Citation Nr: 21074426 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 15-15 993 DATE: December 15, 2021 ORDER Entitlement to an initial disability rating in excess of zero percent from September 10, 2014, 10 percent from February 17, 2020, and 20 percent from April 30, 2021 for osteoarthritis of the right knee with limitation of extension is denied. Entitlement to an initial disability rating in excess of 10 percent prior to February 18, 2020 and zero percent thereafter for osteoarthritis of the right knee with limitation of flexion is denied. Entitlement to an initial disability rating of 20 percent, but no higher, from September 10, 2014 for osteoarthritis of the right knee with patellar subluxation and instability is granted. Entitlement to an initial disability rating of 20 percent from March 30, 2016 for symptomatic medial meniscal tear of the right knee is granted. Entitlement to an initial disability rating in excess of zero percent prior to April 30, 2021 and 20 percent thereafter for left knee disability with limitation of extension is denied. Entitlement to an initial disability rating in excess of 10 percent prior to April 30, 2021 and zero percent thereafter for left knee disability with limitation of flexion is denied. Entitlement to an initial disability rating of 10 percent, but no higher, from September 10, 2014 for residuals of left knee meniscectomy is granted. FINDINGS OF FACT 1. From September 10, 2014 to February 18, 2020, the Veteran's right knee osteoarthritis disability was manifested by flexion limited to no less than 100 degrees and extension to 5 degrees. 2. From February 18, 2020 to April 30, 2021, the Veteran's right knee osteoarthritis disability was manifested by flexion limited to no less than 70 degrees and extension to 10 degrees. 3. From April 30, 2021, the Veteran's right knee osteoarthritis disability has been manifested by flexion limited to no less than 90 degrees and extension to 15 degrees. 4. From September 10, 2014, the Veteran's right knee disability has been manifested by moderate recurrent patellar subluxation and instability. 5. From March 30, 2016, tears of the ACL and medial meniscus of the right knee have been manifested by frequent episodes of locking and effusion. 6. From September 10, 2014 to April 30, 2021, the Veteran's left knee disability was manifested by flexion limited to no less than 85 degrees and extension to 5 degrees. 7. From April 30, 2021, the Veteran's left knee disability has been manifested by flexion limited to no less than 90 degrees and extension to 15 degrees. 8. From September 10, 2014, the Veteran's left knee disability, status-post meniscectomy, has been manifested by intermittent residuals of popping and effusion. CONCLUSIONS OF LAW 1. From September 10, 2014 to February 18, 2020, the criteria for an initial disability rating in excess of 10 percent for right knee osteoarthritis with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5003, 5260, 5261. 2. From February 18, 2020, the criteria for a compensable initial disability rating for right knee osteoarthritis with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 3. From September 10, 2014 to February 18, 2020, the criteria for an initial compensable disability rating for right knee osteoarthritis with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 4. From February 18, 2020 to April 30, 2021, the criteria for an initial disability rating in excess of 10 percent for right knee osteoarthritis with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 5. From April 30, 2021, the criteria for an initial disability rating in excess of 20 percent for right knee osteoarthritis with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 6. From September 10, 2014, the criteria for a disability rating of 20 percent, but no higher, for the service-connected instability of the right knee are met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 7. From March 30, 2016, the criteria for a separate initial rating of 20 percent for residuals of ACL and medial meniscal tears of the right knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.27, 4.71a, DC 5258. 8. From September 10, 2014 to April 30, 2021, the criteria for an initial disability rating in excess of 10 percent for left knee disability with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 9. From April 30, 2021, the criteria for a compensable initial disability rating for left knee disability with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 10. From September 10, 2014 to April 30, 2021, the criteria for an initial compensable disability rating for left knee disability with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 11. From April 30, 2021, the criteria for an initial disability rating in excess of 20 percent for left knee disability with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 12. From September 10, 2014, the criteria for a separate initial rating of 10 percent for residuals of status-post meniscectomy of the left knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.27, 4.71a, DC 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2006 to January 2007 and March 2011 to August 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which assigned a 10 percent initial rating for right knee osteoarthritis and a 10 percent initial rating for left knee ACL and meniscal tear from September 10, 2014. The Veteran filed a notice of disagreement (NOD) in December 2014. A statement of the case (SOC) was issued in May 2015 and