Citation Nr: 21070426 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 19-14 984 DATE: November 23, 2021 ORDER Entitlement to a rating of 50 percent, but no higher, for service-connected migraine headaches is granted. Entitlement to a rating in excess of 10 percent for service-connected patellar tendinitis with patellar exostoses, right knee is denied. Entitlement to a rating in excess of 10 percent for service-connected patellar tendinitis with patellar exostoses, left knee is denied. Entitlement to a rating in excess of 10 percent for service-connected right knee extension associated with patellar tendinitis with patellar exostoses, right knee is denied. Entitlement to a rating in excess of 0 percent for service-connected left knee extension associated with patellar tendinitis with patellar exostoses, left knee is denied. Entitlement to a rating in excess of 10 percent for service-connected right knee instability associated with patellar tendinitis with patellar exostoses, right knee is denied. Entitlement to a rating in excess of 10 percent for service-connected left knee instability associated with patellar tendinitis with patellar exostoses, left knee is denied. FINDINGS OF FACT 1. The probative evidence of record shows that the Veteran's migraine headaches cause very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 2. The Veteran's patellar tendinitis with patellar exostoses of the right knee manifested as pain and stiffness without limitation of flexion to a compensable degree. 3. The Veteran's patellar tendinitis with patellar exostoses of the left knee manifested as pain and stiffness without limitation of flexion to a compensable degree. 4. The Veteran's right knee extension associated with patellar tendinitis with patellar exostoses of the right knee manifested as, at most, limitation to 10 degrees. 5. The Veteran's left knee extension associated with patellar tendinitis with patellar exostoses of the left knee manifested as, at most, limitation to 5 degrees. 6. The Veteran's right knee instability associated with patellar tendinitis with patellar exostoses of right knee is manifested by slight instability. 7. The Veteran's left knee instability associated with patellar tendinitis with patellar exostoses of the left knee is manifested by slight instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating of 50 percent, but no higher, for service-connected migraine headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.124(a), Diagnostic Code 8100. 2. The criteria for entitlement to a rating in excess of 10 percent for service-connected patellar tendinitis with patellar exostoses, right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Codes 5024-5260. 3. The criteria for entitlement to a rating in excess of 10 percent for service-connected patellar tendinitis with patellar exostoses, left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Code 5024-5260. 4. The criteria for entitlement to a rating in excess of 10 percent for service-connected right knee extension associated with patellar tendinitis with patellar exostoses, right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Code 5261. 5. The criteria for entitlement to a rating in excess of 0 percent for service-connected left knee extension associated with patellar tendinitis with patellar exostoses, left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Code 5261. 6. The criteria for entitlement to a rating in excess of 10 percent for service-connected right knee instability associated with patellar tendinitis with patellar exostoses, right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Code 5257. 7. The criteria for entitlement to a rating in excess of 10 percent for service-connected left knee instability associated with patellar tendinitis with patellar exostoses, left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.40, 4.45, 4.71(a), Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from June 1983 to November 2003. This appeal comes to the Board of Veterans' Appeals (Board) from a September 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a May 2020 decision, the Board, in pertinent part, denied increased ratings for the Veteran's migraine headaches and bilateral knee disabilities. The Board also remanded the issue of service connection for a left ankle condition. In a February 2021 rating decision, the RO granted service connection for left ankle strain with arthritis with an evaluation of 10 percent effective June 1, 2016. The Veteran did not disagree with the rating or effective date assigned to this award. Therefore, this is considered a full grant of benefits, and the issue of service connection for left ankle strain is no longer on appeal. Subsequently, the Veteran appealed the part of the May 2020 Board decision that denied increased ratings for migraine headaches and bilateral knee disabilities to the Court of Appeals for Veterans Claims (Court). In June 2021, the Court granted a Joint Motion for Partial Remand (JMPR), which vacated and remanded the Board's denial of increased ratings for migraine headaches and bilateral knee disabilities. Before turning to the analysis of the Veteran's claims, the Veteran had previously sought a total disability rating based on individual unemployability (TDIU). At the time of his filing, however, the Veteran indicated that he was still employed and earning a wage above the poverty threshold. There has been no indication of a change in the Veteran's employment status since that time. Accordingly, the issue of entitlement to a TDIU is not raised before the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In rating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity, or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or maligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). 