Citation Nr: 21073375 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 17-49 740 DATE: December 8, 2021 ORDER Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee condition is denied. Entitlement to service connection for a lumbar spine disability, to include as secondary to a service-connected left knee condition is denied. Entitlement to an evaluation in excess of 20 percent disabling for service-connected left knee degenerative joint disease (DDD) prior to August 16, 2017 and in excess of 30 percent disabling for a left total knee replacement from October 1, 2018 forward, is denied. FINDINGS OF FACT 1. The Veteran's right knee disability is not secondary to his service-connected left knee condition and is not otherwise causally related to an in-service injury or disease. 2. The Veteran's lumbar spine disability is not secondary to his service-connected left knee condition and is not otherwise causally related to an in-service injury or disease. 3. Prior to August 16, 2017, the Veteran's left knee disability was not manifested by flexion limited to 30 degrees or less with pain, instability and giving out. 4. From October 1, 2018 forward, the Veteran's left total knee replacement has not been manifested by chronic residuals consisting of severe painful motion or weakness in the affected extremity. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 2. The criteria for establishing entitlement to service connection for a lumbar spine disability, to include as secondary to a service-connected left knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 3. The criteria for establishing entitlement to an evaluation in excess of 20 percent disabling for service-connected left knee degenerative joint disease (DDD) prior to August 16, 2017 have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5260 (2020). 4. The criteria for establishing entitlement to an evaluation in excess of 30 percent disabling for a left total knee replacement from October 1, 2018 forward have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5055 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active-duty service with the United States Army from May 1981 to May 1984. This matter is on appeal from an April 2015 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) which denied the Veteran's claims of entitlement to service connection for a lumbar spine and right knee disabilities. That decision also denied his claim of entitlement an evaluation in excess of 20 percent disabling for his service-connected left knee condition, pursuant to Diagnostic Code 5260. During the appeal period, the AOJ issued an additional rating decision, dated September 2017, which granted a temporary total disability evaluation for the Veteran's left knee replacement, from August 16, 2017 to September 30, 2018. Thereafter, an evaluation of 30 percent disabling was assigned, under Diagnostic Code 5055. See 38 C.F.R. § 4.71a. Pursuant to a November 2019 Board decision, this matter was remanded for additional development to include scheduling the Veteran for a new VA examination. As the requested development is now complete, this matter has been returned to the Board for appellate consideration. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2020). Copies of compliant VCAA notices were located in the claim's file. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active-duty service. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303 (a), 3.304 (2020). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2020). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2020). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee condition The Veteran contends that he is entitled to service connection for a right knee disability, to include as secondary to his service-connected left knee condition. As discussed in more detail below, the preponderance of the evidence is against his claim. In analyzing this claim, the question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. On review of the record, the Board concludes that while a current diagnosis of osteoarthritis of the right knee has been shown, the preponderance of the evidence weighs against finding that the Veteran right knee condition is causally related to active service, to include as secondary to his service-connected left knee condition. Service treatment records indicate that the Veteran reported a pre-enlistment injury to the right knee. In May 1980, an arthrogram revealed vertical tear in the posterior horn of the lateral meniscus of the right knee. The injury was the subject of a worker's compensation claim. Nevertheless, a physical examination found no disqualifying abnormalities at enlistment in February 1981. One month later, in March 1981, an x-ray of the right knee revealed substantially normal findings. No complaints of impaired range of motion or pain were reported. In June 1983, the Veteran sought treatment for bilateral knee pain. A temporary profile was granted with restrictions on running and marching for 2 weeks. At separation, a report of medical history referenced a "trick" or locked knee. Post-service treatment records confirm complaints of knee pain. In April 2002, a primary care treatment record noted complaints of