centimeters) but less than 144 square inches (929 square centimeters). A 40 percent rating is assigned when the area of the scar(s) covers at least 144 square inches (929 square centimeters) or greater. 38 C.F.R. § 4.118, Diagnostic 7801. Note (1) to the pre-amended Diagnostic Code 7801 stated that a deep scar is one associated with underlying soft tissue damage. Prior to August 13, 2018, Diagnostic Code 7802 provided rating criteria for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118, Diagnostic 7802 (2017). The amended version is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802 (August 13, 2018). Both versions state that a 10 percent disability rating is warranted when the area of the scar covers 144 square inches (929 square centimeters) or greater. Under both the old and new rating criteria, Diagnostic Code 7804 provides disability ratings for scars that are unstable or painful. A 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful. A 30 percent rating is warranted for five or more scars that are unstable or painful. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, an additional 10 percent should be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118, Diagnostic 7804. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. Factual Background At the outset, as noted above, the Board acknowledges that, that the Veteran's right knee disability has been assigned temporary total ratings throughout the appeal. Since the periods in which the 100 percent ratings were in effect were already assigned the maximum rating, they are outside the scope of this appeal. Therefore, the complaints and findings during these periods will not be discussed or considered. Turning to the evidence of record, the Veteran has been afforded multiple VA examinations throughout the appeal period. In a September 2011 VA examination, the Veteran was found to have right knee chondromalacia, and bilateral DJD and s/p meniscectomy. He reported flareups and asserted that his right knee pain was constant and sharp at times. He also reported swelling, stiffness, and that his knee would give out (he fell twice in the last 6 months), and occasional popping. Precipitating factors included prolonged standing and sitting. Regarding the left knee, his pain was intermittent, and it occasionally gave out. On examination, initial range of motion (ROM) testing revealed right knee flexion to 100 degrees, with pain at 100 degrees, and normal extension. Left knee flexion was limited to 130 degrees, with pain at 130 degrees and normal extension. Repetitive use testing revealed right knee flexion to 90 degrees and normal extension. Left knee flexion was limited to 130 degrees, with pain at 130 degrees and normal extension. Functional loss was due to excess fatiguability, pain on movement, and popping in the right knee. Muscle strength was normal and joint stability testing was normal. There was no history of patellar subluxation or dislocation or shin splints. The Veteran was found to have a bilateral meniscal condition, with surgeries, and frequent episodes of join pain. The Veteran also had several prior meniscectomies. The Veteran did use a cane, occasionally for his knee pain. The Veteran was not found to have a painful scar. The Veteran also reported working as a truck driver and that his knee condition was aggravated by his employment. In a May 2015 VA examination, the Veteran reported right knee pain and multiple operations. He also reported swelling and flareups, to include knee buckling. Functional loss included difficulty with stairs, walking and unable to run. On examination, initial ROM testing of the right knee revealed flexion to 130 degrees and normal extension. Pain was noted to cause functional loss on flexion and there was pain with weightbearing. There was crepitus. The Left knee was also normal, but there was pain on flexion causing functional loss. the Veteran was found to have disturbance of locomotion and interference with standing. His muscle strength was normal and there was no muscle atrophy or ankylosis. Joint stability testing was normal. The Veteran was found to have a bilateral meniscal condition that involved tears and frequent episodes of joint locking, pain, and effusion. The Veteran used assistive devices of braces and canes. The Veteran was not found to have any painful scars. The scars on the right knee were 1.2 x 0.2 cm and 1.1 x 0.1 cm and on the left knee were 1 x 0.2 cm and 1.5 x 0.2 cm. The scars were not painful or unstable or greater 39 square centimeters. No functional impact was noted; the Veteran was working as a referee, although prolonged standing and walking aggravated knees. In an August 2015 VA addendum opinion, the examiner asserted that during flare-ups due to his right knee, the Veteran had had difficulties walking stairs, walking was limited to 1/2 block, and standing was limited to 3 hours. Sitting was ok. Due to his bilateral knee condition, the Veteran could not run and it was hard to change position (get up from the chair; sitting to standing). Sitting, however, was OK. The examiner noted that a July 2015 VA treatment record indicates that the Veteran does referee basketball. He will run up and down the court for a couple of hours (however, his right knee does bother him and it swells up). In a March 2020 VA examination, the Veteran reported that his left knee had been giving him problems for the last two years. He experienced flareups such that his standing was limited, and he is unable to run or walk more than 12 block. In addition, squatting hurts. Initial ROM testing revealed right knee flexion limited to 130 degrees and normal extension. There was normal left knee flexion and normal extension. Pain was noted on flexion and extension. There was tenderness and no crepitus. Muscle strength was normal and there was no atrophy or ankylosis. There was no joint instability or shin splints. Residual side effects of meniscectomy included pain. The