Citation Nr: 21071850 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 18-35 599 DATE: December 1, 2021 ORDER Entitlement to ratings in excess of 10 percent for the period prior to October 11, 2016 and in excess of 60 percent for the period from November 1, 2018, onward, for total left knee replacement (previously rated as chondromalacia, left knee) is denied. Entitlement to ratings in excess of 10 percent for the period prior to December 13, 2016; 30 percent for the period from February 1, 2017 through November 9, 2017; and 60 percent for the period from January 1, 2019, onward, for total right knee replacement (previously rated as chondromalacia, right knee) is denied. Entitlement to a separate rating in excess of 10 percent for the period from February 7, 2021, onward, for left knee instability is denied. Entitlement to a separate rating in excess of 10 percent for the period from February 7, 2021, onward, for right knee instability is denied. FINDINGS OF FACT 1. For the period prior to October 11, 2016, the Veteran's left knee disability did not more nearly approximate flexion limited to 30 degrees or less or extension limited to 15 degrees or more. 2. For the period from November 1, 2018, onward, the Veteran's left knee disability was rated at the maximum schedular rating under Diagnostic Code (DC) 5055. 3. For the period prior to December 13, 2016, the Veteran's right knee disability did not more nearly approximate flexion limited to 30 degrees or less or extension limited to 15 degrees or more. 4. For the period from February 1, 2017 through November 9, 2017, the Veteran's right knee disability was manifested by no more than intermediate degrees of residual weakness, pain, or limitation of motion with flexion no worse than 80 degrees, normal extension, and no ankylosis. 5. For the period from January 1, 2019, onward, the Veteran's right knee disability was rated at the maximum schedular rating under DC 5055. 6. For the period from February 7, 2021, onward, the Veteran's left knee disability has been shown to be productive of no worse than mild instability. 7. For the period from February 7, 2021, onward, the Veteran's right knee disability has been shown to be productive of no worse than mild instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to ratings in excess of 10 percent for the period prior to October 11, 2016 and in excess of 60 percent for the period from November 1, 2018, onward, for total left knee replacement (previously rated as chondromalacia, left knee) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.21, 4.71a, DC 5260, 5261, 5055. 2. The criteria for entitlement to ratings in excess of 10 percent for the period prior to December 13, 2016; 30 percent for the period from February 1, 2017 through November 9, 2017; and 60 percent for the period from January 1, 2019, onward, for total right knee replacement (previously rated as chondromalacia, right knee) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.21, 4.71a, DC 5260, 5261, 5055. 3. The criteria for entitlement to a separate rating in excess of 10 percent for the period from February 7, 2021, onward, for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.21, 4.71a, DC 5257. 4. The criteria for entitlement to a separate rating in excess of 10 percent for the period from February 7, 2021, onward for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.21, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1982 to February 1987. She served honorably in the U.S. Army, including service in the Republic of Korea. The Board thanks the Veteran for her service to our country. The issues of left and right knee increased ratings were previously before the Board in July 2019, when the Board denied the claims. The Veteran appealed the Board's decision to the U.S. Court of Appeals for Veterans Claims (Court). In an April 2020 Order, granting an April 2020 Joint Motion for Partial Remand (Joint Motion), the Court vacated and remanded the July 2019 Board decision consistent with the terms of the Joint Motion, concluded that it did not have jurisdiction over the remanded claims of service connection for posttraumatic disorder and total disability rating due to individual unemployability, and dismissed the appeal as to the remaining issue of entitlement to a combined 10 percent evaluation under 38 C.F.R. § 3.324. The Board remanded this case in September 2020 for additional development. In a February 2021 decision, the Board granted separate ratings of 10 percent for left and right knee instability and remanded the issues of increased ratings for left and right total knee replacements (previously rated as left and right knee chondromalacia) and for left and right knee instability from February 7, 2021, onward. The case has now returned to the Board for further appellate review. Increased Rating 1. Entitlement to ratings in excess of 10 percent for the period prior to October 11, 2016 and in excess of 60 percent for the period from November 1, 2018, onward, for total left knee replacement (previously rated as chondromalacia, left knee) is denied. 