he perfected a timely appeal in May 2015. In March 2019, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. In an October 2019 Board decision, the claims were remanded for further evidentiary development. In a March 2020 rating decision, the RO increased the assigned rating for osteoarthritis of the right knee with painful and limited extension to 10 percent from January 5, 2020. The RO also assigned a separate disability rating for osteoarthritis of the right knee with moderate instability; a 20 percent rating was assigned from January 5, 2020. In a May 2021 rating decision, the RO increased the assigned ratings for left knee limitation of extension and osteoarthritis of the right knee with painful and limited extension to 20 percent each from April 30, 2021. The May 2021 rating decision decreased the assigned rating for osteoarthritis of the right knee with instability to 10 percent from August 1, 2021 and decreased the assigned rating for left knee ACL and meniscal tears to zero percent from April 30, 2021. The RO also decreased the evaluation for right knee osteoarthritis under DC 5260 to zero percent from February 18, 2020. Additionally, the RO determined that the appropriate effective date for the assignment of the 20 percent rating for impaired extension of the right knee joint is February 18, 2020. With respect to the increased and separately assigned initial ratings, the Veteran has not expressed satisfaction; these claims thus remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). As will be discussed below, a review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A supplemental statement of the case (SSOC) was issued in May 2021. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. The October 2019 Board decision also remanded the matter of entitlement to service connection for a back disability. In a November 2020 rating decision, the RO granted service connection for lumbar spine strain degenerative disc disease (DDD) and assigned a 10 percent rating from September 10, 2014. See Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second NOD must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). 1. Entitlement to an initial disability rating for osteoarthritis of the right knee with limitation of extension in excess of zero percent from September 10, 2014, 10 percent from February 17, 2020, and 20 percent from April 30, 2021. 2. Entitlement to an initial disability rating for osteoarthritis of the right knee with instability in excess of 20 percent from January 5, 2020 and 10 percent from August 1, 2021. 3. Entitlement to an initial disability rating for osteoarthritis of the right knee with limitation of flexion in excess of 10 percent prior to February 18, 2020 and zero percent thereafter. 4. Entitlement to an initial disability rating for left knee limitation of extension in excess of zero percent prior to April 30, 2021 and 20 percent thereafter. 5. Entitlement to an initial disability rating for left knee disability limitation of flexion in excess of 10 percent prior to April 30, 2021 and zero percent thereafter. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. 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; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also 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). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. The United States Court of Appeals for Veterans Claims (Court) has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint's functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021 and both the old and revised rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, Diagnostic Code 5003 was only changed to clarify that it applies specifically to degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is 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 there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Additionally, Diagnostic Codes 5260 (leg, limitation of flexion) and 5261 (leg, limitation of extension) were also not changed by the revisions to the musculoskeletal system, effective February 7, 2021. The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). Prior to the regulatory change DC 5257 provided the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257. As of February 7, 2021, under the amended criteria, the DC 5257 indicated that knee, other impairment of should be rated as follows: Recurrent subluxation or instability: For unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation, a 30 percent disability rating is warranted For one of the following a 20 percent disability rating is warranted: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider pre-scribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation, a 10 percent disabling rating is warranted. Patellar instability: For a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker a 30 percent disabling rating is warranted. For a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker, a 20 disability rating is warranted. For a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker, a 10 percent disability rating is warranted. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Diagnostic Codes 5258 and 5259 were not changed by the revisions to the musculoskeletal code. DC 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. DC 5259 provides that a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. In this case, the Veteran's osteoarthritis of the right knee with painful motion and limited extension is assigned a zero percent rating from September 10, 2014, 10 percent from February 18, 2020, and 20 percent from April 30, 2021 pursuant to Diagnostic Code (DC) 5261. A separate rating is assigned for right knee joint ostearthritis with limitation of flexion at 10 percent from September 10, 2014 and zero percent from February 18, 2020 pursuant to DC 5003-5260. Osteoarthritis of the right knee with instability is assigned a separate 20 percent rating from January 5, 2020 and 10 percent from August 1, 2021 under DC 5257. As to left knee limitation of extension, the Veteran is assigned a zero percent rating from September 10, 2014 and 20 percent from April 30, 2021 under DC 5261. A separate disability rating is assigned for left knee ACL and meniscal tears, evaluated as 10 percent from September 10, 2014 and zero percent from April 30, 2021 pursuant to DC 5259-5260. For the reasons set forth below, the Board finds that higher initial ratings are not warranted for the service-connected right or left knee disabilities based upon limitation of motion. However, the Board does find that a 20 percent disability rating, but no higher, is warranted for right knee instability from September 10, 2014, the date of service connection. The Board also finds that a separate 20 percent rating is warranted for symptomatic meniscal tear of the right knee from March 30, 2016 and a separate 10 percent rating is warranted for residuals of meniscectomy of the left knee from the date of service connection, September 10, 2014. The Veteran was afforded a VA examination in October 2014 at which time the examiner confirmed diagnoses of left knee meniscal tear, left knee ACL tear, and right knee osteoarthritis. The examiner noted the Veteran's report of frequent popping out of right knee associated with swelling. The Veteran described knee pain at 9/10 with flare-ups during cold weather, or when walking or exercising. The Veteran underwent ACL surgery on his left knee in 2008. Range of motion testing revealed right knee flexion to 120 degrees and left knee flexion to 130 degrees; extension was zero degrees in both knees. After repetitive use testing, right knee flexion of 110 degrees was documented in the right knee and 125 degrees in the left knee. Pain contributed to functional loss. There was pain weight-bearing. There was no pain or tenderness to palpation. The examiner reported that contributing factors of disability include less movement than normal, pain on movement, and swelling. The examiner reported that pain, weakness, fatigability, or incoordination significantly limit functional ability during flare-ups or when the joint is used repeatedly over time. The examiner estimated that there was an additional loss of 10 degrees of right knee flexion and 5 degrees of left knee flexion, as well as 5 degrees of right and left knee extension. The Veteran's muscle strength was intact. There was no evidence of atrophy or ankylosis. There was no history of recurrent patellar subluxation. The Veteran endorsed a history of lateral instability in the right knee, which the examiner described as moderate. The examiner indicated that the Veteran does not have a history of recurrent effusion. Joint stability testing was normal, bilaterally. The examiner reported that the Veteran does have a history of meniscal tear in the left knee with moderate residual symptoms. The Veteran underwent ACL reconstruction and medial meniscus debridement in December 2008. The examiner reported that the Veteran does occasionally use a right knee brace. The examiner further stated that the Veteran's bilateral knee disabilities impact his ability to work; specifically, "[t]he Veteran could perform activities of daily living except [for] the referenced limitations." In his December 2014 NOD, the Veteran reported that he has severe pain on motion in his right and left knees, which worsens with standing and walking. VA treatment records dated in February 2016 noted right ACL laxity. A March 30, 2016 MRI report documented a right ACL tear, as well as a tear of the right medial meniscus. VA treatment records dated in May 2016 noted instability, pain, and swelling in the Veteran's right knee. The treatment provider explained that the Veteran experienced episodes of instability when he is playing sports with pivoting motion. At the March 2019 Board hearing, the Veteran endorsed swelling, pain, and difficulty in range of motion of both knees. He described popping, locking, and stability issues bilaterally. The Veteran was afforded a VA examination in February 2020 at which time the examiner did not render any diagnosis with respect to the left knee; in fact, it is unclear the extent to which the February 2020 VA examiner evaluated the Veteran's left knee. The VA examiner diagnosed right knee meniscal tear, right knee ACL tear, right knee joint osteoarthritis, and right knee limitation of extension. The Veteran reported that his right knee pain has become more severe. He indicated that his knee "catches, skips, and gives out" and he is "unable to make quick left or right movements." He also reported that his right knee dislocates. The Veteran's right knee disability is treated with ibuprofen, rest, ice, elevation, and compression. The Veteran endorsed right knee flare-ups manifested by dislocation. He reported that, if his knee dislocates, his symptoms "can be bad for a couple days, unable to ambulate." He experiences dislocations every month or two. The Veteran indicated that he "[m]issed days due to knee flares. Walking on uneven surfaces causes