Veteran had a right knee stable scar that was not painful. The Veteran used a brace and cane for his bilateral knee pain. No impact on sedentary work. Physical job functional limitations. Passive ROM was same as active and pain was noted to be constant. The Veteran's gait was stable. In May 2021, the Veteran was afforded a VA examination. The examiner diagnosed the Veteran with bilateral knee meniscal tear (onset right knee 1997, left knee 1998), left knee anterior cruciate ligament (onset 2021), tear bilateral osteoarthritis (onset right knee 2003, left knee 2013), and right patellar chondromalacia (onset 2003). The Veteran reported that his knees give out when he walks, his right knee buckles at least twice a day, he uses his cane if needed and the left knee buckles at least once a day. The left knee gets painful when he is in bed and he experiences bilateral flareups. Regarding functional loss, the Veteran had to quit sports and quit refereeing due to inability to run although he can walk about 10000 steps in a day, does some gardening--but cannot kneel to pull the weeds. His driving is limited to 3 hours at a maximum. On examination, for the right knee, initial ROM testing revealed right knee forward flexion limited to 120 degrees and normal extension. Pain was noted on extension and began at 60 degrees. Passive ROM was the same as active ROM. There was no evidence of crepitus but there was evidence of tenderness. Repetitive use testing observed use over time, and flareup testing/estimations revealed right knee forward flexion limited to 110 degrees and extension limited to 10 degrees. The Veteran was found to have interference with sitting, standing, swelling, disturbance of locomotion and instability of station. There was no evidence of muscle atrophy or ankylosis. Joint stability testing revealed recurrent subluxation or peristent instability and no ligament tear/sprain. The Veteran required a prescription for use of a cane and brace for patellar instability and for ambulation. There was no recurrent patellar instability or evidence of surgical repair of the knee for patellar instability. There was no indication of tibial or fibular impairment. There was evidence of a meniscal tear with frequent episodes of locking and joint pain. Specifically, the Veteran's knee was always unstable when walking and the Veteran has to use a cane often. Regarding the left knee, May 2021 initial ROM testing revealed forward flexion limited to 110 degrees and normal extension. Pain was noted on flexion and began at 80 degrees. Passive ROM was the same as active ROM. There was no evidence of crepitus but there was evidence of tenderness. Repetitive use testing, observed use over time, and flareup testing/estimations revealed right knee forward flexion limited to 100 degrees and extension limited to 10 degrees. The Veteran was found to have interference with sitting, swelling, disturbance of locomotion and instability of station. There was no evidence of muscle atrophy or ankylosis. Joint stability testing revealed recurrent subluxation or peristent instability and there was evidence of an incomplete ligament tear/sprain that was not repaired. The Veteran required a prescription for use of a cane and brace for patellar instability and for ambulation. There was no recurrent patellar instability or evidence of surgical repair of the knee for patellar instability. There was no indication of tibial or fibular impairment. There was evidence of a meniscal tear with frequent episodes of locking and joint pain. Specifically, the Veteran's knee was always unstable when walking and the Veteran has to use a cane often. The May 2021 VA examiner found no history of frequent effusion. Functional impact was noted such that there is interference with occupation activities requiring kneeling and squatting and requiring prolonged walking and driving. In May 2021, the Veteran was also afforded a VA scar examination. The Veteran was noted to have 5 residual scars on his body. None of the scars were painful or unstable. The scars on the right knee were measured at 1.47 centimeters squared. and of the left knee were 0.04 centimeters squared. There was no underlying tissue damage, limitation of motion, or other pertinent physical findings or complications. Throughout the appeal period, the Veteran also sought treatment from VA. For instance, a January 2010 VA treatment record reflects pain, no significant knee joint effusion. In a February 2013 VA treatment record, the Veteran had only minor complaints about his right knee. He experienced pain in his left knee. He walked relatively well with no major limp without assistive devices. He had some significant atrophy in his quadriceps, though was able to do straight leg raises. He was definitely weaker on the left than the right. The knee itself had "excellent range of motion with full extension and full flexion. The knee was stable during testing in all directions. There was no effusion. The McMurray test was negative. Assessment was mild knee pain. A January 2014 VA treatment records show right knee pain. The Veteran was found to have small joint effusion. There was suprapatellar component of the joint effusion-correlate with physical examination findings. In June 2014, the Veteran also reported chronic knee problems and right knee pain more severe than left. He reported "locking" and "giv[ing]way" episodes, pain, swelling with activities of daily living. The Veteran was able to walk about 3 miles, with swelling, climb in a normal fashion, and use steps. The Veteran was able to walk and run as part of his part time job. On examination, the Veteran's right knee flexion and left knee flexion was limited to 130 and normal extension. There was no effusion or laxity. There was McMurray with pain at medial joint line. In a December 2014 VA treatment record the Veteran reported pain since last October. He was limping and had occasional swelling, and giving way on a frequent