1. Entitlement to a rating in excess of 30 percent for service-connected migraine headaches. A rating of 50 percent, but no higher, is warranted for the Veteran's service-connected migraine headaches. The Veteran's service-connected migraine headaches are rated at 30 percent under 38 C.F.R. § 4.124(a), Diagnostic Code 8100. Under Diagnostic Code 8100, a 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. A maximum 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124(a), Diagnostic Code 8100. The criteria for rating migraines are successive. Johnson v. Wilkie, 30 Vet. App. 245, 247 (2018). Successive criteria exist where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). Although 38 C.F.R. §§ 4.7 and 4.21 generally provide that symptoms need only more nearly approximate the criteria for a higher rating to warrant such a rating, those regulations do not apply where the rating schedule establishes successive criteria. The phrase "completely prostrating" (which is required for a 50 percent rating) is defined as "completely lacking in vitality or will" and "powerless to rise." Johnson v. Wilkie, 30 Vet. App. 245 (2018). The United States Court of Appeals for Veterans Claims (Court) has indicated this phrase means the headaches "must render the veteran entirely powerless." Id. at 253. This differs from "characteristic prostrating" (which is required for a 30 percent rating), which means that the migraine attacks "typically produce powerlessness or a lack of vitality." Further, "prolonged" has been defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. "[P]roductive of severe economic inadaptability" has been defined as either 'producing' or 'capable of producing' severe economic inadaptability." Id. (citing Pierce v. Principi, 18 Vet. App. 440 (2004)). "Economic inadaptability" does not mean unemployability, as such would undermine the purpose of regulations pertaining to a total disability rating based on individual unemployability. Pierce v. Principi, 18 Vet. App. 440, 446 (2004); 38 C.F.R. § 4.16. The Veteran was afforded a VA examination in July 2016. The Veteran reported experiencing constant head pain, throbbing head pain, pain localized to one side of the head, and pain on both sides of the head. The Veteran also endorsed nausea, sensitivity to light and sound, and changes to vision. The examiner noted that the typical duration of head pain was one to two days, and that the typical location was the left side. The examiner noted that the Veteran did not endorse characteristic prostrating attacks of migraine headache pain or non- migraine headache pain. The examiner noted that when headache pain occurred, the Veteran reported that he had to leave work to take his medication and lie down in a darkened room. The Veteran was afforded a VA examination in August 2018. The Veteran endorsed constant head pain, pulsating head pain, and pain on both sides of the head. The Veteran stated that pain worsened with physical activity. The examiner noted that the Veteran also experienced nausea, sensitivity to light and sound, and changes in vision. The typical duration of head pain was noted as less than one day with location on both sides of the head. The examiner noted that the Veteran experienced characteristic prostrating migraine attacks once monthly but did not have very prostrating and prolonged attacks of migraine or non-migraine pain productive of severe economic inadaptability. The Veteran was afforded a VA examination in January 2019. The examiner noted that the Veteran endorsed experiencing pulsating or throbbing head pain, pain on both sides of the head, and worsening pain with activity. The examiner noted that the Veteran also had nausea, sensitivity to light and sound, and changes in vision. Typical duration of pain was noted as one to two days with typical location of pain noted as both sides of the head. The examiner noted migraine and non-migraine characteristic prostrating attacks with a frequency of more than once per month. However, the examiner noted that the Veteran did not experience very prostrating and prolonged attacks of either migraine or non-migraine pain productive of severe economic inadaptability. The examiner noted that during episodes, the Veteran retreated to a dark and quiet room. Based on a thorough review of the medical and lay evidence, the Board finds that a rating of 50 percent, but no higher, is warranted for the Veteran's service-connected migraine headaches. The Veteran's migraine headache symptoms included pulsating and throbbing head pain, pain on both sides of the head, worsening pain with activity, nausea, sensitivity to light and sound, and changes in vision. The examiner noted that the typical duration of head pain was one to two days. Indeed, on his January 2019 VA examination, the examiner noted that the Veteran experienced characteristic prostrating attacks with a frequency of more than once per month. The Veteran's headaches were severe and prolonged. Although the VA examiners did not note that the Veteran's migraine headaches caused severe economic inadaptability, the Board finds otherwise. During his July 2016 VA examination, the Veteran reported that he had to leave work to take his medication and lie down in a darkened room. Again, on his January 2019 VA examination, the Veteran reported that his migraine headaches impacted his work in that during episodes, he had to retreat into dark/quiet room. Therefore, the Board finds that the severity, frequency, and duration of the Veteran's migraine headaches most closely approximate the criteria for a 50 percent rating under Diagnostic Code 8100. Additionally, the Board notes that the 50 percent is the maximum rating allowable under Diagnostic Code 8100; therefore, a rating in excess of 50 percent cannot be assigned. 