pain and increases chances of [d]islocation. Once stepped off a high curb and dislocated knee, [h]ad difficulty with walking long distances on uneven surfaces, squatting, or bending causes more pain." Range of motion testing revealed flexion to 95 degrees and extension to 5 degrees in the right knee. Range of motion testing of the left knee showed flexion to 120 degrees and extension to zero degrees. The examiner indicated that, with respect to the Veteran's right knee, "[d]ecreased range of motion makes ambulation difficult and makes him somewhat unsure on his feet at times." Pain was noted on examination of the right knee, which causes functional loss. There was pain on palpation of the right knee, "over all knee joint, medial and anterior the wors[t]." There was no additional limitation of motion on repetitive use testing. The examiner reported that pain and fatigue of the right knee significantly limit the Veteran's functional ability with repeated use over a period of time. The examiner estimated that flexion is additionally limited to 85 degrees and extension limited to 5 degrees with repeated use over time. The examiner further indicated that pain, weakness, lack of endurance, and incoordination of the right knee significantly limit the Veteran's functional ability during flare-ups. The examiner estimated that flexion is additionally limited to 70 degrees and extension limited to 10 degrees with flare-ups. The examiner noted that the Veteran's locomotion is slightly ataxic. Muscle strength was intact and there was no evidence of atrophy. The examiner identified slight recurrent subluxation of the right knee and slight lateral instability in the right knee. There is recurrent effusion; specifically, "Veteran described substantial swelling and fluid buildup with flare-ups." Joint stability testing revealed 1+ (0-5 mm) at medial instability and 2+ (5-10 mm) at lateral instability in the right knee. The examiner noted that an April 2016 MRI report showed a posterior horn medial meniscus tear in the right knee. The examiner indicated that the Veteran does not use assistive devices. The examiner reported that the Veteran's right knee disability does impact his ability due to functional loss outlined above. He indicated that there is no objective evidence of pain on passive range of motion or when the joint is used in nonweight-bearing. The Veteran was afforded a VA examination in August 2020, which seemed to primarily evaluate the left knee and it is unclear the extent to which the right knee was examined in this examination. The examiner diagnosed left knee ACL tear, status-post ACL reconstruction and left knee meniscus tear status-post medical meniscus debridement. The Veteran reported that his instability is worsening. He is unable to make quick movements. He works in construction and has difficulty navigating uneven terrain, will stumble, and experiences pops with swelling. The Veteran endorsed flare-ups of left knee symptomatology; specifically, "random popping sensation to left knee, followed by subsequent swelling, requires about one week for swelling to reduce and return back to functional capacity." The Veteran indicated that he is unable to run and is extra cautious with avoiding quick/sudden movements during flare-ups to include when he is playing with his daughter. When he is at work, the Veteran is unable to kneel for prolonged periods and forces him to lay down to accomplish tasks. The Veteran avoids climbing ladders when carrying anything heavier than a toolbelt. Range of motion testing revealed flexion to 120 degrees and extension, bilaterally. There was pain throughout motion. The examiner indicated that the left knee is tender at the anterior, superolateral aspect. There was no pain with weight-bearing or crepitus. There was no additional limitation of motion on repetitive use testing. Pain, incoordination, and fatigue significantly limited functional ability with repeated use over a period of time. The examiner estimated that range of motion measurements remained the same during flare-ups and over time. The examiner identified disturbance of locomotion as an additional factor contributing to the Veteran's right knee disability; specifically, "knee giving out due to chronic ACL tear." In the left knee, the Veteran reported swelling after flare-ups and popping. Muscle strength was intact in the right knee and reduced at 4/5 in the left knee. There was no evidence of atrophy or ankylosis. The examiner indicated that the Veteran has moderate recurrent subluxation in the right knee, but no history of lateral instability. There was recurrent effusion in the left knee with popping episodes. There was no joint instability on objective testing. The examiner indicated that the Veteran's left side meniscal tear results in frequent episodes of joint locking, joint pain, and joint effusion. The examiner indicated that the "[h]istory of medial meniscus tear left knee, continues to report intermittent locking/popping, joint pain and swelling." The examiner indicated that the Veteran's knee disabilities do impact his ability to work; specifically, he is "[u]nable to kneel for prolonged periods, limits climbing ladders." The examiner reported that there is objective evidence of pain when the right and left knees are used in nonweight-bearing. Passive range of motion is the same as active. The examiner opined, "[s]ymptoms of popping, sensation of instability, swelling, and pain are from overlapping conditions of ACL tear and medial meniscus