2. Entitlement to ratings in excess of 10 percent for the period prior to December 13, 2016; 30 percent for the period from February 1, 2017 through November 9, 2017; and 60 percent for the period from January 1, 2019, onward, for total right knee replacement (previously rated as chondromalacia, right knee) is denied. 3. Entitlement to a separate rating in excess of 10 percent for the period from February 7, 2021, onward, for left knee instability is denied. 4. Entitlement to a separate rating in excess of 10 percent for the period from February 7, 2021, onward for right knee instability is denied. The Veteran generally contends that increased ratings are warranted for her left and right knee disabilities. Specifically, she contends that ratings in excess of 10 percent for her left and right knee disabilities prior to her total knee replacements are warranted as her deteriorating disabilities led to the surgeries. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The current claim for increase was filed in May 2014, and the Board will look at the evidence within the year prior to that filing to determine whether an increase occurred within that time frame. Under DC 5260, for limitation of flexion of the leg, a noncompensable rating is warranted for flexion limited to 60 degrees, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. Under DC 5261, for limitation of extension of the leg, a noncompensable rating is warranted for extension limited to 5 degrees, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. Under DC 5055, prosthetic replacement of a knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity warrants a 60 percent rating. With intermediate degrees of residual weakness, pain, or limitation of motion, the disability is to be rated by analogy to DCs 5256, 5261, or 5262. The minimum rating is 30 percent. During the pendency of the instant appeal, VA promulgated new regulations governing ratings for musculoskeletal system and muscle disabilities, effective February 7, 2021. See 85 Fed. Reg. 76,453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a veteran's appeal, the version most favorable to the veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to her claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. While there have been no changes to DCs 5260 or 5261, DC 5055 for knee replacement has been amended; however, the revisions are not for application given the facts of the case. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board has reviewed all of the evidence in the Veteran's record. Although the Board is required to provide reasons and bases supporting its decision, there is no need to discuss each item of evidence in the record. The Board will summarize the pertinent evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence of record shows, or does not show, with respect to the claim. See Gonzalez v. West, 218 F.3d 1278, 1380-81 (Fed. Cir. 2000). The Veteran's left knee was assigned a total rating for the period from October 11, 2016 through October 31, 2018; accordingly, this period is not for consideration by the Board with respect to the left knee. Her right knee was assigned total ratings for the periods from December 13, 2016 through January 31, 2017 and November 10, 2017 through December 31, 2018; accordingly, these periods are not for consideration by the Board with respect to the right knee. In a July 2014 VA examination report, the Veteran did not report that flare ups impacted the function of the knee or lower leg. She reported pain and stiffness in both knees after prolonged standing and during and after long walks and stated that the symptoms only lasted a short time. On examination, the examiner noted normal flexion and extension with no objective evidence of painful motion bilaterally. The examiner noted no limitation of motion bilaterally on observed repetitive use. The examiner noted that pain limited functional ability during flare-ups or after repeated use over time but concluded that range of motion could not be estimated as the Veteran was unable to replicate the estimated limitation at the time of examination. Joint stability testing was normal and the examiner noted that there was no history of recurrent patellar subluxation or dislocation, no tibial and/or fibular impairment, and no meniscal condition. The examiner noted crepitus with patella femoral movement and noted no other pertinent physical findings, complications, conditions, signs, and/or symptoms. The examiner noted that she occasionally used knee braces when needed for pain. The examiner concluded that functioning was not so diminished that she would be equally well served by amputation with prosthesis. The examiner concluded that her left and right knee disabilities had no impact on her ability to work. In an August 2014 women's health history and physical note, the Veteran reported that she had managed her knees with exercise, keeping her weight controlled, pain medications, and braces. She denied prior orthotic evaluation, imaging, physical therapy, or other formal intervention. She denied swelling. The provider noted no effusions or deformity, full range of motion bilaterally, slight "J tracking" of the right knee, bilateral crepitus, normal ligament testing, and normal McMurray testing. In an April 2015 private