Citation Nr: 21070442 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 11-17 830 DATE: November 24, 2021 ORDER Entitlement to a rating in excess of 10 percent for a right knee condition manifested by impairment of motion is denied. Entitlement to a 10 percent rating, but no more, for right knee instability is granted. REMANDED Entitlement to a rating in excess of 10 percent for a left knee condition is remanded. FINDINGS OF FACT 1. For the entirety of the appeal period, the Veteran's right knee patellofemoral syndrome is manifested by flexion limited to no less than 120 degrees, full extension, and no ankylosis, impairment of the tibia or fibula, or dislocated semilunar cartilage; however, the right knee has been actually painful for the entire appeal period. 2. For the entirety of the appeal period, the Veteran has exhibited slight instability of the right knee; however, at no point has the left knee exhibited moderate or worse instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for a right knee condition manifested by limitation of motion are not met for the entirety of the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5099-5010, 5260, 5261. 2. A 10 percent rating, but not higher, is warranted for right knee instability for the entirety of the appeal period. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 2001 to December 2003. This matter was last before the Board in March 2020, whereupon the claims seeking increased ratings for the right and left knee conditions were both denied. Following the Veteran's appeal, the U.S. Court of Appeals for Veterans Claims (Court) in January 2021 issued a Joint Motion for Remand (JMR) in which the Court vacated the Board's March 2020 decision as it pertained to the increased ratings claims and remanded the matter back to the Board. The Board is now addressing the two increased ratings claims once again with additional consideration of the rationale outlined by the Court in support of its JMR. The Board has considered whether a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has been raised by the Veteran during the pendency of this appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that VA must address the issue of entitlement to TDIU in increased-rating claims when the issue of unemployability either is raised expressly or by the record. The Court's guidance in Rice applies even in the instant case where the Veteran has expressly raised the issue of entitlement to TDIU and that separate claim has been adjudicated in a final decision. As such, although the Board acknowledges that it denied entitlement to TDIU in a November 2020 decision, the question of whether entitlement to TDIU has been raised by the extant increased rating claim before it must be contended with. That being said, a review of available VA treatment records as well as correspondence from the Veteran does not reflect that the Veteran contends that the symptomatology associated with her bilateral knee conditions has precluded her from securing and following substantially gainful employment. Although it is acknowledged that the Veteran ceased working in 2009, evidence obtained from her former employer indicates that she left of her own accord and was not let go due to limitations from her various disabilities. Moreover, the various VA examiners who have evaluated the severity of the bilateral knee conditions did not find that together they had such a severe impact on the Veteran's occupational functioning during the appeal period that she was precluded from securing and following substantially gainful employment. Accordingly, a claim for TDIU has not been raised by the record in the instant appeal, and the Board need not reassess whether TDIU is warranted on the basis of the bilateral knee condition increased rating claims. Increased Rating for the Right Knee Condition The Veteran is service connected for a right knee condition, characterized as patellofemoral pain syndrome. The condition has been rated as 10 percent disabling for the entirety of the appeal period. As the Veteran filed her claim seeking an increase of the evaluations for the bilateral knee conditions on November 4, 2009, the relevant time period of evaluation is up to one year prior to the filed claim, that is, from November 4, 2008. To that end, the Board notes that any increase in severity must have become "factually ascertainable" within this one-year period prior to the date of the claim. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o); VAOPGCPREC 12-98 (1998). The Veteran seeks an evaluation in excess of 10 percent rating for the entirety of the appeal period. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, "pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a 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. As will be discussed, none of the diagnostic codes applicable to the evaluation of the Veteran's various musculoskeletal conditions on appeal were altered by these amendments, except for the criteria for evaluating instability of the knees; any ancillary impacts to each the various evaluations detailed below are discussed in due course. When electing whether to apply the amended criteria or the criteria previously in place, the Board will apply those criteria that are most beneficial to the Veteran. For the period from December 31, 2003 to August 9, 2012, the right knee condition was rated pursuant to 38 C.F.R. § 4.71a, 5099-5010. Diagnostic Code 5099 represents an unlisted disability requiring rating by analogy to one of the disorders listed under 38 C.F.R. § 4.71a; 38 