left shoulder, lower back, and bilateral knee pain following a fall over the previous weekend. A physical examination of the right knee failed to show any evidence of effusion. Range of motion was limited to 130 degrees, with mild patella femoral crepitation. Current diagnoses included chondromalacia of the right patella and degenerative lumbar disc disease. In May 2016, X-rays of both knees confirmed arthritis, possibly more severe in the right knee. Review of the record indicated that the Veteran has been scheduled for multiple VA examinations. On examination in September 2017, range of motion testing could not be conducted as the Veteran remained under an orthopedist's care due to a recent left total knee replacement. Pursuant to the November 2019 Board remand decision, the Veteran's claim was remanded to schedule a new examination. On examination in February 2020, current diagnoses include right knee osteoarthritis. According to the Veteran's medical history, he experienced an onset of left knee pain in-service which caused him to favor the right knee. To treat his symptoms, he was prescribed a shoe lift. With regular use, the Veteran reported an increase in pain. Reportedly, a surgical procedure was performed on the knee prior to enlistment. In 2017, a left total knee replacement was conducted. The Veteran states that a right knee replacement was also recommended. Pain was described as constant, nagging, and rated as an 8 on a 10-point scale. Due to pain, the Veteran was unable to sit for longer than 20 minutes, stand for more than 10 minutes, or walk for more than 200 yards. No incapacitating episodes were reported. To treat pain, the Veteran endorsed use of Ibuprofen, stretching exercises, ice and heat therapy. No flare-ups were reported. Range of motion of the right knee yielded normal findings, with no evidence of painful motion. There was no evidence of pain with weight bearing, crepitus, nor localized tenderness. No additional functional loss or loss of range of motion was observed with repetitive use testing. Range of motion of the left knee revealed flexion and extension limited to 120 degrees. Abnormal range of motion does not contribute to functional loss. No pain was observed on examination, to include with weight-bearing. There was no evidence of localized tenderness, pain to palpation, or crepitus. No additional functional loss or loss of range of motion was observed with repetitive use testing. Neither pain, weakness, fatigability or incoordination significantly limit the Veteran's functional ability over time with repeated use. No additional factors were listed as contributing to the Veteran's bilateral knee disability. Muscle strength testing yielded normal findings, bilaterally. There is no evidence muscle atrophy or ankylosis. Joint stability testing yielded normal findings, bilaterally. No additional conditions were associated with the Veteran's knee disability, to include shin splints, a meniscal condition. A prior history of surgical procedures included an arthroscopic meniscectomy on the right knee in 2002 and a total knee replacement of the left knee in August 2017. Diagnostic testing revealed osteoarthritis of the right knee. No functional impairment was indicated. Considering the Correia factors, there was no evidence of pain with passive range of motion or non-weight bearing. In support of the stated conclusion, the examiner noted that prior to enlistment, the Veteran underwent surgery to the right knee only due to a workman's compensation for an injury. The suggestion of a surgical intervention to the bilateral knees was voluntarily reported by the Veteran during an enlistment interview. Moreover, the surgical procedure performed was a lateral collateral ligament repair of the knee. The lateral collateral ligament is on the outside of the knee and has no bearing on the process of arthritis. Although the Veteran has been granted service-connection for a left total knee replacement, the weight of the medical literature does not support contralateral arthritis due to over-compensation. Thus, no direct or indirect relationship between the Veteran's left knee and right knee conditions has been established. Therefore, the examiner opined that it is less likely as not (less than 50 percent probability) that the Veteran's current right knee arthritis was causally related to or aggravated by active service, to include as secondary to his service-connected left knee condition. In an addendum opinion, dated September 2020, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran's right knee disability, which was noted upon entry into active service, was aggravated beyond its natural progression by an in-service event, injury, or illness. In support of the stated conclusion, the examiner noted that there was no objective evidence that the veteran's pre-existing vertical tear of the posterior horn of the lateral meniscus (diagnosed per right knee arthrogram dated May 1980) increased in severity during active military service. No related treatment was noted during active service. At separation, an unspecific report of a "trick" or "locked" knee was endorsed in April 1984. Years later, in April 1996, X-ray findings revealed "early degenerative joint disease." The diagnostic impression suggested that the Veteran's symptoms resulted from a natural progression of his pre-enlistment right knee injury. Moreover, the examiner noted that there is no clear evidence to suggest that an injury to one lower extremity would have any significant impact on the opposite uninjured limb unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or shortening of the injured lower extremity resulting in a limb length discrepancy of more than 4 or 5 centimeters. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is deemed competent to report on his current symptoms and their onset. However, there is no evidence that he possesses the specialized skills and expertise necessary to render complex medical opinions or opine as nature and etiology of his current symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. In this case, service treatment records suggest a pre-enlistment knee injury, with no disqualifying defects observed at enlistment. Only a single instance of treatment for knee pain was reported in service. At separation, the Veteran endorsed a "trick or lock knee." Years later, the Veteran complained of right knee pain following a fall on or about 2002. A current diagnosis of chondromalacia of the right patella was noted. On examination in February 2020, a current diagnosis of osteoarthritis of the right knee was indicated. While the Board acknowledges the Veteran's subjective belief that his right knee condition is causally related to active service, to include as secondary to his service-connected left knee condition, the medical evidence does not support his contentions. Notably, the VA examiner considered the possibility of a secondary causal linkage between the Veteran's right knee condition and his service-connected left knee condition, the weight of the medical literature does not support contralateral arthritis due to over-compensation. Moreover, the record conforms an onset of new complaints of right knee pain many years after separation and as incident to a fall. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for a right knee disability, as secondary to his service-connected left knee disability must be denied. 2. Entitlement to service connection for a lumbar spine disability, to include as secondary to a service-connected left knee condition The Veteran contends that he is entitled to service connection for a lumbar spine disability, to include as secondary to his service-connected left knee condition. As discussed in more detail below, the preponderance of the evidence is against his claim. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that while a current diagnosis degenerative lumbar disc disease with a possible herniated disc has been documented, the preponderance of the evidence weighs against finding that the Veteran's lumbar spine condition is causally related to active service, to include as secondary to his service-connected left knee disability. Review of service treatment records indicate that no disqualifying abnormalities were identified at enlistment. However, at separation, the Veteran endorsed "recurrent back pain" which he described as occasional pain with lifting in April 1984. No additional complaints of back pain were indicated. Post service treatment records indicate that the Veteran reported low back pain following a fall in April 2002. In an orthopedic surgery record, bearing the same date, reports of pain impacted the lower back, left shoulder, and bilateral knees. Magnetic resonance imaging (MRI) revealed a herniated disc at L4-L5, with evidence of a previous laminectomy at L5-S1. A current diagnosis of degenerative lumbar disc disease with a herniated disc was indicated. An orthopedic record, dated May 2002, suggested that the Veteran's lumbar spine condition worsened due to aggravation by service-connected left knee condition. Aggravation was suggested as due to disturbance the Veteran's gait. Due to pain, the Veteran was required to lie down every 2 hours. He also experienced difficulty sitting for more than 2 hours at a time and walking or standing in excess of 30 minutes. A private physician's opinion, dated July 2001, noted acknowledged prior treatment for the Veteran's degenerative disc disease and spinal stenosis. It was suggested he was unable to work due to his condition. Other treatment records suggest that steroid injections were prescribed to treat pain. In December 2015, a subsequent MRI was conducted without contrast. During the clinical interview, the Veteran reported worsening low back pain with radiculopathy impacting the left lower extremity that extended from the thigh into the foot. The diagnostic impression noted persistent loss of lordotic curvature of the lumbar spine, likely secondary to muscle spasms. Other findings included multi-level degenerative disc disease within the lower three lumbar disc space levels with post-operative left laminectomy at L5-S1 (in the 1980s) and probable moderate right and mild left neural foraminal stenosis at the lumbosacral junction. A moderate broad based-disc bulge was observed with underlying annular tears associated mild bilobed protrusions (centrally) and right para-centrally at L4-L5, which results in