tear, unable to differentiate." The Veteran underwent another VA examination of his right and left knees in October 2020. He reported current symptoms of "[p]ain on bottom of right patella and medially and laterally. On the left knee pain is superior to the knee joint. Reports intermittent swelling of the knee. Sometimes right knee feels like it is out of place." The Veteran endorsed flare-ups; specifically, intermittent dislocations (twice per year) of the right knee with moderate swelling. He denied flare-ups of the left knee. The Veteran reported that he cannot perform any lateral movements. He is only able to run a half mile before pain sets in. He has difficulty walking on uneven surfaces. There was objective evidence of crepitus, bilaterally. Range of motion testing revealed flexion to 90 degrees in the right knee and 95 degrees in the left knee. Extension was to zero degrees in both knees. Pain was noted on examination, but does not result in functional loss. There was no additional limitation of motion on repetitive use testing. The examiner reported that pain and weakness significantly limit the Veteran's functional ability with repeated use over a period of time and during right knee flare-ups. The examiner indicated that this additionally limited flexion to 80 degrees in the right knee and 85 degrees in the left knee. Muscle strength was intact. There was no atrophy or ankylosis. There was slight recurrent subluxation in the right knee, but no history of lateral instability or recurrent effusion in either knee. Joint stability testing revealed no objective evidence of instability in either knee. The examiner indicated that the Veteran had meniscal conditions in both knees; residuals included frequent episodes of joint locking and joint pain in the right knee. The examiner indicated that the residuals signs of the meniscectomy in the left knee are continued pain and decreased range of motion. The Veteran did not use any assistive devices. The examiner reported that the Veteran's right and left knee disabilities do impact his ability to work. The examiner explained, "[t]he Veteran would be unable to perform a job that requires frequent lateral movements or running due to his right knee osteoarthritis with moderate instability or his left knee ACL and meniscal tear status-post repair with residuals. There was no objective evidence of pain on passive range of motion testing or when the knee joints were used in nonweight-bearing. In a December 2020 statement, the Veteran's spouse reported that the Veteran's knee disabilities have not improved over time. The Veteran has instability of the right knee with very frequent episodes of buckling. His knee cracks when he walks or uses the stairs. He has pain and popping in his knees. In a December 2020 statement, the Veteran asserted that the February 2020 VA examination properly evaluated his knee disabilities because the examination was not hindered by social distancing. He reported that the October 2020 VA examiner was unaware he had torn his ACL and meniscus in the right knee. The Veteran was most recently afforded a VA examination in April 2021 at which time he reported current symptoms of "[p]ain on bottom of right patella and medially and laterally. On the left knee pain is superior to the knee joint. Reports intermittent swelling of the knees. Sometimes right knee feels like it is out of place." The Veteran takes ibuprofen as needed (about twice daily). The Veteran endorsed flare-ups of right knee symptomatology, occurring three times a month. He has left knee flare-ups one to two times per week. His right knee flare-ups are moderate to severe and his left knee flare-ups are mild to moderate. His right knee dislocated recently, this occurs once a month and is severe. The Veteran's "right knee flare-ups are precipitated by lateral movements, pushing off of the right foot or quick pivots." His left knee flare-ups are precipitated by standing and walking for long periods and walking on uneven surfaces. Flare-ups are alleviated by ibuprofen, rest, ice, compression, elevation, and relocating the right patella. The Veteran indicated that he is "[u]nable to stand longer than 30-60 minutes without resulting flare-ups. Unable to perform squats, when needing to be low, [he] tries to lay down, cannot knee on either knee, [s]tairs do cause discomfort." The Veteran reported that his right knee with dislocate and both knees have a sensation of "skipping a beat" where they are not moving as normal and are sometimes locked. His right knee swells after dislocation. Active range of motion testing revealed flexion to 90 degrees and extension to 10 degrees in the right knee, and flexion to 95 degrees and extension to 10 degrees in the left knee. Passive range of motion testing showed flexion to 110 degrees and extension to 5 degrees, bilaterally. There was evidence of crepitus in the right knee. There was additional loss of function after three repetitions: specifically, flexion to 90 degrees and extension to 10 degrees, bilaterally. Pain causes functional loss in the right knee, and pain and lack of endurance cause functional loss in the left knee. The examiner indicated that the procured evidence does not suggest that pain, fatigability, weakness, lack of endurance, or incoordination significantly limit functional ability with repeated use over time. The examiner indicated that the examination was being conducted during a flare-up. He further reported that pain significantly limits the Veteran's functional ability