C.F.R. §§ 4.20, 4.27. Pertinent regulations do not require that all cases show all the findings specified by the Rating Schedule, but findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. In the present case, the Veteran's knee disability has been rated as analogous to traumatic arthritis under Diagnostic Code 5010. Diagnostic Code 5010 provides that traumatic arthritis will be rated as analogous to degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, where limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Furthermore, a 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010. The 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Id., Note 1. In addition, the 20 percent and 10 percent ratings based on x-ray findings will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024. Id., Note 2. Before evaluating the propriety of the Veteran's disability rating for the right knee condition, the Board notes that the diagnostic code for evaluating musculoskeletal conditions under 5010 was revised to specify that this evaluation is to be used solely for the evaluation of post-traumatic arthritis as opposed to degenerative arthritis. Restricting the definition of Diagnostic Code 5010 ultimately serves only to preclude the assignment of a 10 percent rating pursuant to Diagnostic Code 5003 where there is noncompensable limitation of motion. That being said, when a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant generally applies. Only the former criteria can be applied for the period prior to the effective date of the new criteria. As such, the Board may consider the applicability of a 10 percent rating pursuant to Diagnostic Code 5003 as per Diagnostic 5010 despite the recent amendments, as the ratings at issue are effective prior to the date of the amendments. See VAOPGCPREC 7-2003 (Nov. 19, 2003); see also 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114. Moving on, for the period from August 9, 2012 to October 4, 2016, the right knee condition was rated pursuant to Diagnostic Code 5260. Most recently, effective October 4, 2016, the right knee condition has been rated pursuant to Diagnostic Code 5261. The Board will consider additional diagnostic codes pertinent to the evaluation of knee disabilities in order to determine the highest possible evaluation for the bilateral knee conditions during the entire period of the appeal. In considering the applicability of the remaining available diagnostic codes, the Board finds that Diagnostic Codes 5256 (ankylosis), 5258 (dislocated semilunar cartilage), 5259 (symptomatic removal of semilunar cartilage), 5262 (disability of the tibia and fibula), and 5263 (genu recurvatum) are not applicable in this instance, as the medical evidence does not show that the Veteran experiences these conditions in either knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257 (both prior to and since February 7, 2021), 5258, 5259, 5263. Under Diagnostic Code 5260, limitation of flexion of the leg, a noncompensable rating is assigned when flexion is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg, a noncompensable rating is assigned when extension is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a. For VA purposes, "normal" extension and flexion of the knee is from zero to 140 degrees, and references to normal motion below indicate that the Veteran, in fact, had motion from zero to 140 degrees. 38 C.F.R. § 4.71a, Plate II. The VA General Counsel has held that a knee disability may receive separate ratings under diagnostic codes evaluating instability (Code 5257) and those evaluating range of motion (Codes 5003, 5010, 5256, 5260, and 5261). See VAOPGCPREC 23-97. The Board additionally notes that separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling, moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. That being said, Diagnostic Code 5257 was amended effective February 7, 2021 to provide ratings for recurrent subluxation or lateral instability. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Diagnostic Code 5257 also provides for ratings based on patellar instability. A 30 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 a brace and either a cane or a 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 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. Note [1] to Diagnostic Code 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to Diagnostic Code 5257 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration. The Veteran was first afforded a VA examination during the appeal period to evaluate the nature and severity of her bilateral knee conditions in March 2010, during which she reported experiencing bilateral knee pain precipitated by long periods of standing, especially while working in her former occupation. When queried, she did not endorse experiencing any flare-ups of musculoskeletal pain. Range of motion testing revealed no loss of flexion or extension. Furthermore, the examiner did not note any evidence of pain on motion or ankylosis. In summation, the examiner found that the bilateral knee conditions resulted in impairment in occupational functioning in the form of pain with prolonged standing. That being said, the examiner also determined that the Veteran was fully capable of carrying out most occupational tasks including physical and sedentary. The severity of the bilateral knee conditions was next evaluated in a January 2011 VA joints examination, during which the Veteran reported that she experienced constant severe aching pain in both knees. Range of motion testing revealed left knee flexion