2. Entitlement to a rating in excess of 10 percent for service-connected patellar tendinitis with patellar exostoses, right knee. 3. Entitlement to a rating in excess of 10 percent for service-connected patellar tendinitis with patellar exostoses, left knee. 4. Entitlement to a rating in excess of 10 percent for service-connected right knee extension associated with patellar tendinitis with patellar exostoses, right knee. 5. Entitlement to a rating in excess of 0 percent for service-connected left knee extension associated with patellar tendinitis with patellar exostoses, left knee. 6. Entitlement to a rating in excess of 10 percent for service-connected right knee instability associated with patellar tendinitis with patellar exostoses, right knee. 7. Entitlement to a rating in excess of 10 percent for service-connected left knee instability associated with patellar tendinitis with patellar exostoses, left knee. Increased ratings for the Veteran's bilateral knee disabilities are not warranted. The Veteran is seeking increased ratings for his service-connected bilateral knee disabilities. The Veteran is currently service-connected for the following knee disabilities: (1) patellar tendinitis with patellar exostoses, left knee rated at 10 percent under 38 C.F.R. § 4.71(a), Diagnostic Code 5024-5260; (2) patellar tendinitis with patellar exostoses, right knee rated at 10 percent under 38 C.F.R. § 4.71(a), Diagnostic Code 5024-5260; (3) right knee extension associated with patellar tendinitis with patellar exostoses, right knee rated at 10 percent under 38 C.F.R. § 4.71(a), Diagnostic Code 5261; (4) left knee extension associated with patellar tendinitis with patellar exostoses rated at 0 percent under 38 C.F.R. § 4.71(a), Diagnostic Code 5261; (5) right knee instability associated with patellar tendinitis with patellar exostoses, right knee rated at 10 percent under 38 C.F.R. § 4.71(a), Diagnostic Code 5257; and (6) left knee instability associated with patellar tendinitis with patellar exostoses, left knee rated at 10 percent under 38 C.F.R. § 4.71(a), Diagnostic Code 5257. Importantly, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71(a) were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. This change only effects the Veteran's claims for increase involving instability and malunion of the tibia and fibula, and the changes are discussed in greater detail below. Diagnostic Code 5256 pertains to ankylosis of the knee. 38 C.F.R. § 4.71(a). The previous version of Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, or a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. 38 C.F.R. § 4.71(a). The new version of Diagnostic Code 5257 retains ratings for recurrent subluxation or instability, providing a 30 percent rating for such instability with unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned for either a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or for an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is assigned 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. The revised Diagnostic Code 5257 also created a new rating for patellar instability; importantly, each of those ratings requires a diagnosed condition of patellar instability for application. Diagnostic Code 5258 provides for assignment of a 20 percent rating with semilunar cartilage dislocated with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71(a). Diagnostic Code 5259 provides for assignment of a 10 percent rating for removal of symptomatic semilunar cartilage. 38 C.F.R. § 4.71(a). Diagnostic Code 5260 provides for a 10 percent rating when flexion of the leg is limited to 45 degrees; a 20 percent rating when flexion is limited to 30 degrees; and a 30 percent rating when flexion is limited to 15 degrees. 38 C.F.R. § 4.71(a). Diagnostic Code 5261 provides for a 10 percent rating when extension is limited to 10 degrees; a 20 percent rating with extension limited to 15 degrees; a 30 percent rating with extension limited to 20 degrees; a 40 percent rating with extension limited to 30 degrees; and a 50 percent rating is assigned with extension limited to 45 degrees. 38 C.F.R. § 4.71(a). The previous version of Diagnostic Code 5262 provides ratings for impairment of the tibia and fibula. A 40 percent rating is assigned for nonunion with loose motion requiring a knee brace; a 30 percent rating is assigned for malunion with marked knee or ankle disability; a 20 percent rating is assigned for malunion with moderate ankle or knee disability; and a 10 percent rating is assigned for malunion with slight knee or ankle disability. 