Citation Nr: 21074174 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-65 945 DATE: December 14, 2021 ORDER A disability rating in excess of 30 percent for service-connected degenerative joint disease of the left knee (previously rated as strain) based on limitation of extension is denied. A separate 20 percent disability rating for service-connected degenerative joint disease of the left knee based on limitation of flexion from August 20, 2021 is granted. A disability rating in excess of 40 percent for service-connected degenerative arthritis of the right knee based on limitation of extension is denied. A separate 20 percent disability rating for service-connected degenerative arthritis of the right knee based on limitation of flexion from August 20, 2021 is granted. A disability rating in excess of 20 percent for service-connected instability of the right knee is denied. FINDINGS OF FACT 1. The preponderance of the evidence shows that extension of the left knee was not limited to 30 degrees or more even with consideration of reduced function on repetitive motion or during flare-ups with no evidence of ankylosis, recurrent subluxation or lateral instability, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum throughout the entire appeal period. 2. Prior to August 20, 2021, flexion of the left knee was not limited to 60 degree degrees or less with consideration of reduced function on repetitive motion or during flare-ups. 3. As of August 20, 2021, flexion of the left knee was limited to 30 degrees during flare-ups. 4. The preponderance of the evidence shows that extension of the right knee was not limited to 45 degrees or more even with consideration of reduced function on repetitive motion or during flare-ups with no evidence of ankylosis, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum throughout the appeal period. 5. Prior to August 20, 2021, flexion of the right knee was not limited to 60 degree degrees or less with consideration of reduced function on repetitive motion or during flare-ups. 6. As of August 20, 2021, flexion of the right knee was limited to 30 degrees during flare-ups. 7. The preponderance of the evidence shows that the Veteran's instability of the right knee is characterized as moderate throughout the appeal period. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for service-connected degenerative joint disease of the left knee (previously rated as strain) based on limitation of extension are not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2020 and 2021). 2. The criteria for a separate 20 percent disability rating from August 20, 2021for service-connected degenerative joint disease of the left knee (previously rated as strain) based on limitation of flexion are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5260 (2020 and 2021). 3. The criteria for a disability rating in excess of 40 percent for service-connected degenerative arthritis of the right knee based on limitation of extension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2020 and 2021). 4. The criteria for a separate 20 percent disability rating from August 20, 2021 for service-connected degenerative arthritis of the right knee based on limitation of flexion are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5260 (2020 and 2021). 5. The criteria for a disability rating in excess of 20 percent for service-connected instability of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5257 (2020 and 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1990 to December 1993. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2015 Regional Office (RO) rating decision. In that rating decision, the RO reduced the Veteran's disability ratings for right knee instability from 20 percent to 10 percent, right knee degenerative arthritis from 40 percent to 10 percent, and left knee degenerative joint disease from 30 percent to 10 percent, effective May 1, 2015. The Veteran's notice of disagreement (NOD) was received in April 2015. The RO issued a statement of the case (SOC) in December 2017. The Veteran's VA Form 9, substantive appeal to the Board, was received in December 2017. In February 2021, the Veteran testified at a video Board hearing before the undersigned Veterans Law Judge. A transcript of the testimony is associated with the claims file. In May 2021, the Board determined that the rating reductions for service-connected right knee instability, right knee degenerative arthritis, and left knee degeneration joint disease were improper and restored the disability ratings. The Board remanded the issues of entitlement to a disability rating in excess of 20 percent for right knee instability, entitlement to a disability rating in excess of 40 percent for right knee degenerative arthritis, and entitlement to a disability rating in excess of 30 percent for left knee degenerative joint disease to the RO for further development and adjudicative action. INCREASED RATING Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). In general, when 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). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The appeal period for the Veteran's claims for increased disability ratings for degenerative disc disease of the lumbar spine with IVDS, radiculopathy of sciatic nerve of the right lower extremity, and residuals of left knee ACL injury is January 24, 2014, the date the RO received the Veteran's claim for an increased rating for his low back disability and left knee disability. 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). 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." Correia v. McDonald, 28 Vet. App. 158 (2016). Furthermore, 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 regulations of the musculoskeletal system were recently amended, effective February 7, 2021. Where a law or regulation changes during the pendency of a claim for increased rating, the amendments cannot be construed to have retroactive effect unless the language requires such a result. See Kuzma v. Principi, 341 F.3d 1327, 1328 (2003) (citing Landgraf v. USI Film Prods., 511 U.S. 244 (1994)). There is not such language in the amendments to the regulations at issue in this case. Consequently, the Board has considered whether an increased evaluation may be warranted under either the old or new version of the schedule for rating disabilities of the spine; but application of the newer regulations can be no earlier than the effective date of the change. 