reduced to 110 degrees and right knee flexion reduced to 120 degrees, with no additional limitations after three repetitions of range of motion or joint ankylosis. An in-person physical examination also revealed pain, stiffness, weakness, decreased speed of joint motion, swelling, crepitus, and tenderness. The Veteran denied any flare-ups of additional symptomatology, and there was no evidence of subluxation, instability, or effusions. The examiner noted that the Veteran was able to stand for 15-30 minutes at a time and was able to walk for a quarter of a mile at a time. It was also noted that the Veteran utilized a brace frequently to assist with ambulation. X-ray examinations dating from June 2009 did not reveal any abnormalities. In summation, the examiner found that the bilateral knee conditions resulted in impairment of occupational functioning in the form of decreased mobility and pain resulting in increased absenteeism and mild effects on physical employment, with no impact on sedentary employment. The Veteran was next afforded a VA knee examination in August 2012, during which she again reported experiencing constant severe aching pain, intermittent swelling, and sometimes weakness. The Veteran also endorsed experiencing flare-ups of additional pain precipitated by prolonged standing, sitting, or walking. Alternatively, she related that cold weather made her knees feel stiffer. Range of motion testing revealed flexion reduced to 130 degrees bilaterally and no loss of extension, with no additional loss of range of motion after repetitive use testing. Further evaluation revealed no instability or ankylosis, although the examiner did acknowledge that pain would result in some loss of functioning. In summation, the examiner found that the bilateral knee conditions would result in impairment of occupational functioning in the form of decreased mobility and pain resulting in mild effects on physical employment, with no impact on sedentary employment. The severity of the bilateral knee condition was evaluated in an October 2016, during which the Veteran reported experiencing constant pain in her knees as well as popping and cracking. She also detailed that she noticed bruising on the medial aspects of both knees. In addition, the Veteran reported experiencing intermittent swelling in the knees upon awakening or in the evening. According to the Veteran, her right knee gave way on occasion. She related that she treated her bilateral knee symptomatology with heat and ice, pain medication, and through the use of knee braces. She did not endorse experiencing flare-ups of symptomatology but did report that prolonged standing and walking made the pain worse. Furthermore, she detailed that she experienced tightness and stiffness upon climbing stairs. Range of motion testing revealed flexion reduced to 120 degrees in the right knee and reduced to 130 degrees in the left knee, with no loss of extension in either knee. The examiner did not note evidence of pain with weight-bearing, crepitus, ankylosis or instability, but did note patellar tenderness bilaterally. There was no additional loss of functioning following repetitive use testing. The examiner was unwilling to estimate any additional loss of function following repeated use, stating that do so without being present would require resorting to speculation. Radiographic testing did not reveal any abnormalities. In summation, the examiner found that the bilateral knee conditions would have no impact on the Veteran's ability to perform sedentary employment and a moderate impact on the Veteran's ability to perform physical employment due to pain upon prolonged standing/walking, squatting, kneeling, or climbing stairs. During the most recent VA knee examination, dated in October 2019, the Veteran reported that she felt a grinding sensation in her knees bilaterally and further detailed that her knees felt very heavy. She asserted that her right knee would give way at times. According to the Veteran, she experienced constant pain in both knees, and was precluded from squatting, kneeling, or running due to the pain in her knees. She did not endorse experiencing flare-ups of symptomatology. Range of motion testing did not reveal any loss of flexion or extension. However, the October 2019 examiner did note evidence of pain with weight-bearing as well as tenderness bilaterally at both the suprapatellar and medial patella areas. There was no additional loss of functioning following repetitive use testing, and while the examiner did acknowledge that the Veteran would experience additional pain following repeated use, he estimated that the additional pain would not result in any loss of range of motion. The examiner also did not note any instability, crepitus, or ankylosis. In summation, the examiner found that the bilateral knee conditions would result in impairment of occupational functioning in the form of causing pain from squatting, bending at the knee, or prolonged kneeling as well as ascending ladders due to knee flexion and pain. A review of post-service VA medical records reflects that the Veteran's bilateral knee conditions have been listed as an active problem for the entirety of the appeal period. In an April 2010 outpatient note, it was reported that the Veteran was experiencing right lower extremity weakness, contributing to her instability of ambulation. However, the Veteran did not specifically complain of her right knee giving way. The Veteran has submitted private medical records pertaining to the treatment of her various medical conditions outside