moderate central canal stenosis. Moderate neural foraminal stenosis was also observed at L3-L4. A repeat MRI was conducted in October 2016. It revealed degenerative disc disease and degenerative joint disease associated with right foraminal and lateral recess narrowing at L1-L2, moderate to severe right foraminal narrowing at L3-L4, severe spinal canal stenosis and moderate bilateral foraminal narrowing at L4-L5, and severe right foraminal narrowing L5-S1. A prior laminotomy was performed to the left lumbar spine at L5-S1. Posterior annular tears, L4-L5 and L5-S1. Only slight progression in neuroforaminal narrowing on the right side at L5-S1, and right lateral recess narrowing at L1-L2; thickening of the partially visualized bladder wall without focal lesion. Previous complaints of symptoms include low back pain with radiculopathy. Pain impacted the left lower extremity and radiated from the left thigh into the calf and foot. Pursuant to a November 2019 Board decision, the Veteran's claim was remanded to obtain an etiological opinion. On examination in February 2020, a current diagnosis of lumbar spine degenerative disc disease was noted. During the clinical interview, the Veteran reported working in an appliance store where he attempted to move a heavy appliance and injured his back. Pain was rated as a 7 on a 10-point scale. Soreness and aching persist constantly. Difficulty standing for more than 10 minutes or walking more than 200 yards. No incapacitating episodes or symptom radiation was reported. The Veteran acknowledged an ability to maintain his own personal care processes without assistance. He denied any experience with flareups. Range of motion testing revealed normal findings. No pain was observed on examination, to include with weight bearing. There was no objective evidence of localized tenderness or pain to palpation. No additional functional loss or loss of range of motion was observed with repetitive use testing. Neither pain, weakness, fatigability or incoordination significantly limit functional ability over a period of time with repeated use. There was no evidence of guarding, muscle spasms, or muscle atrophy. No additional factors were listed as contributing the Veteran's disability. Muscle strength testing yielded normal findings. Deep tendon reflexes were normal. A sensory examination also yielded normal findings. Straight left raise testing was also normal. There was no evidence of radiculopathy or ankylosis. No neurologic abnormalities were identified. There was no evidence of intervertebral disc syndrome (IVDS). The Veteran denied use of assistive devices. No other pertinent physical findings were identified. Scars were observed on the lower back, measuring at 4 centimeters (cm) in length by 0.2 cm in width. No diagnostic testing was indicated. The Veteran made no reference to a functional impact as to his ability to work. As to the Correia factors, passive range of motion was not deemed medically appropriate as there is no collateral joint. Therefore, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran's lumbar spine disability is causally related to active service, to include as secondarily related to his service-connected left knee condition. In support of the stated conclusion, the examiner acknowledged a review of the medical literature and found no support for a causal linkage between his lumbar spine degenerative disc disease and over-compensation due to a left total knee replacement (or lower extremity condition). In an addendum opinion, dated September 2020, the examiner opined that it is less likely as not (less that 50 percent probability) that the Veteran's current back disability was caused or aggravated by his service-connected left knee disability. In support of the stated conclusion, the examiner indicated that current medical literature is silent for any mechanism by which degenerative osteoarthritis of the knees may cause or aggravate lumbar spine degenerative arthritis. Disc degeneration and accompanying arthritis is a common development. Age related changes are present in 40 percent of adults over age 35 years and in almost all individuals over age 50. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is deemed competent to report on his current symptoms and their onset. However, there is no evidence that he possesses the specialized skills and expertise necessary to render complex medical opinions or opine as nature and etiology of his current symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. In this case, service treatment records are silent for any evidence of a lumbar spine condition. In fact, complaints of recurrent back pain were first noted at separation. Post-service treatment records document complaints of low back pain following a fall in 2002. One year earlier, complaints of similar symptoms were also reported. An MRI revealed degenerative disc disease and possible herniated disc. Other records suggest a current diagnosis of spinal stenosis. Prescribed treatments included steroid injections. In February 2020, a VA examiner considered the suggestion of a correlation between the Veteran's service-connected left knee condition and aggravation of his lumbar spine condition due to disturbance of his gait. However, no "nexus" was found between his lumbar spine condition and overcompensation or a disturbed gait related to his service-connected left knee condition. While the Board does not doubt the veracity of the Veteran's complaints of pain and related symptoms, the evidence of record fails to show a causal linkage to active service. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are inapplicable. The Veteran's claim of entitlement to service connection for a lumbar spine disability, to include as secondary to his service-connected left knee disability must be denied. Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2020). The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10 (2020). Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness which causes additional disability beyond that reflected on range of motion measurements must be considered. 38 C.F.R. § 4.40 (2020); DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45 (2020). Additionally, evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. 38 C.F.R. § 4.14 (2020). However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. Id.; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011) (holding that pain alone does not constitute function loss and is just one fact to be considered when evaluating functional impairment). When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to an evaluation in excess of 20 percent disabling for service-connected left knee degenerative joint disease (DDD) prior to August 16, 2017 and in excess of 30 percent disabling for a left total knee replacement from October 1, 2018 forward. The Veteran contends that his service-connected left knee condition warrants a higher evaluation throughout the appeal period. As a preliminary matter, the Board observes that the Veteran filed an increased rating claim for his left knee disability, status-post (s/p) total knee replacement in August 2017. For the period prior to August 16, 2017, his left knee condition was evaluated as 20 percent disabling, pursuant to Diagnostic Code 5260. See 38 C.F.R. § 4.71a. Thereafter, a temporary total evaluation of 100 percent disabling was granted for 13 months s/p left total knee replacement, pursuant to Diagnostic Code 5055. From October 1, 2018 forward, an evaluation of 30 percent disabling was assigned. Pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260 provides that a noncompensable rating is warranted where flexion of the knee is limited to 60 degrees, a 10 percent rating is warranted where flexion of the knee is limited to 45 degrees, a 20 percent rating is warranted where flexion of the knee is limited to 30 degrees, and a 30 percent rating is warranted where flexion of the knee is limited to 15 degrees. Under Diagnostic Code 5055, a prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board notes that effective February 7, 2021, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disabilities. 85 Fed. Reg. 76453 (Nov. 30, 2020). VA's General Counsel, in a precedent opinion, has held that when a new regulation is issued while a claim is pending before VA, unless clearly specified otherwise, VA must apply the new provision to the claim from the effective date of the change as long as the application would not produce retroactive effects. VAOPGCPREC 7-03; 69 Fed. Reg. 25179 (2003). The amended versions may only be applied as of their effective date. Before that time, only the former version of the regulation may be applied. VAOPGCPREC 3-00; 65 Fed. Reg. 33422 (2000). Importantly, the former version remains for consideration throughout the rating period on appeal, both prior to and after the effective date of the change. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Effective February 7, 2021, Diagnostic Code 5003 was revised only insofar as it was renamed to make clear that this diagnostic code only applies to degenerative arthritis. Additionally, Diagnostic Code 5010 was revised rate post-traumatic arthritis as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. See 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010). Under the revised version of Diagnostic Code 5055, effective February 7, 2021, a minimum 30 percent rating is warranted for total knee replacement only. A 60 percent rating is warranted for prosthetic replacement of the knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion are rated by analogy to diagnostic codes 5256, 5261, or 5262. A 100 percent rating is warranted for 4 months following knee resurfacing or replacement. See 85 Fed. Reg. 76453, 76461 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055). Diagnostic Codes 5256 (ankylosis of the knee), 5260 (flexion of the knee), and 5261 (extension of the knee) were not changed by the February 7, 2021, amendments. While Diagnostic Codes 5257 (subluxation or instability) and 5262 (impairment of tibia and fibula) were revised, these diagnostic codes are not for application based on the findings in this case, as described below. Review of the record indicates that the Veteran has continued to seek treatment for his service-connected left knee disability. During an orthopedic consultation in March 2017, the Veteran was evaluated for worsening burning and stabbing pain along the