basis, but does not fall down. The Veteran worked as a referee. The Veteran's right knee had full range of motion equal to the left and ligaments were stable. There were negative Lachman's and McMurray tests and the patella was stable. An April 2014 VA treatment record shows right knee pain off and on. The Veteran bowled two times a week and doesn't sit and rest at all. He reported that overall his right knee pain was affected by changing weather. The Veteran reported bowling two times a week but doesn't really sit or rest at all. He also asserted that he felt that his knees were more flexible and that he might be travelling soon. He returned a pair of crutches and his active range of motion was flexion limited to 120 degrees in the right knee and 130 degrees in the left knee with normal extension in both knees. The Veteran was noted to have a faint linear scar. In a March 2015 VA treatment record, the Veteran reported pain. On examination, he had mildly decreased extension and flexion in stance and swing. Active range of motion of the right knee was flexion limited to 115 degrees and normal extension. Active range of motion of the left knee was flexion limited to 130 degrees and normal extension. Muscle strength was normal, and sensation was grossly intact. The Veteran denied numbness and tingling but reported occasional burning sensation. The right patella was mildly hypomobile in all directions with edema. See also March 2015 Private Treatment Record (noting knee pain). In a May 2015 VA treatment record, the Veteran had no significant intraarticular effusion. There was soft tissue swelling going all the way down to the ankle from the distal thigh. He was able to ambulate. Active range of motion of the right knee was flexion limited to 110 degrees and normal extension. Active range of motion of the left knee was flexion limited to 130 degrees and normal extension. The Veteran had normal muscle strength, but his right patella was mildly hypermobile in all directions. VA treatment records from June 2019 show that the Veteran was fitted for a right knee brace, and his knee was evaluated, he is able to referee flag football bowl two times a week and play golf two times per week. In an October 2019 VA treatment record, the Veteran was noted to be familiar to the clinic due to his last round of PT earlier that year prior to a PRP injection in July 2019. The Veteran reported that he "felt good" while on vacation in Hawaii which he attributes to the heat, swimming in salt water, and increased walking. He asserted that he did feel a pop at the left medial superior knee which continued to bother him and is painful to the touch. The Veteran is able to walk mor than 10,000 steps/day while on vacation, and when he returned home, was able to officiate three football games with 20,000 steps, including jogging, per game. The Veteran continued to wear brace diligently. On examination, the Veteran had mild antalgic gait pattern. ROM testing revealed right knee and left knee flexion limited to 120 degrees, right knee extension limited to 5 degrees and normal left knee extension. Muscle strength was 4+/5. See also September 2019 VA Treatment Record (knee evaluation); August 2019 VA Treatment Record (knee evaluation); June 2019 VA Treatment Record. November 2019, December 2019, and January 2020 VA treatment records show that the Veteran was still referring and remains active with running and bowling. The Veteran has also contributed multiple statements regarding his disabilities. In a July 2015 DRO hearing, the Veteran reported that his right knee is unstable and caused him to fall 1-2 times per month. His left knee is unstable and also caused falls as well. He used a cane because his walking is limited and a brace. Before he stopped working the employer placed him on modified duty as a salesperson rather than as a driver but even working as a salesperson he had to stand or get up to pick up packages and supplies and help to get them to the customers' cars and that was problematic. There was fear he would fall and hurt himself causing a workman's compensation claim or fall and injure a customer. He testified as to how he spends his days since he stopped working. He does housework such as cleaning the bathroom or vacuuming but he must stop doing housework every 30 minutes to rest due to pain and/or to sit down and elevate his leg. He just moved to another apartment because the old apartment had a tub shower and stepping into the tub became very problematic and he had near falls. The new apartment has a walk-in shower. He is limited travelling because he is on blood thinners; needs to be able to go to a clinic if he has symptoms. He requires accommodations on the ground floor because walking any stairs is nearly impossible. In a July 2015 correspondence, the Veteran argued that his service-connected conditions, considered both singly and in combination, prevent Mr. [REDACTED] from performing any kind of substantial work activity because of limitations with sitting, standing, walking, pain, side effects from medications and the need to elevate his lower extremities throughout the day per medical advice. In his October 2019 Board hearing the Veteran also reported that he has to grab a wall twice a day to make sure he does not fall because his knee buckles. He experiences swelling and wears a brace. His symptoms have persisted thorough the appeal period. The left knee will also buckle and clicks three times a week. He experiences locking in both knees. In a January 2020 VA treatment record, the Veteran was noted to bowl for fun and work part time as a referee, his neck, back and shoulder pain do not interfere for those activities. In an August 2020 statement, the Veteran's representative asserted that the Veteran referees youth sports. It is parttime and seasonal work from August-November and January-April. During these seasons the Veteran would referee 1-6 hours per week and only earned $127 per week or $70 