note, the Veteran reported that pain had been worse in the last few months to the point where it was difficult to squat, go up or down the stairs, or run. She reported that she was only able to cycle without pain. She reported that she enjoyed lifting weights and was in significant pain with leg extension. She reported trying braces, ibuprofen, diclofenac, and meloxicam without relief. She complained of pain, giving way, locking, and crepitus. With respect to the right knee, the provider noted no erythema, warmth, or swelling; full range of motion; moderate crepitus; and no appreciable instability. With respect to the left knee, the provider noted no erythema or warmth, some swelling, some crepitus, and mildly diminished balance and coordination. In an April 2015 private left knee MRI report, the provider noted ligaments and tendons intact, normal menisci, mild lateral subluxation, and small-to-moderate joint effusion. Later that month, she reported pain which was worse with any type of running or movement. She reported that she tried to run over the weekend, which gave her more pain. She reported treating with anti-inflammatory medications including ibuprofen and meloxicam with continuing pain. Her provider encouraged her to avoid running and to begin walking, swimming, or cycling. The provider discussed with the Veteran an eventual need for arthroscopy or unicompartmental or total knee arthroplasty. In May 2015, the Veteran received viscosupplementation injections and reported some improvement. A June 2015 imaging report showed normal bilateral knees with no effusion or fractures. In an orthopedic consultation from the same day, the Veteran reported ongoing problems with her knees since service which began to increase as she entered her 40s. She reported increased pain with increased walking or any bent knee activities. She reported generally treating exacerbations with rest and elevation. On examination, the provider noted that she lacked a few degrees of full extension in both knees and that passive extension caused increased pain but resulted in full extension. The provider noted flexion of 120 degrees on the right and 100 degrees on the left. The provider noted that there was no effusion or instability in either knee. In an August 2015 private note, the Veteran reported having continued bilateral knee pain and difficulty with even simple hiking or walking activities. She reported that viscosupplementation resulted in slight reduction in pain but that it was very minimal. In a September 2015 orthopedic surgery note, the Veteran reported that she was not taking any anti-inflammatories. The provider noted no effusion or instability in either knee. The provider noted decreased flexion in the knees by 15 to 20 degrees because of anterior pain. In February 2016 her private provider noted good range of motion bilaterally with no effusion, laxity, or instability. Later that month and in March 2016, she again received viscosupplementation injections and reported some improvement. In a May 2016 private note, she reported that following viscosupplementation she still had pain and difficulty ascending and descending stairs, kneeling, and getting out of low chairs. In a June 2016 private note, the Veteran reported taking Motrin 800 but still having pain. She reported that she had not gotten much relief from viscosupplementation in the past. She reported having so much pain that she was having difficulty with activities of daily living, even when standing in the kitchen or walking around the house. In a July 2016 VA note, she reported that Celecoxib helped manage her pain. In an October 2016 private note, the provider noted right knee flexion limited to 135 degrees with normal extension. In a February 2017 private note, the Veteran's provider noted stable range of motion and stated that she was doing well regarding her right knee replacement. In an April 2017 private note, she reported continued pain in her bilateral knees, right greater than the left, as well as stiffness. She reported feeling a dull pain constantly with sharp pains coming and going, made worse with standing or sitting. Her provider noted that she ambulated with a normal gait without the use of an assistive device. The provider noted no laxity or instability. In an April 2017 VA examination report, the Veteran reported bilateral knee pain with a moderate amount of sitting, standing, walking, and stair climbing. She reported increased pain when exposed to cold, damp weather. On examination, the examiner noted right knee flexion limited to 90 degrees and normal extension on initial range of motion testing with no additional functional loss on observed repetitive use. The examiner stated that pain, fatigue, weakness, and lack of endurance manifested in right knee flexion limited to 80 degrees with repetitive use over time or during flare-ups. The examiner identified less movement than normal, disturbance of locomotion, and interference with sitting and standing as additional factors contributing to disability. The examiner concluded that the Veteran did not have ankylosis. Joint stability testing was normal and the examiner noted that there was no history of recurrent patellar