with flare-ups, bilaterally. He indicated that, during flare-ups, flexion was limited to 90 degrees with extension limited to 15 degrees, bilaterally. There was no evidence of atrophy or ankylosis. There was slight recurrent subluxation of the right and left knees. The examiner indicated that the Veteran had a complete ligament tear repair fail in the right knee. He reported there was no recurrent patellar instability. The Veteran has bilateral meniscal tears manifested by frequent episodes of joint pain and locking in the right knee. Joint stability testing was normal and showed no objective evidence of instability in either knee. The Veteran did not use assistive devices. The examiner reported that the Veteran's knee disabilities do impact his ability to work. The examiner explained, "[t]he Veteran would be unable to perform a job that requires frequent lateral movements (pivoting) or running." Right knee With respect to the right knee, the Veteran is currently assigned a zero percent rating for osteoarthritis with painful motion and limitation of extension, evaluated as zero percent disabling from September 10, 2014, 10 percent disabling from February 18, 2020, and 20 percent disabling from April 30, 2021. He is also assigned a separate rating for limitation of flexion of the right knee, evaluated as 10 percent disabling from September 10, 2014 and zero percent from February 18, 2020. Based on the evidence of record, as detailed in pertinent part above, the Board finds that right knee disability ratings in excess of zero percent for limitation of extension and 10 percent for limitation of flexion were not warranted prior to February 18, 2020. VA examination and treatment records referenced above demonstrated, at worst, 100 degrees of flexion and 5 degrees of extension (as documented by the October 2014 VA examiner and taking into account additional limitation on repetitive use and during flare-ups). Such findings warrant noncompensable disability ratings under DC 5260 and 5261. However, prior to February 18, 2020, the RO assigned a 10 percent rating for the right knee based on limitation of flexion with painful motion. To this end, as the range of motion findings equate to noncompensable ratings under Diagnostic Codes 5260 and 5261, only one 10 percent rating may be assigned. Thus, a disability rating in excess of 10 percent for painful flexion and zero percent for limitation of extension of the right knee is not warranted prior to February 18, 2020. Similarly, for the period dating from February 18, 2020 to April 30, 2021, the Veteran has been assigned a 10 percent rating for osteoarthritis of the right knee with limited extension, as well as a noncompensable rating for osteoarthritis of the right knee with limitation of flexion. The evidence of record, described above, indicated that, at worst, the Veteran's right knee disability exhibited reduced flexion to 70 degrees and extension to 10 degrees. See the VA examination reports dated February 2020, August 2020, and October 2020. As such, the evidence demonstrates that a 10 percent rating is warranted based upon extension limited to 10 degrees in the right knee from February 18, 2020 to April 30, 2021. As the Veteran's right knee flexion was limited to no worse than 70 degrees, a compensable rating is not warranted. As such, increased ratings are not warranted for the right knee from February 18, 2020 to April 30, 2021. For the period from April 30, 2021, the evidence demonstrates flexion to 90 degrees and extension to 15 degrees. As such, a disability rating in excess of 20 percent is not warranted based upon limitation of extension, and a compensable disability rating is not warranted based upon limitation of flexion of the right knee. Critically, functional loss must be rated under the diagnostic code pertaining to limitation of motion of the affected joint, pursuant to 38 C.F.R. § 4.40; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991) (noting that functional loss due to pain is to be rated at the same level as where motion is impeded); DeLuca v. Brown, 8 Vet. App. 202, 205-06 (noting that the disabling effect of painful motion must be considered when rating joint disabilities) (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (stating that functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion)); c.f., Petitti v. McDonald, 27 Vet. App. 415 (2015). Hence, there is no basis upon which to find additional limitation due to functional factors. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 202; Mitchell, 25 Vet. App. at 32. As indicated above, the Veteran's functional impairment and impaired motion during flare-ups is contemplated in the assigned disability ratings. As set forth above, the Veteran does not meet the criteria for the assignment of a separate compensable disability ratings for limitation of flexion or extension in his right knee under VAOPGCPREC 09-2004, VAOPGCPREC 23-97, or VAOPGCREC 9-98 from the date of service connection. As indicated above, the Veteran is assigned a separate disability rating for subluxation and instability of the right knee pursuant to DC 5257, evaluated as 20 percent from January 5, 2020 and 10 percent from August 1, 2021. However, review of the record shows that the Veteran complained of right knee instability at the October 2014 VA examination and described frequent "popping out" of the right knee. Although joint stability testing did not document objective evidence of instability, the examiner indicated that the Veteran had a