per week. In July 2021, the Veteran provided a vocational assessment. The clinician noted review of the record and the Veteran's work history. He asserts that the Veteran graduated high school and has no additional education or training. He worked as a truck driver and basketball referee. This was a medium physical demand occupation that does not have transferable skills to alternative sedentary occupations. The clinician opined that the Veteran is unable to obtain and maintain substantial gainful employment. He asserts that the limitations of the Veteran's disabilities include chronic severe pain with flareups and that the Veteran has limited transferable skills to a sedentary employment. In addition, the Veteran's part time employment would be considered marginal sheltered employment. The Veteran would be unable to compete in a labor market due to his nontransferable skills and inability to complete tasks without frequent breaks. 1. Entitlement to a disability rating for left knee disability in excess of 10 percent, under Diagnostic Code 5260 (painful motion), is denied. 2. Entitlement to a separate disability rating for left knee disability of 10 percent, and no higher, under Diagnostic Code 5261 (limitation of extension), is granted. 3. Entitlement to a disability rating for left knee disability of 20 percent, and no higher, under Diagnostic Code 5257 (instability), prior to February 7, 2021, and under Diagnostic Code 5010-5257 (instability), from February 7, 2021 to May 11, 2021, is granted. 4. Entitlement to a disability rating for left knee disability in excess of 20 percent under Diagnostic Code 5010-5257 (instability), from May 11, 2021, is denied. The Veteran is seeking a higher disability rating for his left knee disability. Specifically, he contends that his disability is more severe than reflected by his currently assigned disability ratings. Regarding the left knee, the Veteran is currently assigned a 10 percent disability rating under Diagnostic Code 5260, for the entire period on appeal. The Veteran is also in receipt of a 20 percent disability rating for instability under Diagnostic Code 5010-5257, effective May 11, 2021. Following a review of the evidence of record, as explained below, the Board finds that a higher disability rating for left knee disability is not warranted under Diagnostic Code 5260 (painful motion). Affording the Veteran the benefit of the doubt, a separate disability rating of 10 percent under Diagnostic Code 5261 (limitation of extension) is warranted. A disability rating of 20 percent, and no higher, prior to February 7, 2021 (under Diagnostic Code 5257) and from February 7, 2021 to May 11, 2021 (under Diagnostic Code 5010-5257) is warranted. A disability rating in excess of 20 percent beginning May 11, 2021 under Diagnostic Code 5010-5257 is not warranted. Limitation of Motion (Diagnostic Codes 5260, 5260) The Board first acknowledges that that although the Veteran was afforded multiple VA examinations throughout the appeal period, the most recent May 2021 VA examination is the only examination that is compliant with the requirements set forth in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Accordingly, only the May 2021 VA examination report will be utilized for evaluation of the Veteran's left knee disability with regard to range of motion, as it is the only adequate examination of record. Additionally, the Board will consider the Veteran's lay statements and other favorable medical findings and use the range of motion findings most favorable to the Veteran throughout the appeal period. Thus, there is no prejudice to the Veteran in not considering the prior VA examinations to rate his disability based on limitation of motion and DeLuca factors. With regard to whether a higher rating is warranted for the left knee under the currently assigned Diagnostic Code 5260, here, the evidence reveals that the Veteran has functional flexion better than 45 degrees. Specifically, the May 2021 VA examiner evaluated ranges of motion, pain, additional limitation of motion and functional loss upon repetitive testing, and limitation on weight-bearing, and found that the Veteran's flexion in the left knee was limited, at worst (i.e. during flareups), to 100 degrees. Accordingly, the preponderance of evidence is against a disability rating of 10 percent, or higher, which contemplates flexion limited to at least 45 degrees, under Diagnostic Code 5260 based on limitation of motion. The Board recognizes, however, that 'painful' motion under Diagnostic Code 5260 warrants at least a minimum compensable rating pursuant to provisions of 38 C.F.R. § 4.59. Here, the evidence shows that the Veteran has painful flexion. See, e.g., May 2015 VA Examination. As such, the currently assigned disability rating of 10 percent for left knee disability under Diagnostic Code 5260 most closely approximates the Veteran's disability picture. With regard to whether a separate rating is warranted for the left knee under Diagnostic Code 5261, the Board finds that a separate rating of 10 percent, and no higher, is warranted for limitation of extension. Specifically, although the VA treatment records and prior VA examinations generally found the Veteran to have normal left knee extension, in the May 2021 VA examination, the Veteran was found to have extension limited to 10 percent. The Board notes that regarding left knee limitation of motion the May 2021 VA examination is the examination most favorable to the Veteran and is the only VA examination of record adequate for adjudicative purposes during this period on appeal consistent with Sharp, supra. Accordingly, affording the Veteran the benefit of the doubt, the Board finds that the Veteran warrants a 10 percent disability rating for limitation of extension under Diagnostic Code 5261, which contemplates limitation of extension to 10 degrees. The preponderance of evidence, however, against finding that a higher disability rating of 