38 C.F.R. § 4.71(a). The new version of Diagnostic Code 5262 provides ratings for impairment of the tibia and fibula, to include medial tibial stress syndrome (MTSS) or shin splints. A 40 percent is assigned for nonunion with loose motion requiring a knee brace. It should also be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or MTSS, or shin splints. A 30 percent is assigned for malunion requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. A 20 percent is assigned for malunion requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity. A 10 percent is assigned for malunion requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities. A 0 is assigned for malunion requiring treatment less than 12 consecutive months, one or both lower extremities. Diagnostic Code 5263 provides for a 10 percent rating for genu recurvatum, acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated. 38 C.F.R. § 4.71(a). Normal flexion of the knee is to 140 degrees, and normal extension of the knee is to 0 degrees. 38 C.F.R. § 4.71, Plate II. Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. Where there is noncompensable limitation of motion, a 10 percent evaluation is assigned for each major joint or group of minor joints, where the limitation is objectively confirmed by swelling, muscle spasm, or satisfactory evidence of painful motion. Where there is no limitation of motion, a 10 percent evaluation is assigned for x-ray evidence of involvement of two or more major joints or minor joint groups, and a 20 percent evaluation is assigned for x-ray evidence of involvement of two or more major joints or minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71(a), Diagnostic Code 5003, Note (1). The knees are considered major joints. 38 C.F.R. § 4.45(f). The Veteran was afforded a VA examination in January 2016. The Veteran reported daily pain bilaterally. The examiner noted symptoms of pain and tenderness bilaterally. Flare-ups were reported to cause severe pain bilaterally. However, functional loss was denied. Initial range of motion measurements for the right knee were as follows: flexion, 0 to 120 degrees; extension, 120 to 0 degrees. Initial range of motion measurements for the left knee were as follows: flexion, 0 to 120 degrees; extension, 120 to 0 degrees. Pain was noted during rest and non-movement and during flexion and extension bilaterally. No evidence of pain with weight bearing was noted. No evidence of localized tenderness or pain on palpation was noted bilaterally. No crepitus was noted bilaterally. Observed repetitive use testing was performed, but no additional functional loss or range of motion after three repetitions was noted bilaterally. Repeated use over time testing was performed. However, it was observed that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The examination was conducted during a flare-up. However, it was observed that pain, weakness, fatigability, or incoordination does not significantly limit functional ability with flare-ups. Muscle strength was recorded as five out of five bilaterally. No muscle atrophy was noted. Ankylosis was denied. Recurrent subluxation, lateral instability, and recurrent effusion were all denied bilaterally. Joint stability testing was performed. However, there was no joint instability found bilaterally. Recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome and any other tibial or fibular impairment were all denied bilaterally. No history of a meniscus condition was noted on either side. Regular use of knee braces was endorsed. The Veteran was afforded a VA examination in July 2016. The examiner noted bilateral patellar tendinitis with patellar exostoses. The Veteran reported increased pain bilaterally. The examiner noted symptoms of pain and tenderness bilaterally. Flare-ups were reported to cause severe sharp aching pain in both knees with duration noted as minutes to hours and frequency noted as daily. The Veteran reported functional loss in that he had more difficulty walking. He stated that if he made sudden movements, it felt like his knees might give out. He stated that he was unable to be as active as he once was. Initial range of motion measurements for the right knee were as follows: flexion, 10 to 120 degrees; extension, 120 to 10 degrees. Initial range of motion measurements for the left knee were as follows: flexion, 5 to 120 degrees; extension, 120 to 5 degrees. Pain was noted on examination and caused functional loss bilaterally. Mild tenderness to palpation of the joints were noted bilaterally. Evidence of pain with weight bearing was noted bilaterally. Evidence of crepitus was noted bilaterally. Observed repetitive use testing was performed, but no additional functional loss or range of motion after three repetitions was noted. Repeated use over time testing was not performed. The examination was not conducted during a flare-up. No other additional factors contributing to disability were noted. Muscle strength was recorded as four out of five bilaterally with reduction in strength attributed entirely to the bilateral knee condition. No muscle atrophy was noted. Ankylosis was denied. Recurrent subluxation, lateral instability, and recurrent effusion were all denied bilaterally. Recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome and any other tibial or fibular impairment were all denied bilaterally. No history of a meniscus condition was noted on either side. Regular use of knee braces was endorsed. A July 2017 orthopedic surgery consult indicated that the Veteran's flexion was limited to 90 degrees bilaterally. The Veteran was afforded a VA examination in January 2019. The examiner noted diagnoses of bilateral knee joint osteoarthritis, bilateral instability, and bilateral patellar tendinitis with patellar exostoses. The Veteran reported pain and stiffness when walking greater than fifty feet. Initial range of motion measurements for the right knee were as follows: flexion, 0 to 130 degrees; extension, 130 to 10 degrees. Initial range of motion