of the VA system. Records from a Manchester Memorial Hospital received by VA in July 2015 do not show any specific treatment for bilateral knee pain. Records from a Grace Health received by VA in October 2018 show that the Veteran in April 2018 reported experiencing weakness in her bilateral knees that had been occurring for the past three or four years, as well as pain and crepitus. Previously, a March 2018 outpatient record reflects that she denied any locking of the right knee. She was recommended for a right knee brace. Separate records from UK HealthCare also received by VA in October 2018 show that in April 2018 the Veteran sought treatment for right knee pain following an incident in which she twisted the right knee and began experiencing increased pain after she heard a pop in her knee. According to the Veteran, her right knee felt like the bones were grinding. A radiographic examination of the right knee at that time revealed moderate size joint effusion with no bony abnormality. In an October 2021 statement, the Veteran asserted that when she stands or walks her kneecaps bilaterally feel like they are grinding together and exhibit both popping and cracking. According to the Veteran, the pain and stiffness in her knees was worse upon waking in the morning as well as in the evening after walking for an entire day. She detailed that she uses a brace on her knees and that she has increasingly relied on her knee brace to improve her stability while walking. Even with the use of braces and consistent physical therapy, the Veteran contends that she cannot sit for more than an hour due to knee stiffness and cannot walk more than one-third of a mile at a time due to knee pain, swelling, and instability. She also asserted that she could not kneel or crouch due to knee pain. Upon consideration of the evidence, the Board finds that a rating in excess of 10 percent for the right knee patellofemoral syndrome manifested by limitation of motion is not warranted at any point during the appeal period. The available evidence, to specifically include the five VA examinations of record, does not reflect that the Veteran experienced any of the symptomatology that would warrant a compensable rating for the right knee under any of the possible applicable diagnostic criteria that evaluate the severity of any limitation of motion. At no point has the Veteran exhibited a loss of flexion or extension that would warrant a compensable rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Although she reported that her right knee would lock up at times, there is no indication that she experienced any dislocated semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5258. The Board also notes that there is no evidence of ankylosis (Diagnostic Code 5256) or impairment of the tibia or fibula (Diagnostic Code 5262). However, the Board does find that the Veteran credibly reported experiencing pain upon ambulation in the right knee, and as such she is entitled to at least a minimal 10 percent initial rating for the right knee condition for the entire period of the appeal. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. In awarding the 10 percent rating for the right knee condition, the Board acknowledges that the provisions of the amendments to 38 C.F.R. § 4.71a apply to claims pending before the Board prior to February 7, 2021 that have not been decided as of that date. Although Diagnostic Codes 5260 and 5261 were not changed by the amendments, application of those criteria results only in a noncompensable rating. As such, the current 10 percent rating is based on application of the criteria for rating traumatic arthritis under Diagnostic Code 5010, which allows for a 10 percent rating as analogous to Diagnostic Code 5003. The Board previously detailed that the recent amendments eliminated this alternative avenue for entitlement to a compensable rating under Diagnostic Code 5010. Accordingly, the Board will apply the previous criteria for rating traumatic arthritis under Diagnostic Code 5010 to allow for this 10 percent rating for the entirety of the appeal period. That being said, even if the Board applies the previous criteria, there is no support for a grant of an increase to a 20 percent rating, which would require x-ray evidence of arthritis with involvement of 2 or more major joints, and is not reflected in the record. 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010. The Board has reviewed the Veteran's lay testimony and the VA treatment records in the claims file, but this evidence does not tend to show that the symptoms of the right knee condition warranted a rating in excess of 10 percent for limitation of motion at any point during the appeal period. As stated, for any additional functional loss to warrant a higher rating, that loss must rise to the level of the more severe symptomatology represented by the ratings in excess of those assigned, which has not been shown. Furthermore, the Board acknowledges that the Veteran reported experiencing flare-ups of bilateral knee symptomatology on the August 2012 VA examination, and the examiner did not opine as to whether the Veteran would experience any additional impairment of function during such flare-ups of symptoms. Moreover, the October 2016 examiner declined to address the issue of increased impairment following repeated use as well, claiming that to do so would require a resort to speculation. That being said, there is no indication from the record that the Veteran would exhibit such a dramatic increase in right knee impairment to warrant a rating