20 percent under Diagnostic Code 5261, which contemplates extension limited to, at worse, 15 degrees. As noted above, the Veteran's extension was, at worst limited to 10 degrees. Instability (Diagnostic Codes 5257, 5258) With regard to whether a separate disability rating is warranted under Diagnostic Code 5257 for left knee disability, for the appeal periods prior to February 7, 2021, and from February 6, 2021 to May 11, 2021, affording the Veteran the benefit of the doubt, a 20 percent disability rating is warranted. Specifically, as described above, the Veteran has reported multiple episodes of knee buckling and instability associated with frequent episodes of locking, pain, effusion, and falls, throughout the appeal period. In the May 2021 VA examination, he was found to have a history of recurrent subluxation, incomplete unrepaired partial ligament tear, and instability of station. The Veteran was also found to have recurrent instability and required a prescription by a medical provider for a brace and cane. See generally VA Treatment Records. Accordingly, the Board finds that a separate 20 percent disability rating under Diagnostic Code 5257 for moderate instability prior to February 7, 2021, and under Diagnostic Code 5010-5257 from February 7, 2021 to May 11, 2021 is warranted. The Board further finds that the record does not indicate that the Veteran's instability was "severe" or of intense quantity. Indeed, aside from in the May 2021 VA examination, the Veteran's VA examinations during this period on appeal show no joint instability. In addition, the record does not show an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation; or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. See May 2021 VA Examination. As such, a disability rating higher than 20 percent under Diagnostic Code 5257, for the entire period on appeal, under the regulations in effect both prior to and following February 7, 2021, for the left knee is not warranted. The Board has considered whether a separate and/or higher rating would be warranted for the Veteran's symptoms of knee buckling and instability associated with frequent episodes of locking, pain, effusion, and falls, throughout the appeal under Diagnostic Code 5258. The Board recognizes that Diagnostic Code 5258 provides a maximum 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. In this case, the Veteran has reported having a locking feeling during flare-ups and consistently reported having pain in the left knee joint, and frequent episodes of locking, effusion, and pain, the Board finds that assigning a separate rating under Diagnostic Code 5258 would amount to pyramiding, as the Veteran's symptoms are contemplated by the rating assigned under Diagnostic Code 5257 for instability and his painful motion is also contemplated by the rating assigned under Diagnostic Code 5260. Therefore, assigning a 20 percent rating under Diagnostic Code 5258 is not appropriate in this case. Additional Ratings (Diagnostic Codes 5256, 5259, 5265, 5263) The Board next considered whether higher or separate ratings were warranted under another appropriate Diagnostic Code. Here, there is no evidence in the claims file showing ankylosis so as to warrant a disability rating under Diagnostic Code 5256. The record shows that the Veteran's left knee was not ankylosed (i.e., frozen). The Board acknowledges that consideration must still be given to whether he is functionally ankylosed in the left knee. Cf. Chavis v. McDonough, __ F.3d __, No. 18-2928 (Fed. Cir. April 16, 2021). Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Here, the Veteran reported increased pain during flare-ups and restricted activity with limited ROM. The Board finds the evidence of record, however, does not support that the Veteran's left knee was immobile even during flare-ups considering he reported being able to walk and climb stairs, albeit with difficulty and limitations. Regarding a compensable disability rating under Diagnostic Code 5259, the Board finds that there is no evidence of removal of semilunar cartilage as such a disability rating under such Code is not warranted. Regarding a disability rating under Diagnostic Code 5262 both prior to and beginning February 7, 2021, the weight of the evidence is against finding that a separate disability rating is warranted for impairment of the tibia and fibula or shin splints. There is also no indication that the Veteran has a malunion of the tibia and/or fibula or has been treated for shin splints. As such a compensable disability under Diagnostic Code 5262 and/or the amended Diagnostic Code 5262 is not warranted. There is also no evidence of record indicating symptomatic removal of semilunar cartilage, or genu recurvatum warranting a rating under such Diagnostic Code. As such, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5259, 5262, or 5263 respectively for his left knee disability. In reaching all of the above determinations, the Board has considered the Veteran's competent lay assertions, VA treatment records, and additional records, to specifically include his reports of pain, knee giving way, limitation of motion, and difficulty standing and walking, and instability. The Veteran is certainly competent to describe his observations and the Board finds that his statements are credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that personal knowledge is "that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted"). However, the Board finds that the objective medical findings by skilled professionals, which incorporate the Veteran's competent assertions, provide the most persuasive evidence regarding the limitations posed by the Veteran's knee disability. Based on the foregoing, and affording the Veteran the benefit of the doubt, the Board finds that entitlement to a disability rating for left knee disability in excess of 10 percent, under Diagnostic Code 5260 (painful motion), is denied; entitlement to a separate disability rating for left knee disability of 10 percent, and no higher, under Diagnostic Code 5261 (limitation of extension), is granted; entitlement to a disability rating for left knee disability of 20 percent, and no higher, prior to February 2, 2021, under Diagnostic Code 5257, and from February 2, 2021 to May 11, 2021, under Diagnostic Code 5010-5257, is granted; and entitlement to a disability rating for left knee disability in excess of 20 percent beginning May 11, 2021, under Diagnostic Code 5010-5257, is denied. 