measurements for the left knee were as follows: flexion, 0 to 130 degrees; extension, 130 to 0 degrees. Pain was noted on examination during flexion and extension, but it was noted not to result in functional loss bilaterally. No localized tenderness or pain on palpation of the joints were noted bilaterally. No evidence of pain with weight bearing was noted bilaterally. No evidence of crepitus was noted bilaterally. Observed repetitive use testing was performed, but no additional functional loss or range of motion after three repetitions was noted. Repeated use over time testing was not performed. The examination was not conducted during a flare-up. Additional factors contributing to disability were noted as interference with sitting and standing. Muscle strength was recorded as five out of five bilaterally. No muscle atrophy was noted. Ankylosis was denied. Joint instability testing was performed, which revealed a result of 1+ on all tests bilaterally. Recurrent subluxation, lateral instability, and recurrent effusion were all denied bilaterally. Recurrent patellar dislocation was indicated bilaterally. However, the examiner noted that it did not affect range of motion bilaterally. When taken together as a whole and with consideration of the other medical evidence of record, the Board finds the January 2016, July 2016, and January 2019 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, medical expertise, adequate findings, sufficient rationales, and proper consideration of the Veteran's lay statements. As for whether the Veteran's bilateral knee disabilities should receive a higher rating under Diagnostic Code 5257 for knee instability, the Board concludes that a higher rating would not be warranted. The Board has considered the Veteran's lay statements regarding complaints of instability. For example, in a March 2015 clinical note, the Veteran reported bilateral knee pain with subjective instability. On his July 2016 VA examination, the Veteran reported that if he made sudden movements, he felt like his knees would give out. However, on his January 2019 VA examination, joint instability testing was performed, which revealed a result of only 1+ on all tests bilaterally. Additionally, the VA examiner noted that it did not affect range of motion. Taking into consider the medical evidence of record and the Veteran's lay statements, the Board finds that the Veteran's instability of his bilateral knee joints cannot be considered to be more than slight. Therefore, a rating in excess of 10 percent for the Veteran's bilateral knee instability is not warranted under Diagnostic Code 5257. Also, the newer version of the criteria is not applicable. Separate ratings are not warranted under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263. The medical evidence of record and lay statements do not show that the Veteran has had ankylosis, a dislocated semilunar cartilage, a removed semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. The Veteran's bilateral knee disabilities caused pain, stiffness, and tenderness bilaterally. The Veteran had severe, sharp aching pain in both knees with duration noted as minutes to hours, and frequency noted as daily. The Veteran reported functional loss in that he had more difficulty walking. The Veteran was unable to be active as he once was. On his January 2016 VA examination, initial range of motion measurements revealed right knee flexion 0 to 120 degrees and right knee extension from 120 to 0 degrees. Initial range of motion measurements for the left knee revealed flexion from 0 to 120 degrees and extension from 120 to 0 degrees. On his July 2016 VA examination, initial range of motion measurements for the right knee revealed flexion from 10 to 120 degrees and right knee extension from 120 to 10 degrees. Initial range of motion measurements for the left knee revealed flexion from 5 to 120 degrees and extension from 120 to 5 degrees. On his January 2019 VA examination, initial range of motion measurements for the right knee revealed flexion from 0 to 130 degrees and extension from 130 to 10 degrees. Initial range of motion measurements for the left knee revealed flexion from 0 to 130 degrees and extension from 130 to 0 degrees. Additionally, a July 2017 orthopedic surgery consult indicated that the Veteran's right and left knee flexion was limited to 90 degrees. Based on the foregoing, it has not been shown that increased ratings are warranted under Diagnostic Codes 5261 and 5260 for the Veteran's bilateral knee disabilities. The Board has also considered the Veteran's lay statements regarding the Veteran's symptomatology. The Board notes that the Veteran is competent to report observations regarding the severity of his symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, and 1376-77 (Fed. Cir. 2007). The Board finds these lay statements to be credible and consistent with the ratings assigned. To the extent he argues that his symptomatology is more severe, the Veteran's statements must be weighed against the other evidence of the record. Here, the specific examination findings of trained health care professionals and documented medical treatment records are of greater probative weight than the more general lay assertions that a higher rating is warranted. Of final note, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, increased ratings are not assignable for the Veteran's service-connected bilateral knee disabilities. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Crawford, 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.