in excess of 10 percent at any point during the appeal period. Indeed, she herself stated during the August 2012 examination that her flare-ups amounted to an increase of pain and stiffness without any specific loss of function. Moreover, each examiner other than the October 2016 examiner found that there would be no additional significant loss of impairment following repeated use of the knees. This is further underscored by the fact that the August 2012 examiner explicitly did not find that the flare-ups would contribute to any additional loss of flexion. Accordingly, the Board does not find that the Veteran's symptoms during a flare-up or following repeated use would be so significant as to equate to flexion reduced to 30 degrees, as would be necessary for an evaluation in excess of the currently assigned ratings or which would warrant a separate rating. Sharp, supra; Correia, supra. The Board acknowledges the Veteran's statements regarding the pain and stiffness she experiences in her right knee. However, painful motion is contemplated and compensated by the 10 percent rating that is currently assigned. DeLuca, supra. Therefore, the Board finds that the assigned 10 percent rating for the right knee condition from November 4, 2009 contemplates the impaired motion exhibited by the Veteran during the appeal period. A rating in excess of that 10 percent is not warranted for limitation of motion of the right knee at any point during the appeal period. Turning to the question of claimed instability, the Board acknowledges that the Veteran has consistently reported experiencing "giving way" in her right knee contributing to instability of station. As most recently detailed in the October 2021 statement, the Veteran contends that this feeling of "giving way" has caused her to avoid many physical activities, to include walking her dog. After a thorough review of the available medical evidence and lay testimony, the Board finds that a separate 10 percent rating, but no more, is warranted for right knee instability for the entirety of the appeal period. Specifically, although instability has never been noted on any of the five VA examinations of records despite testing, the Board finds that the evidence of record is at least in equipoise as to whether the Veteran experiences the slight instability that is necessary to warrant a 10 percent rating pursuant to Diagnostic Code 5257. To that end, the Board notes that it is unclear from the record whether the Veteran's right knee instability would qualify as "persistent" under the newly revised criteria for evaluating knee instability. However, the Board will apply the criteria most favorable to the Veteran, and in this instance the criteria in place prior to the February 2021 amendments allow for the newly assigned 10 percent disability rating. That being stated, the Board cannot establish that the Veteran exhibited any more than slight instability at any point during the appeal period, as again she has never been formally evaluated as having any instability of station due to her right knee disability, to include on multiple VA examination wherein instability was specifically tested for. Accordingly, a separate 10 percent rating, but no more, for right knee instability is warranted for the entirety of the appeal period, that is, from November 4, 2009. Of final note, the Veteran has not 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). REASONS FOR REMAND Entitlement to an increased rating for a left knee condition is remanded. As detailed above, the Veteran has submitted correspondence in October 2021 wherein she described her symptomatology and the extent to which it has contributed to impairment of her physical functioning. In reviewing that correspondence, the Board finds that it appears that the Veteran is asserting that the symptomatology of her left knee condition has worsened since it was last evaluated in an October 2019 VA examination. Specifically, the Veteran asserted that she experienced instability in her left knee with the same degree of frequency as her right knee and used a knee brace on both knees. This is a significant deviation from her prior assertions in which she contended only that she experienced instability in her right knee. In light of the apparent escalation in the severity of the left knee symptomatology, the Veteran is entitled to be scheduled for a new VA examination to evaluate the current severity of the left knee condition, with a specific focus on determining whether she experiences left knee instability, and, if so, how severe that instability is. Hart v. Mansfield, 21 Vet. App. 505 (2007). This matter is REMANDED for the following action: Schedule the Veteran for a VA examination for the purpose of determining the current level of impairment from the service-connected left knee condition, utilizing the most up-to-date Disability Benefits Questionnaire. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of any associated functional effects of the left knee condition, with specific attention paid to detailing whether the Veteran experiences any instability of station that is attributable to her left knee condition. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups of the left knee, if they are endorsed by the Veteran. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. With regard to the matters above, if it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). All opinions must be supported by a rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Collins, 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.