subluxation, no history of recurrent effusion, no tibial and/or fibular impairment, and no meniscal condition. The examiner noted pain, stiffness, and decreased range of motion as residuals of her December 2016 right knee surgery. The examiner noted no other pertinent physical findings, complications, conditions, signs, and/or symptoms. The examiner noted that she constantly used a cane. The examiner concluded that functioning was not so diminished that she would be equally well served by amputation with prosthesis. The examiner concluded that she had bilateral knee pain with a moderate amount of sitting, standing, walking, and stair climbing and increased pain when exposed to cold, damp weather. In a July 2017 private note, the Veteran reported using the elliptical for 30 to 45 minutes and walking for fitness. She reported that the stationary bicycle was painful for both knees. She reported that the majority of her symptoms were worse when sitting still and then trying to move or when doing too much activity. The provider noted passive right knee flexion limited to 100 degrees and hyperextension of 2 degrees. Later that month, the provider noted full knee active extension, progress with her passive flexion, and continued 2 degree deficit of passive extension. At the end of the month, she reported right knee pain, swelling, instability, locking, giving way, and stiffness occurring constantly since her surgery. She reported that over the counter medication was controlling her pain. On physical examination, the provider noted right knee flexion limited to 90 degrees with no flexion contracture. In an August 2017 note, the Veteran reported that her knees were worse than before her surgeries. Later that month, she again reported pain, swelling, popping, locking, giving away, and stiffness since her surgery. In an August 2017 statement, the Veteran's spouse related that knee pain and range of motion made it impossible for the Veteran to kneel. In another statement, the Veteran stated that she did not previously have shoes that accommodated her right leg brace but, after purchasing different shoes, she wore her brace regularly. Following a September 2017 left knee patellofemoral arthroplasty, the Veteran was instructed to ambulate using a walker or cane as needed. Later that month, in a private treatment note, she reported right knee intermittent pain and swelling since her surgery. In a July 2018 statement, the Veteran stated that prior to seeking care at VA, her knee pain had progressed such that basic functions like climbing stairs and getting in and out of a car were difficult and painful. She stated that she had to manually slide her kneecap back into place many times each day. She stated that she lost interest in long walks with her spouse and was unable to sit long periods of time without her joints becoming stiff and painful. In an October 31, 2018 psychiatry note, the Veteran reported working her knees every day as they would become stiff otherwise. She reported usually riding her stationary bicycle for 20 minutes per day and walking about one-half mile. In a December 2018 private note, the Veteran complained of constant pain, swelling, and stiffness of the right knee; she had no left knee complaints. She reported that over-the-counter pain medication was not controlling her pain. The provider noted that she could ascend and descend stairs with the assistance of a handrail and required no assistive devices in order to ambulate. The provider noted right knee range of motion limited to 50 degrees with no flexion contracture. In an April 2019 VA examination report, the Veteran reported having viscosupplementation in 2015 and early 2016 but that her pain had worsened. She reported taking Celecoxib, Gabapentin, Linaclotide, and Tramadol. She reported persistent pain and stiffness since her surgeries and increased pain with motion. She reported increased pain with bending, squatting, crawling, and transferring into and out of chairs. On examination, initial range of motion testing showed right knee flexion limited to 50 degrees with normal extension and left knee flexion limited to 80 degrees with normal extension. No additional functional loss was noted on observed repetitive use. The examiner stated that pain, fatigue, weakness, and lack of endurance did not result in significantly limited functional ability with repeated use over time. The examiner stated that pain, fatigue, weakness, and lack of endurance manifested in right knee flexion limited to 30 degrees and left knee flexion limited to 60 degrees during flare-ups. The examiner remarked that passive range of motion was the same as active range of motion. The examiner identified disturbance of locomotion and interference with sitting and standing as additional factors contributing to disability. The examiner concluded that the Veteran did not have ankylosis. Joint stability testing was normal and the examiner noted that there was no history of recurrent patellar subluxation, no history of recurrent effusion, no tibial and/or fibular impairment, and no meniscal condition. The examiner noted chronic bilateral residuals consisting of severe painful motion or weakness and