1. Entitlement to a disability rating in excess of 30 percent for service-connected degenerative joint disease of the left knee (previously rated as strain) prior to August 20, 2021. 2. Entitlement to a separate compensable disability rating for the service-connected degenerative joint disease of the left knee (previously rated as strain) based on limitation of flexion. The Veteran contends that he is entitled to a higher rating for his service-connected degenerative joint disease of the left knee because he had been experiencing an increase in frequency and severity of pain symptoms, stiffness, and swelling that inhibits walking and movement. The Veteran's service-connected degenerative joint disease of the left knee is currently rated as 30 percent disabling under Diagnostic Code 5003-5261. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code for the left knee reflects that traumatic arthritis under Diagnostic Code 5003 is the service-connected disorder and that limitation of extension rated under Diagnostic Code 5261 is the residual condition. Under Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For purpose of rating a disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, (limitation of flexion), a 10 percent disability rating is warranted for flexion limited to 45 degrees. Limitation of flexion to 30 degrees warrants a 20 percent disability rating. A 30 percent disability rating is assigned for flexion limited to 15 degrees or less. In order for the Veteran to receive a 10 percent rating under Diagnostic Code 5261 (limitation of leg extension), the evidence must show that his knee disability is manifested by leg extension limited to 10 degrees. A 20 percent rating under Diagnostic Code 5261 is warranted if the evidence shows leg extension limited to 15 degrees. The Veteran is entitled to a 30 percent disability rating for leg extension limited to 20 degrees. Leg extension limited to 30 degrees warrants a 40 percent disability rating and leg extension limited to 45 degrees warrants a 50 percent disability rating. A veteran who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (September 17, 2004). The preponderance of the evidence is against a rating in excess of 30 percent for left knee osteoarthritis throughout the appeal period. However, the evidence is at least evenly balanced as to whether a separate 20 percent disability rating for limitation of flexion from August 20, 2021. The Board acknowledges the Veteran's lay reports of symptoms of that pain and swelling in the knee inhibits his walking and movement. He described the impact of flare-ups is that he cannot walk or stand because of the pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating flexion limited to 45 degrees or less prior to August 20, 2021 or extension limited to 30 degrees or more at any time during the appeal period. The evidence shows that left knee flexion was limited to 30 degrees during flare-ups from August 20, 2021. In this regard, a May 2014 VA examination reveals that flexion of the left knee was to 120 degrees with pain beginning at 120 degrees and extension was to zero degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with three repetitions. There was no additional limitation in range of motion of knee and lower leg following repetitive-use testing. The Veteran experiences less movement than normal, incoordination, and pain on movement. The left knee did not have tenderness or pain to palpation for joint line or soft issue of the left knee. The examiner noted that there were contributing factors of pain, weakness, fatigability, incoordination, and additional limitation of functional ability of the knee during flare-ups or repeated use over time. The examiner determined that the degree of range of motion loss during pain on use or flare-ups was approximately 10 degrees of flexion of the left knee. Thus, flexion of the left knee was to 110 degrees during flare-ups or after repeated use over time. Muscle strength testing was normal. The anterior and posterior stability tests of the left knee was within normal limits. The medial-lateral stability test of the left knee was within normal limits. The examiner determined that there was no evidence or history of recurrent left knee patellar subluxation/dislocation. A Knee and Lower Leg Condition Disability Benefits Questionnaire by a private physician assistant reveals that left knee flexion was to 120 degrees and left knee extension was to zero degrees. Range of motion of the left knee did not change after repetitive use testing. An August 2021 VA examination reveals that flexion of the left knee was to 60 and extension was to zero degrees. The examiner documented that pain was exhibited on flexion and extension. Passive range of motion was the same as active range of motion. There was evidence of pain on weight-bearing, active motion, passive motion, and it causes functional loss. The Veteran was able to perform repetitive use testing with three repetitions. Flexion of the left knee was limited to 50 degrees after the completion of three repetitions. Extension of the left knee was to zero degrees after the completion of three repetitions. The examiner estimated that flexion was limited to 40 degrees and extension was to zero degrees after repeated use over time based on the information procured from relevant sources including lay statements from the Veteran. The examiner estimated that flexion of the left knee was limited to 30 degrees and extension was to zero degrees during flare-ups based on the information procured from relevant sources including lay statements from the Veteran. The evidence of record, the most pertinent of which is discussed above, shows that the Veteran did not have compensable limitation of motion with respect to flexion prior to August 20, 2021 or extension limited to 30 degrees or more at any time during the appeal period. However, as of August 20, 2021, the medical evidence reflects that the left knee flexion was limited to 30 degrees during flare-ups warranting a separate 20 percent disability rating under Diagnostic Code 5260 for limitation of flexion. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Disabilities of the knee and leg may also be evaluated under Diagnostic Codes 5256, 5257, 5258, 5259, 5262, or 5263. However, the medical and lay evidence shows that the Veteran's left knee disability is not manifested by ankylosis, recurrent subluxation or lateral instability, dislocation of the semi-lunar cartilage, symptomatic removal of semilunar cartilage, or any impairment of the tibia and fibula, or genu recurvatum throughout the entire appeal period. Thus, Diagnostic Codes 5256, 5257, 5258, 5259, 5262 and 5263 are not applicable in this case under the prior criteria or as of February 7, 2021 under the amended criteria. 3. Entitlement to a disability rating in excess of 40 percent for service-connected degenerative arthritis of the right knee on the basis of limitation of extension. 4. Entitlement to a separate compensable disability rating for service-connected degenerative arthritis of the right knee on the basis of limitation of flexion. 5. Entitlement to a disability rating in excess of 20 percent for service-connected instability of the right knee The Veteran contends that he is entitled to a higher rating for his service-connected degenerative arthritis of the right knee because he had been experiencing an increase in frequency and severity of pain symptoms, stiffness, and swelling that inhibits walking and movement. The Veteran's service-connected degenerative arthritis of the right knee is currently rated as 40 percent disabling under Diagnostic Code 5261. The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. In order for the Veteran to receive a 10 percent rating under Diagnostic Code 5261 (limitation of leg extension), the evidence must show that his knee disability is manifested by leg extension limited to 10 degrees. A 20 percent rating under Diagnostic Code 5261 is warranted if the evidence shows leg extension limited to 15 degrees. The Veteran is entitled to a 30 percent disability rating for leg extension limited to 20 degrees. Leg extension limited to 30 degrees warrants a 40 percent disability rating and leg extension limited to 45 degrees warrants a 50 percent disability rating. A veteran who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (September 17, 2004). Under Diagnostic Code 5260, (limitation of flexion), a 10 percent disability rating is warranted for flexion limited to 45 degrees. Limitation of flexion to 30 degrees warrants a 20 percent disability rating. A 30 percent disability rating is assigned for flexion limited to 15 degrees or less. The preponderance of the evidence is against a rating in excess of 40 percent for right knee degenerative arthritis on the basis of limited extension throughout the appeal period. However, the evidence is at least evenly balanced as to whether a separate 20 percent disability rating is warranted for limitation of flexion of the right knee from August 20, 2021. The Board acknowledges the Veteran's lay reports of symptoms of that pain and swelling in the knee inhibits his walking and movement. He described the impact of flare-ups is that he cannot walk or stand because of the pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating right knee flexion limited to 45 degrees or less prior to August 20, 2021 or extension limited to 45 degrees or more at any time during the appeal period. The evidence shows that right knee flexion was limited to 30 degrees during flare-ups from August 20, 2021. In this regard, a May 2014 VA examination reveals that flexion of the right knee was to 75 degrees with pain beginning at 75 degrees. Extension of the right knee was to zero degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with three repetitions. There was no additional limitation in range of motion of knee and lower leg following repetitive-use testing. The Veteran experienced less movement than normal, incoordination, pain on movement, and instability of station. The right knee did not have tenderness or pain to palpation for joint line or soft issue of the right knee. The examiner noted that there were contributing factors of pain, weakness, fatigability, incoordination, and additional limitation of functional ability of the right knee during flare-ups or repeated use over time. The examiner determined that the degree of range of motion loss during pain on use or flare-ups was approximately 10 degrees of flexion of the right knee. Thus, flexion of the right knee was to 65degrees during flare-ups or after repeated use over time. Muscle strength testing was normal. The anterior and posterior stability tests of the right knee was within normal limits. The medial-lateral stability test revealed instability of 1+ (0-5 millimeters). The examiner determined that there was no evidence or history of recurrent right knee patellar subluxation/dislocation. A Knee and Lower Leg Condition Disability Benefits Questionnaire by a private physician assistant reveals that right knee flexion was to 120 degrees and right knee extension was to zero degrees. Range of motion of the right knee did not change after repetitive use testing. An August 2021 VA examination reveals that flexion of the right knee was to 60 and extension was to zero degrees. The examiner documented that pain was exhibited on flexion and extension. Passive range of motion was the same as active range of motion. There was evidence of pain on weight-bearing, active motion, passive motion, and it caused functional loss. The Veteran was able to perform repetitive use testing with three repetitions. Flexion of the right knee was limited to 50 degrees after the completion of three repetitions. Extension of the right knee was to zero degrees after the completion of three repetitions. The examiner estimated that right knee flexion was limited to 40 degrees and extension was to zero degrees after repeated use over time based on the information procured from relevant sources including lay statements from the Veteran. The examiner estimated that flexion of the right knee was limited to 30 degrees and extension was to zero degrees during flare-ups based on the information procured from relevant sources including lay statements from the Veteran. The evidence of record, the most pertinent of which is discussed above, shows that the Veteran did not have compensable limitation of motion with respect to flexion of the right knee prior to August 20, 2021 or extension limited to 45 degrees or more at any time during the appeal period. However, as of August 20, 2021, the medical evidence reflects that the right knee flexion was limited to 30 degrees during flare-ups warranting a separate 20 percent disability rating under Diagnostic Code 5260 for limitation of flexion from that date. The Veteran is also in receipt of a separate 20 percent disability rating for right knee instability. Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Prior to February 7, 2021, under this diagnostic code, slight recurrent subluxation or lateral instability warrants a 10 percent disability rating. A 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability. Severe recurrent subluxation or lateral instability warrants a 30 percent disability rating. The United States Court of Appeals for Veterans Claims has held that nothing in Diagnostic Code 5257 provides that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee. English v. Wilkie,30 Vet. App. 347, 349 (2018). The words "slight," "moderate" and "severe" are not defined in the VA Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. 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. Furthermore, the Disability Benefits Questionnaire (DBQ) evaluation criteria for knee examinations ask the examiner to identify whether instability, if present, falls within the range of 1+ (0-5 mm), 2+ (5-10 mm) or 3+ (10-15 mm). These examination criteria provide an equitable basis on which to find that 1+ instability is "slight," 2+ is "moderate," and 3+ is "severe." In this case, there is objective evidence of instability of the right knee. A May 2014 VA examination shows that the Veteran had 1+ medial-lateral instability. Posterior and anterior instability tests were normal. The examiner noted that there was no evidence or history of recurrent patellar subluxation or dislocation. The examiner documented that there was no x-ray evidence of patellar subluxation. The examiner revealed that the Veteran's right knee symptoms included incoordination and instability of station. The examiner noted that regarding instability of the right knee, there was no change in diagnosis and at that time the condition was active. An August 2021 VA examination shows that the Veteran reported that his right knee instability causes difficulty in walking more than a quarter mile and standing more than 20 minutes. The examiner determined that the Veteran's had recurrent subluxation or persistent instability of the fight knee. The examiner stated that there was not and there had not been a ligament tear or sprain. The Veteran also did not require a prescription (by a medical provider) of a cane, walker, crutches, or brace for ambulation. The examiner noted that there was no recurrent patellar instability. The Veteran's right knee did not have any surgical procedures. The examiner documented that right knee anterior instability test result was 1+ (0-5mm). The right knee posterior instability test, medical instability test, and lateral instability test were normal. The examiner determined that there was moderate recurrent subluxation of the right knee. There was no history of lateral instability of the right knee. Based on the evidence of record, the most pertinent of which was discussed above, the Veteran's right knee instability more nearly approximates moderate instability throughout the appeal period. Specifically, as noted above, the right knee medial-lateral instability was 1+ in the May 2014 VA examination and right knee anterior instability test result was 1+ (0-5mm) in the August 2021 VA examination. The August 2021 VA examiner determined that the Veteran had moderate subluxation. The lay and medical evidence is silent as to the frequency and severity of any symptoms of right knee instability such as the weakness and/or incoordination. However, the August 2021 VA examiner noted that due to the Veteran's right knee instability or that the instability of the right knee resulted in falls. The objective medical evidence and the description of the impact of the Veteran's right knee instability is not consistent with severe instability. Thus, the preponderance of the evidence shows that a separate disability rating in excess of 20 percent for service-connected right knee instability is not warranted at any time during the appeal period. Furthermore, as the Board granted a separate 20 percent disability rating for limitation of flexion from August 20, 2021, the Veteran's right knee disability is now assigned a combined rating of 60 percent. Assignment of a higher rating for right knee instability as of August 20, 2021 would violate the amputation rule. In this regard, VA regulation stated that the "combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed." 38 C.F.R. § 4.68. Under 38 C.F.R. § 4.71a, Diagnostic Code 5162, an amputation of the middle or lower third of the thigh warrants a 60 percent evaluation. Such level includes the knee. Thus, regardless of whether the Veteran's right knee disability meets the requirements for a 30 percent disability rating as of August 20, 2021, a separate 30 percent disability rating cannot be assigned, as doing so would violate the amputation rule. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Disabilities of the knee and leg may also be evaluated under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263. However, the medical and lay evidence shows that the Veteran's left knee disability is not manifested by ankylosis, dislocation of the semi-lunar cartilage, symptomatic removal of semilunar cartilage, or any impairment of the tibia and fibula, or genu recurvatum throughout the entire appeal period. Thus, Diagnostic Codes 5256, 5257, 5258, 5259, 5262 and 5263 are not applicable in this case under the prior criteria or as of February 7, 2021 under the amended criteria. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Berry, 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.