5. Entitlement to a separate disability rating for right knee disability of 10 percent, and no higher, under Diagnostic Code 5260 (painful motion), prior to May 11, 2021, is granted. 6. Entitlement to a disability rating for right knee disability in excess of 10 percent under Diagnostic Code 5010-5260 (painful motion), from May 11, 2021, is denied. 7. Entitlement to a separate disability rating for right knee disability of 10 percent, and no higher, under Diagnostic Code 5261 (limitation of extension), prior to May 11, 2021, is granted. 8. Entitlement to a disability rating for right knee disability in excess of 10 percent under Diagnostic Code 5010-5261 (limitation of extension), from May 11, 2021, is denied. 9. Entitlement to a disability rating for right knee disability, in excess of 20 percent under Diagnostic Code 5257, except for periods when temporary 100 percent rating was in effect, is denied. The Veteran is seeking a higher disability rating for his right knee disability. Specifically, he contends that his disability is more severe than reflected by his currently assigned disability ratings. Regarding the right knee, the Veteran is currently assigned a 20 percent disability rating under Diagnostic Code 5257 for the entire period on appeal (except for periods when temporary 100 percent rating was in effect). The Veteran is also in receipt of a 10 percent disability rating for right knee limitation of flexion under Diagnostic Code 5010-5260, and a noncompensable disability for right knee limitation of extension rating under Diagnostic Code 5010-5261, effective May 11, 2021. Following a review of the evidence of record, the Board finds that a disability rating in excess of 20 percent under Diagnostic Code 5257 is not warranted. A disability rating of 10 percent, and no higher, under Diagnostic Code 5260 (painful motion), prior to May 11, 2021, is warranted. A disability rating in excess of 10 percent from May 11, 2021, under Diagnostic Code 5010-5260 (painful motion), is not warranted. A separate disability rating of 10 percent under Diagnostic Code 5261 prior to May 11, 2021 (limitation of extension) is warranted. A disability rating in excess of 10 percent from May 11, 2021, under Diagnostic Code 5010-5261 (limitation of extension), is not warranted. Limitation of Motion (Diagnostic Codes 5260, 5261) As previously discussed, the Board acknowledges that that although the Veteran was afforded multiple VA examinations throughout the appeal period, the most recent May 2021 VA examination is the only examination that is compliant with the requirements set forth in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Accordingly, only the May 2021 VA examination report will be utilized for evaluation of the Veteran's left knee disability with regard to range of motion, as it is the only adequate examination of record. Additionally, the Board will consider the Veteran's lay statements and other favorable medical findings and use the range of motion findings most favorable to the Veteran throughout the appeal period. Thus, there is no prejudice to the Veteran in not considering the prior VA examinations to rate his disability based on limitation of motion and DeLuca factors. With regard to whether an initial rating is warranted for the right knee prior to May 11, 2021 and in excess of 10 percent beginning May 11, 2021, under the currently assigned Diagnostic Code 5260, here, the evidence reveals that the Veteran has functional flexion better than 45 degrees. Specifically, the May 2021 VA examiner evaluated ranges of motion, pain, additional limitation of motion and functional loss upon repetitive testing, and limitation on weight-bearing, and found that the Veteran's flexion in the left knee was limited, at worst (i.e. during flareups), to 100 degrees. Accordingly, the preponderance of evidence is against a disability rating of 10 percent, or higher, which contemplates flexion limited to at least 45 degrees, under Diagnostic Code 5260 based on limitation of motion. The Board acknowledges that a September 2011 VA examiner found that the Veteran's flexion was limited to 90 degrees during repetitive use testing and that this examination is not compliant with Sharp, supra. However, the Board finds that a remand to obtain a retrospective opinion as to the functional loss during flare ups would not raise any reasonable possibility of further substantiating the Veteran's claim and the available evidence is sufficient to adjudicate the instant claim. 38 C.F.R. § 3.159(d); see Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (holding that the Board is not required to remand a claim for additional development when it would impose unnecessary burdens on VA with no additional benefit flowing to the veteran). Specifically, at no point during the appeal period do VA treatment records or VA examinations or the Veteran's lay assertions show that the Veteran's flexion is limited to 45 degrees or less. As such, a disability rating under Diagnostic Code 5260 of 10 percent, or higher, based on limitation of motion is not warranted at any period on appeal. The Board recognizes, however, that 'painful' motion under Diagnostic Code 5260 warrants at least a minimum compensable rating pursuant to provisions of 38 C.F.R. § 4.59. Here, the evidence shows that the Veteran has painful flexion. See, e.g., May 2015 VA Examination. As such, a separate disability rating for painful flexion is