stiffness. The examiner noted no other pertinent physical findings, complications, conditions, signs, and/or symptoms. The examiner noted no use of assistive devices. The examiner concluded that functioning was not so diminished that she would be equally well served by amputation with prosthesis. The examiner concluded that she had moderately severe impairment due to loss of range of motion in both knees; she could not drive a car; she had difficulty transferring into and out of chairs; and she could not squat, kneel, or crawl. In an April 2019 pain consultation, the provider noted left and right knee flexion of less than 90 degrees and normal gait. In a May 2019 psychiatry note, the Veteran reported limited flexion and falling down the stairs when she was unable to bend her right knee. In a June 2019 mental health consultation, the Veteran reported that she had been prescribed a cane and walker but seldom used them. She reported taking multiple medications including Celecoxib and Tylenol. She reported difficulty sitting for greater than 20 minutes and standing or lying down to relieve pain. In a June 2019 private note, the Veteran reported constant left knee pain. She reported treating with pain medication and that the medication did not control her pain. The provider noted that she could ascend and descend stairs with the assistance of a handrail, could walk more than 10 blocks, and required no assistive devices in order to ambulate. The provider noted left knee range of motion limited to 90 degrees with flexion contracture of 5 to 10 degrees. In a July 2019 psychology note, the Veteran reported knee pain from lifting her dog or anything over 15 pounds. She denied any safety concerns or need for occupational therapy. The provider noted that she stood after 35 minutes and rubbed her knees and that she did not use a knee brace, cane, walking stick, or walker. In an August 2019 psychology note, the provider noted that she walked unaided. In a December 2019 private note, the Veteran reported intermittent left and right knee pain, swelling, giving way, and stiffness since her surgeries. She reported mild or occasional pain when walking and using stairs. She reported treating with pain medication and home exercises and that the medication controlled her pain. The provider noted that she could ascend and descend stairs with the assistance of a handrail, could walk less than 5 blocks, and required no assistive devices in order to ambulate. The provider noted left and right knee range of motion limited to 70 degrees with flexion contracture of 5 to 10 degrees. In a July 2020 private note, the Veteran reported constant left knee pain and stiffness for one year and constant right knee pain, giving way, and stiffness for one year. The provider noted that she could ascend and descend stairs with the assistance of a handrail, could walk between 5 and 10 blocks, and required no assistive devices in order to ambulate. The provider noted left knee range of motion limited to 100 degrees and right knee range of motion limited to 85 degrees with no flexion contracture bilaterally. The provider recommended a conservative approach on the left and surgery on the right knee. In an October 2020 VA addendum opinion, the clinician stated available records had been reviewed in conjunction with a phone interview of the Veteran using the acceptable clinical evidence process, which is used when existing medical evidence supplemented with an interview would provide sufficient information and an in-person or telehealth examination would likely provide no additional relevant evidence. With respect to the Veteran's left and right knee range of motion, the clinician concluded that, prior to October 11, 2016 and December 13, 2016, respectively, pain on active and passive motion manifested in flexion limited to 120 degrees and normal extension in both knees. The clinician noted decreased flexion of 15 to 20 degrees noted in the September 2015 treatment note as well as other orthopedic and neurologic notes giving an excellent "picture" of the Veteran's knee ranges of motion. The clinician concluded that she had pain on weight-bearing and nonweight-bearing. With respect to flare-ups, the Veteran reported that at the time of the January 2018 examination (during which she carried a total disability rating for each knee), she lost about 20 percent additional range of motion due to flare-ups. Based on this and the January 2018 examination, the clinician concluded that flexion was limited to 95 degrees and extension was limited to 35 degrees. In a March 2021 private note, the Veteran reported pain with all movement and the sensation of instability. She reported frequent, moderate left knee pain. The provider noted in the history of present illness over-the-counter knee brace. In an April 2021 VA examination report, the Veteran reported that prior to her surgeries, she had constant severe pain bilaterally with grinding sensations. She reported continuing to have significant issues with bending both knees. She reported a recent hyperextension injury of the left knee and that it felt very loose, like it could give way. She reported constant dull and sharp aching pains of both