history of moderate lateral instability in the right knee. In addition, the October 2014 examiner noted that the Veteran occasionally relied on the use of a right knee brace. VA treatment records dated in February 2016 documented the Veteran's right ACL laxity and a March 2016 MRI revealed a torn ACL. Moreover, right knee instability was again documented in May 2016. Accordingly, the Board finds that the 20 percent rating under DC 5257 for moderate lateral instability is warranted from the date of service connection, September 10, 2014. With respect to the period dating from August 1, 2021, the Board notes that the 10 percent assigned rating for right knee instability under DC 5257 is based upon findings set forth in the April 2021 examination report. Objective joint stability testing was normal and the examiner characterized the Veteran's recurrent subluxation as "slight." However, the VA examiner noted that the Veteran continues to experience episodes of dislocation of the right knee, occurring approximately once per month. The examiner additionally reported that the Veteran would be unable to perform a job that requires frequent lateral movements such as pivoting due to his right knee joint instability. Moreover, both the Veteran and his spouse have submitted statements indicating that the Veteran's right knee subluxation has not decreased at any time from the date of service connection. The Board therefore finds that a separate 20 percent rating is warranted from the date of service connection, September 10, 2014 throughout the appeal period under DC 5257. The Board has considered whether a higher rating would be warranted, including under the revised DC 5257 (in effect from February 7, 2021). To this end, the Board recognizes that the April 2021 VA examiner reported that, with respect to the Veteran's right ligament tear, there was a complete tear repair, which failed. Additionally, as described above, there is evidence of patellar subluxation documented in the record. Critically, the evidence of record does not show that the Veteran has been prescribed the use of a brace or other assistive device, or that he relies on any time of assistive device for ambulation. Moreover, the assignment of a 10 percent disability rating under the revised DC 5257, for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker, does not avail the Veteran. As such, a rating in excess of 20 percent is not warranted under the revised version of DC 5257. Additionally, the Board finds that a separate 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint is warranted from March 30, 2016, the date of the MRI report documenting the medial meniscal tear in the Veteran's right knee. Here, the evidence clearly documents a meniscal tear of the right knee, coupled with documentation of stiffness, locking, popping, crepitus, and effusion. Accordingly, separate 20 percent ratings are warranted for the right meniscal tear under DC 5258 from March 30, 2016. A 30 percent disability rating may be assigned for ankylosis at a favorable angle in full extension, or in slight flexion between zero and 10 degrees. 38 C.F.R. § 4.71a, DC 5256. However, as indicated above, none of the other examination and treatment records nor the lay evidence contained in the claims file documents ankylosis of the right knee or symptoms producing the functional equivalent of ankylosis. As such, the Board finds that a higher disability rating under DC 5256 is not warranted. The Board has also considered whether DC 5055 (knee replacement) is applicable in this matter. However, a total knee replacement was not performed; as such, DC 5055 is not for application. Left knee With respect to the left knee, the Veteran is currently assigned a 10 percent disability rating for left knee ACL and meniscal tear from September 10, 2014 and a zero percent rating from April 30, 2021 under DC 5260. A separate disability rating for limitation of extension of the left knee is assigned under DC 5261 with a zero percent rating assigned from September 10, 2014 and a 20 percent rating assigned from April 30, 2021. Based on the evidence of record, as detailed in pertinent part above, the Board finds that left knee disability ratings in excess of zero percent for limitation of extension and 10 percent for limitation of flexion were not warranted prior to April 30, 2021. VA examination and treatment records referenced above demonstrated, at worst, 85 degrees of flexion and 5 degrees of extension (as documented by the October 2014 and October 2020 VA examiners and taking into account additional limitation on repetitive use and during flare-ups). Such findings warrant noncompensable disability ratings under DC 5260 and 5261. However, prior to April 30, 2021, the RO assigned a 10 percent rating for the left knee based on limitation of flexion with painful motion under DC 5260. To this end, as the range of motion findings equate to noncompensable ratings under Diagnostic Codes 5260 and 5261, only one 10 percent rating may be assigned for this period. Thus, a disability rating in excess of 10 percent for painful flexion and zero percent for limitation of extension of the left knee is not warranted prior to April 30, 2021. For the period dating from April 30, 2021, the evidence of record demonstrates limitation of flexion to 90 degrees and limitation of extension to 15 degrees. As such, a disability rating in excess of 20 percent is not warranted based upon limitation of extension, and a compensable disability rating is not warranted based upon limitation of flexion of the left knee. Functional loss must be rated under the diagnostic code pertaining to limitation of motion of the affected joint, pursuant to 38 C.F.R. § 4.40; Schafrath, 1 Vet. App. at 592 (noting that functional loss due to pain is to be rated at the same level as where motion is impeded); DeLuca, 8 Vet. App. at 205-06 (noting that the disabling effect of painful motion must be considered when rating joint disabilities); Mitchell, 25 Vet. App. at 37 (stating that functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion)); c.f., Petitti, supra. Hence, there is no basis upon which to find additional limitation due to functional factors. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 202; Mitchell, 25 Vet. App. at 32. As indicated above, the Veteran's functional impairment and impaired motion during flare-ups is contemplated in the assigned disability ratings. As set forth above, the Veteran does not meet the criteria for the assignment of a separate compensable disability ratings for limitation of flexion or extension in his left knee under VAOPGCPREC 09-2004, VAOPGCPREC 23-97, or VAOPGCREC 9-98 from the date of service connection. The Board has considered whether a separate rating for the left knee disability under DC 5257 is warranted. However, the evidence does not show that the Veteran has experienced symptoms of subluxation or instability in the left knee. Although it is well-documented that the Veteran underwent an ACL repair surgery on his left knee in 2008, there is no there is no probative evidence of subluxation, lateral instability, or patellar instability of the left knee during the appeal period. As such, a separate rating under DC 5257 is not warranted. See 38 C.F.R. § 4.71a, DC 5257. Additionally, the Board finds that a separate 10 percent rating for cartilage, semilunar, removal of, symptomatic is warranted under DC 5258 for the left knee disability. The Board recognizes that the RO had previously assigned a combined rating for the meniscal tear with the ACL tear of the left knee under DCs 5260 and 5261. However, the evidence of record documents episodes of effusion and popping in his left knee. Specifically, the August 2020 VA examiner documented the Veteran's report that his left knee flare-ups are manifested by "random popping sensation to the left knee followed by subsequent swelling." These episodes require about one week for the swelling to reduce and return to full functional capacity. See the VA examination report dated August 2020; see also the Board hearing transcript dated March 2019. Although the August 2020 VA examiner described these episodes of popping and effusion as 'frequent,' said episodes were not documented by any other VA examiner. See the VA examination reports dated October 2014, February 2020, October 2020, and April 2021. The Veteran has routinely described his left knee symptomatology as less severe than that of his right knee. Id.; see also the Veteran's statement dated December 2020 and the Board hearing transcript dated March 2019. As such, the Board finds that a 10 percent rating, but no higher, is warranted throughout the appeal period based upon the Veteran's residual symptoms of following his 2008 meniscectomy. A 30 percent disability rating may be assigned for ankylosis at a favorable angle in full extension, or in slight flexion between zero and 10 degrees. 38 C.F.R. § 4.71a, DC 5256. However, as indicated above, none of the other examination and treatment records or the lay evidence contained in the claims file documents ankylosis of the left knee or symptoms producing the functional equivalent of ankylosis. As such, the Board finds that a higher disability rating under DC 5256 is not warranted. The Board has also considered whether DC 5055 (knee replacement) is applicable in this matter. However, a total knee replacement was not performed; as such, DC 5055 is not for application. In sum, the Board has considered the entire record, including the Veteran's reported symptomatology and the objective clinical evidence. For the reasons set forth above, the Board finds that initial ratings in excess of 10 percent prior to February 18, 2020 and zero percent thereafter are not warranted for right knee osteoarthritis with limitation of flexion, and initial ratings in excess of zero percent prior to February 18, 2020, 10 percent from February 18, 2020 to April 30, 2021, and 20 percent thereafter are not warranted for right knee osteoarthritis with limitation of extension. Further, the Board finds that a 20 percent disability rating is warranted for right knee instability under DC 5257 from September 10, 2014, the date of service connection. The Board additionally finds that a separate 20 percent rating is warranted for the right knee disability under DC 5258 from March 30, 2016 based upon the torn ACL and medial meniscus. With respect to the left knee, the Board finds that initial ratings in excess of 10 percent prior to April 30, 2021 and zero percent thereafter are not warranted for limitation of flexion of the left knee, and initial ratings in excess of zero percent prior to April 30, 2021 and 20 percent thereafter are not warranted for limitation of extension of the left knee. The Board further finds that a separate 10 percent initial rating, but no higher, is warranted for residuals of meniscectomy under DC 5259 from the date of service connection. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, 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.