warranted under Diagnostic Code 5260 for the period on appeal prior to May 11, 2021 and the currently assigned disability rating of 10 percent for right knee disability under Diagnostic Code 5150-5260 most closely approximates the Veteran's disability picture. With regard to whether a separate rating is warranted for the right knee under Diagnostic Code 5261, prior to May 11, 2021, the Board finds that a separate rating of 10 percent, and no higher, is warranted for limitation of extension. Specifically, although the VA treatment records and prior VA examinations generally found the Veteran to have normal right knee extension, in the May 2021 VA examination, the Veteran was found to have extension limited to 10 percent. The Board notes that regarding right knee limitation of motion the May 2021 VA examination is the examination most favorable to the Veteran and is the only VA examination of record adequate for adjudicative purposes during this period on appeal consistent with Sharp, supra. Accordingly, affording the Veteran the benefit of the doubt, the Board finds that the Veteran warrants a 10 percent disability rating for limitation of extension under Diagnostic Code 5261, which contemplates limitation of extension to 10 degrees. The preponderance of evidence, however, against finding that a higher disability rating of 20 percent under Diagnostic Code 5261, for the entire period on appeal, which contemplates extension limited to, at worse, 15 degrees. As noted above, during the appeal, the Veteran's extension was, at worst limited to 10 degrees. Instability (Diagnostic Codes 5257, 5258) With regard to whether a higher disability rating is warranted under Diagnostic Code 5257 for right knee disability, the Board finds that a disability rating in excess of 20 percent is not warranted. The Board acknowledges that the Veteran has reported multiple episodes of knee buckling and instability associated with frequent episodes of locking, pain, effusion, and falls, throughout the appeal period. However, the record generally does not show that the Veteran's disability is severe or extreme in nature. Here, in the May 2021 VA examination, he was found to have a history of recurrent subluxation and instability of station, but the Veteran's VA treatment records and VA examinations generally show that the Veteran's joint stability testing is normal. Furthermore, the record does not show an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation; or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. See May 2021 VA Examination. As such, a disability rating higher than 20 percent under Diagnostic Code 5257, for the entire period on appeal, under the regulations in effect both prior to and following February 7, 2021, for the right knee is not warranted. The Board has considered whether a separate and/or higher rating would be warranted for the Veteran's symptoms of knee buckling and instability associated with frequent episodes of locking, pain, effusion, and falls, throughout the appeal under Diagnostic Code 5258. The Board recognizes that Diagnostic Code 5258 provides a maximum 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. In this case, the Veteran has reported having a locking feeling during flare-ups and consistently reported having pain in the right knee joint, and frequent episodes of locking, effusion, and pain, the Board finds that assigning a separate rating under Diagnostic Code 5258 would amount to pyramiding, as the Veteran's symptoms are contemplated by the rating assigned under Diagnostic Code 5257 for instability and his painful motion is also contemplated by the rating assigned under Diagnostic Code 5260. Therefore, assigning a 20 percent rating under Diagnostic Code 5258 is not appropriate in this case. Additional Ratings (Diagnostic Codes 5256, 5259, 5265, 5263) The Board next considered whether higher or separate ratings were warranted under another appropriate Diagnostic Code. Here, there is no evidence in the claims file showing ankylosis so as to warrant a disability rating under Diagnostic Code 5256. The record shows that the Veteran's right knee was not ankylosed (i.e., frozen). The Board acknowledges that consideration must still be given to whether he is functionally ankylosed in the right knee. Cf. Chavis v. McDonough, __ F.3d __, No. 18-2928 (Fed. Cir. April 16, 2021). Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Here, the Veteran reported increased pain during flare-ups and restricted activity with limited ROM. The Board finds the evidence of record, however, does not support that the Veteran's right knee was immobile even during flare-ups considering he reported being able to walk and climb stairs, albeit with difficulty and limitations. Regarding a compensable disability rating under Diagnostic Code 5259, the Board finds that there is no evidence of removal of semilunar cartilage as such a disability rating under such Code is not warranted. Regarding a disability rating under Diagnostic Code 5262 both prior to and beginning February 7, 2021, the weight of the evidence is against finding that a separate disability rating is warranted for impairment of the tibia and fibula or shin splints. There is also no indication that the Veteran has a malunion of the tibia and/or fibula or has been treated for shin splints. As such a compensable disability under Diagnostic Code 5262 and/or the amended Diagnostic Code 5262 is not warranted. There is also no evidence of record indicating symptomatic removal of semilunar cartilage, or genu recurvatum warranting a rating under such Diagnostic Code. As such, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5259, 5262, or 5263 respectively for his right knee disability. In reaching all of the above determinations, the Board has considered the Veteran's competent lay assertions, VA treatment records, and additional records, to specifically include his reports of pain, knee giving way, limitation of motion, and