knees, stiffness, and feeling that both knees will give out. Current treatment consisted of physical therapy and knee braces. She reported daily flare ups manifesting in more intense pain which could last for hours, precipitated by activity and prolonged sitting and alleviated by rest and heating pad use. She reported being unable to walk or stand during flare-ups. She reported that she was unable to bend, kneel, squat, or run; had difficulty standing or walking for prolonged periods and going up and down stairs; and could only drive short distances. She reported that her knees would give out at times without warning. On examination, initial range of motion testing showed right knee flexion limited to 60 degrees with normal extension and left knee flexion limited to 75 degrees with normal extension. No additional functional loss was noted on observed repetitive use. The examiner stated that pain, fatigue, weakness, and lack of endurance manifested in right knee flexion limited to 55 degrees and left knee flexion limited to 70 degrees with repeated use over time or during flare-ups. The examiner noted that passive range of motion was the same as active range of motion. The examiner identified less movement than normal as an additional factor contributing to disability. The examiner concluded that the Veteran did not have ankylosis. The examiner noted a history of instability and no history of frequent effusion. The examiner noted recurrent subluxation or persistent instability with no ligament tear, which did not require a prescription of an assistive device for ambulation. The examiner noted no recurrent patellar instability. The examiner noted no tibial and/or fibular impairment and no meniscal condition. The examiner noted chronic bilateral residuals consisting of severe painful motion or weakness and stiffness. The examiner noted no other pertinent physical findings, complications, conditions, signs, and/or symptoms. The examiner noted constant use of a brace for bilateral residuals of her total knee replacements. The examiner concluded that functioning was not so diminished that she would be equally well served by amputation with prosthesis. The examiner concluded that she was unable to bend, kneel, squat, or run; had difficulty standing or walking for prolonged periods and going up and down stairs; and could only drive short distances due to bilateral residuals of her total knee replacements. In an April 2021 addendum opinion, the examiner concluded that, prior to her October and December 2016 surgeries, the Veteran's active flexion of both knees was limited to 120 degrees. The examiner stated that passive range of motion could not be estimated but did not provide a reason. Left and right knee ratings for the period prior to October 11, 2016 and December 13, 2016, respectively For the period prior to October 11, 2016, the evidence of record shows flexion of the left knee limited, at most, to 100 degrees. For the period prior to December 13, 2016, the evidence of record shows flexion of the right knee limited, at most, to 120 degrees. The Veteran was consistently noted to have normal extension except for once when she was noted to lack "a few degrees of extension" bilaterally. Further, the October 2020 clinician estimated active and passive range of motion to be 120 degrees based on the September 2015 note and other reports which painted an excellent "picture" of her range of motion; the April 2021 examiner reached the same conclusion with respect to active range of motion. There is no evidence of record demonstrating flexion limited to 30 degrees or less or extension limited to 15 degrees or more. The Board acknowledges the Veteran's contention that, prior to her 2016 surgeries, the condition of her knees deteriorated and symptomatology increased. The benefit of the doubt doctrine is not applicable based on "pure speculation or remote possibility." Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Rather, the evidence must rise to a state of equipoise for the veteran to prevail. See Skoczen v. Shinseki, 564 F.3d 1319, 1324 (Fed. Cir. 2009). Indeed, the Federal Circuit rejected the idea that a veteran must be awarded benefits unless VA produces affirmative evidence refuting the claim. Id. at 1329. While there is evidence of left and right knee pain and functional limitation, it would be pure speculation or remote possibility to conclude that any deterioration in condition or increase in symptomatology manifested in flexion limited to 30 degrees or less or extension limited to 15 degrees or more to warrant ratings in excess of 10 percent. Right knee rating for the period from February 1, 2017 through November 9, 2017 For the period from February 1, 2017 through December 31, 2018, flexion of the right knee was limited, at most, to 80 degrees. Extension was consistently noted to be normal, with the exception of hyperextension noted twice in July 2017. There is no evidence of ankylosis and the examiner concluded that there was no ankylosis. The Board observes that during this period the Veteran walked and used her elliptical for 30 to 45 minutes for fitness. She relayed working at a pace she can tolerate. As the Veteran's right knee