lateral aspect of the left knee with giving way. Joint grinding and swelling were also reported. Use of a knee brace and steroid injections were unable to resolve his pain. Worsening symptoms were reported with prolonged walking, standing, and sitting. The right knee was also described as symptomatic. A physical examination of the left knee noted evidence of effusion, crepitus, and tenderness along the medial and lateral joint line. Range of motion was described as flexion and extension from -3 to 110 degrees. In August 2017, the Veteran was evaluated by an orthopedic surgeon. A current diagnosis of end stage osteoarthritis of the left knee. During the clinical interview, the Veteran reported bilateral knee pain with running, walking, and standing. He listed his current employment as a Cook. Physical therapy exercises, rest, and oral medications improve his pain. A total knee arthroplasty was recommended. On examination in September 2017, a range of motion testing could not be conducted as the Veteran remained under an orthopedist's care due to a recent left total knee replacement. Six months later, in March 2018, diagnostic imaging revealed increased activity surrounding the left knee prosthesis which is consistent with inflammatory/degenerative changes. Pursuant to the November 2019 Board remand decision, the Veteran's claim was remanded to schedule a new examination. On examination in February 2020, range of motion of left knee revealed flexion and extension limited to 120 degrees. Abnormal range of motion does not contribute to functional loss. No pain was observed on examination, to include with weight-bearing. There was no evidence of localized tenderness, pain to palpation, or crepitus. No additional functional loss or loss of range of motion was observed with repetitive use testing. Neither pain, weakness, fatigability or incoordination significantly limit the Veteran's functional ability over time with repeated use. No additional factors were listed as contributing to the Veteran's knee disability. Muscle strength testing yielded normal findings, bilaterally. There is no evidence muscle atrophy or ankylosis. Joint stability testing yielded normal findings, bilaterally. No additional conditions were associated with the Veteran's knee disability, to include shin splints, or a meniscal condition. As noted above, portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021; however, the changes regarding Diagnostic Code 5055 do not materially impact the disposition of this decision. On review of the record, the Board finds that a higher evaluation is not warranted for any point during the appeal period. To warrant an evaluation of 30 percent disabling under Diagnostic Code 5260, the medical evidence must show flexion of the knee is limited to 15 degrees. Prior to August 2017, medical evidence has not met the required showing. In fact, the Veteran's flexion was limited to no worse than 110 degrees, with pain, locking, swelling, and giving way. From October 1, 2018, forward, an evaluation in excess of 30 percent disabling has not been established for the Veteran's left total knee replacement under Diagnostic Code 5055. See 38 C.F.R. § 4.71a. To establish entitlement to an evaluation of 60 percent disabling, the medical evidence must show that Veteran's left total knee replacement has been manifested by symptomatology that more nearly approximates severe painful motion and weakness. In this case, the required showing has not meet met. In particular, the Board notes that the Veteran has reported pain and difficulty with prolong walking and standing. However, at no time has his symptomology been described as severe or associated with weakness. The Board has considered whether a higher rating, through a single rating or combination, could be assigned by using the rating criteria specific to the knee rather than Diagnostic Code 5055, but finds that this would not result in a higher rating at any time during the time appeal period. In this regard, the Board initially notes that as Diagnostic Code 5055 contemplates painful motion and weakness, separate ratings (in addition to rating under Diagnostic Code 5055) under Diagnostic Codes 5259, 5260 or 5261 would constitute impermissible pyramiding. 38 C.F.R. §§ 4.14, 4.71a. Furthermore, consideration of other diagnostic codes for rating a knee disability, such as Diagnostic Codes 5256, 5258, 5259, 5262, and 5263, is inappropriate as the Veteran's left knee disability does not include the pathology required in the criteria for those Diagnostic Codes of ankylosis, dislocation of the semilunar cartilage, tibia or fibula impairments, or genu recurvatum. 38 C.F.R. § 4.71a. While the Board does not doubt the veracity of the Veteran's complaints of pain and related symptoms, the evidence of record fails to an increase in severity that warrants a higher evaluation at any time. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an evaluation in excess of 20 percent disabling for service-connected left knee degenerative joint disease (DDD) prior to August 16, 2017 and in excess of 30 percent disabling for a left total knee replacement from October 1, 2018 forward must be denied. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.