difficulty standing and walking, and instability. The Veteran is certainly competent to describe his observations and the Board finds that his statements are credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that personal knowledge is "that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted"). However, the Board finds that the objective medical findings by skilled professionals, which incorporate the Veteran's competent assertions, provide the most persuasive evidence regarding the limitations posed by the Veteran's knee disability. Based on the foregoing, and affording the Veteran the benefit of the doubt, the Board finds that entitlement to a disability rating for right knee disability, in excess of 20 percent under Diagnostic Code 5257, except for periods when temporary 100 percent rating was in effect, is denied; entitlement to a separate disability rating for right knee disability of 10 percent, and no higher, under Diagnostic Code 5260 (painful motion), prior to May 11, 2021, is granted; entitlement to a disability rating for right knee disability in excess of 10 percent under Diagnostic Code 5010-5260 (painful motion), from May 11, 2021, is denied; entitlement to a separate disability rating for right knee disability of 10 percent, and no higher, under Diagnostic Code 5261 (limitation of extension), prior to May 11, 2021, is granted; and entitlement to a disability rating for right knee disability in excess of 10 percent under Diagnostic Code 5010-5261 (limitation of extension), from May 11, 2021, is denied. 10. Entitlement to an initial compensable disability rating for right knee scars is denied. 11. Entitlement to an initial compensable disability rating for left knee scars is denied. The Veteran is seeking a higher disability rating for his service-connected scars. Specifically, he contends that his disabilities are more severe than reflected by his currently assigned disability ratings. The Veteran is currently assigned non-compensable ratings for his service-connected scars of the right and left knees under Diagnostic Code 7802. Following a review of the record in its entirety, the Board finds that the evidence of record does not show that an initial compensable disability rating is warranted. In this regard, there is no evidence of a burn scar, disfigurement of the face, head, or neck; the scar is deep and/or nonlinear; it is not at least 39 sq. cm, or 929 sq. cm, and there is no indication that the scar is painful or unstable, or displays any other disabling effects. Accordingly, the Board finds that Diagnostic Codes 7800, 7801, 7802, 7804 and 7805 (to include the amended Diagnostic Codes) are not applicable in this case. In reaching the above determinations, the Board has considered the Veteran's competent lay assertions. The Veteran is certainly competent to describe his observations and the Board finds that his statements are credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that personal knowledge is "that which comes to the witness through the use of his senses-that which is heard, felt, seen, smelled, or tasted"). However, the Board finds that the objective medical findings by skilled professionals, to include the Veteran's records and May 2021 VA examination, which incorporate the Veteran's competent assertions, provide the most persuasive evidence regarding the limitations posed by the Veteran's scar. Accordingly, the Board finds that the preponderance of the evidence shows that an initial compensable disability rating for left knee and right knee scars is not warranted. The Board finds the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to a TDIU due to service-connected disabilities is remanded. The Veteran is seeking entitlement to a TDIU. Specifically, the Veteran contends that he is unable to obtain and maintain substantially gainful employment due to his service-connected disabilities and that any intermittent or part-time employment he had during this period was marginal. See, e.g., July 2021 Vocational Assessment. Following a review of the record, the Board cannot make a fully informed decision regarding the Veteran's claim for entitlement to a TDIU. Additional development is needed to decide the claim and a remand is therefore warranted. Specifically, the Board acknowledges that the Veteran has asserted he last worked fulltime in 2013. However, the record indicates that the Veteran was able to work, in some capacity, until, at least, 2019-2021. See May 2021 VA Examination (The Veteran reported that "he had to quit sports, even playing gold as well as refereeing."); see also October 2019 VA Treatment Record (The Veteran reported swimming and was able to officiate three football games with 20,000 steps, including jogging, per game). Further development is necessary to determine when the Veteran became, in fact, incapable of obtaining or maintaining substantially gainful employment due to his service-connected disabilities or if any additional employment was marginal. On remand, efforts should be made to obtain and clarify this information, if possible. The matter is REMANDED for the following action: 1. The AOJ should request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) medical records and/or employment records for the period on appeal, (e.g., salary statements, wage receipts, W-2s, and/or tax returns or other pertinent financial documents for each year). Further details as to his family situation and dependents at this time is also requested. Ensure that all such documentation is added to the claims file. 2. The AOJ should then review the record and readjudicate the claim for entitlement to a TDIU, after arranging for any additional development indicated. If the benefit sought remains denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and her representative opportunity to respond, and return the record to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Kaufer, 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.