disability did not more nearly approximate extension limited to 30 degrees or more or severe painful motion or weakness, a rating in excess of the minimum 30 percent rating is not warranted for the right knee during this period. Left and right knee ratings for the periods from November 1, 2018 and January 1, 2019, respectively For the periods from November 1, 2018 and January 1, 2019, the Veteran was in receipt of the maximum schedular disability ratings for residuals of her left and right knee total knee replacement surgeries. Accordingly, the appeal is denied. Separate ratings for left and right knee instability for the period from February 7, 2021, onward Under the previous regulations, DC 5257, for other impairment of the knee, is rated as 10 percent disabling for slight, 20 percent disabling for moderate, and 30 percent disabling for severe recurrent subluxation or lateral instability. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. The new regulations effective February 7, 2021 included revisions to DC 5257. However, the updated regulations state that when an evaluation is assigned for joint resurfacing or the prosthetic replacement of a joint under diagnostic codes 5051 through 5056, an additional rating under § 4.71a may not also be assigned for that joint, unless otherwise directed. See 38 C.F.R. § 4.71a, Prosthetic Implants and Resurfacing subsection, Note (1). As a separate rating under DC 5257 is therefore precluded in this case under the updated regulations, the Board's assessment will be limited to left and right knee ratings in excess of 10 percent under DC 5257 of the previous regulations. For the period from February 7, 2021, onward, the Veteran's bilateral instability does not more nearly approximate moderate instability. The Veteran reported the sensation of instability and that her knees will give out "at times" without warning. The April 2021 examiner concluded that she had no ligament tear and, noting her braces for her surgery residuals, concluded that the instability did not require a prescription for an assistive device. As the severity, frequency, and duration of bilateral instability does not more nearly approximate moderate instability, ratings in excess of 10 percent under DC 5257 are not warranted. Other separate ratings during the periods on appeal The Board has considered whether separate ratings not already contemplated may be warranted for the left and right knee disabilities and concludes that they are not. During the relevant periods on appeal there is no evidence of ankylosis or the functional equivalent of ankylosis, the Veteran was consistently noted to have range of motion, and VA examiners consistently concluded that her disabilities did not manifest in ankylosis. There is no evidence of recurrent effusion, and there is no evidence of dislocated semilunar cartilage or removal of semilunar cartilage of the bilateral knees; further, examiners consistently concluded that there were no meniscal conditions bilaterally. Finally, there is no evidence of a tibial or fibular impairment and VA examiners consistently concluded that there were no such impairments. Hence, after reviewing all the evidence of record, the Board finds that the preponderance of the evidence is against finding that increased ratings for the Veteran's left and right knee disabilities are warranted. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The claim is, therefore, denied. Gilbert, 1 Vet. App. at 55; 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board acknowledges the Veteran's citing of Thun v. Peake, 22 Vet. App. 111 (2008). To the extent that this citation may be construed as a contention for extraschedular benefits, the Board notes that no specific argument has been presented identifying symptoms so exceptional as to warrant an extraschedular analysis and the Board has not identified any in its review of the record. Functional effects associated with a service-connected disability need not be explicitly listed in a diagnostic code in order to show that they are indeed contemplated under that code. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). As explained above, pain is a factor to be considered with arthritis and other musculoskeletal disabilities. As the natural functional effects of pain may include limitations in walking, standing, sitting, kneeling, squatting, crawling, and ascending and descending stairs, such functional effects are contemplated in the diagnostic codes under which the Veteran's knee disabilities are evaluated. Accordingly, the Board finds that functional loss due to pain is ratable on a schedular basis and that VA has fulfilled its duty to maximize benefits by exhausting all schedular alternatives for rating a disability, including assigning a higher schedular rating if the disability more nearly approximates the higher rating, before triggering the extraschedular analysis, which is meant to be "exceptional." See Morgan v. Wilkie, 31 Vet. App. 162, 164 (2019). As the first Thun element is not met, the Board does not need to address the second Thun requirement. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Vashaw, 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.