Citation Nr: 21074507 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 06-03 503 DATE: December 15, 2021 ORDER Entitlement to an initial disability rating in excess of 10 percent for osteoarthritis, left knee, status-post medical meniscectomy based on limitation of flexion, from January 1, 2003, to February 13, 2011, is denied. Entitlement to a separate 20 percent disability rating for osteoarthritis, left knee status-post medial meniscectomy based on frequent episodes of "locking," pain, and effusion into the joint from January 1, 2003 to February 13, 2011, is granted. Entitlement to an initial disability rating in excess of 20 percent osteoarthritis, left knee, status-post medical meniscectomy based on frequent episodes of "locking," pain, and effusion into the joint, from February 14, 2011, to March 24, 2019, is denied. Entitlement to a separate 10 percent disability rating for osteoarthritis, left knee status-post medial meniscectomy based on limitation of flexion, from February 14, 2011, to March 24, 2019, is granted. Entitlement to a separate 30 percent disability rating for osteoarthritis, left knee, status-post medial meniscectomy based on lateral instability from January 1, 2003, to March 24, 2019, is granted. Entitlement to a disability rating in excess of 60 percent for total left knee arthroplasty (previously rated as osteoarthritis, left knee, status-post medial meniscectomy) from May 1, 2020, forward is denied. FINDINGS OF FACT 1. From January 1, 2003 to February 13, 2011, the Veteran's osteoarthritis, left knee, status-post medial meniscectomy has manifested as painful motion. 2. From January 1, 2003 to March 24, 2019, the Veteran's osteoarthritis, left knee, status-post medial meniscectomy has manifested as frequent episodes of locking, pain, and effusion into the joint, the highest schedular evaluation under Diagnostic Code 5258. 3. From January 1, 2003 to March 24, 2019, the Veteran's osteoarthritis, left knee, status-post medial meniscectomy has manifested as severe recurrent lateral instability, the highest schedular evaluation under Diagnostic Code 5257. 4. From February 14, 2011, to March 24, 2019, the Veteran's osteoarthritis, left knee, status-post medial meniscectomy has manifested as painful motion. 5. From May 1, 2020, the Veteran's total left knee arthroplasty has manifested as chronic residuals of severe painful motion or weakness in the affected extremity, the highest schedular evaluation for residuals under Diagnostic Code 5055. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 10 percent for osteoarthritis, left knee status-post medial meniscectomy based on limitation of flexion from January 1, 2003 to February 13, 2011, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5003-5259. 2. The criteria for entitlement to a separate 20 percent disability rating for osteoarthritis, left knee status-post medial meniscectomy based on frequent episodes of "locking," pain, and effusion into the joint from January 1, 2003 to February 13, 2011, have been met. 38 U.S.C. §§ 1155, 5107; 38C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5258. 3. The criteria for entitlement to a disability rating in excess of 20 percent osteoarthritis, left knee, status-post medical meniscectomy based on frequent episodes of "locking," pain, and effusion into the joint, from February 14, 2011, to March 24, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5003-5258. 4. The criteria for entitlement to a separate 10 percent disability rating for osteoarthritis, left knee status-post medial meniscectomy based on limitation of flexion from February 14, 2011, to March 24, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 5. The criteria for a separate 30 percent disability rating for osteoarthritis, left knee, status-post medial meniscectomy based on lateral instability from January 1, 2003, to March 24, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5257. 6. The criteria for entitlement to a disability rating in excess of 60 percent for total left knee arthroplasty from May 1, 2020, forward have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1983 to January 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in July 2004 and September 2008. In November 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The Board previously remanded this matter in February 2018, February 2020, May 2020, and January 2021 for further development. During the most recent remand, a May 2021 rating decision assigned a 60 percent disability rating for the Veteran's total left knee arthroplasty, effective May 1, 2020. Increased Disability Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App.at 126. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107;38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 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 to38 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."). The provisions of sections 4.40 and 4.45 thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca, 8 Vet. App.at 206-07 (holding that the provisions of 4.40 and 4.45 are not subsumed by the diagnostic codes applicable to the affected joint). Moreover, the intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. See 38 C.F.R. § 4.59. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Additionally, the United States Court of Appeals for Veterans Claims (the Court) recently held that the plain language of § 4.59 indicates that the regulation is not limited to the evaluation of musculoskeletal disabilities under diagnostic codes predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Court held that § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is being evaluated is predicated on range of motion measurements. Id. at 354. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. During the relevant time periods, under Diagnostic Code 5010, arthritis due to trauma, substantiated by X-ray findings, is to be rated as degenerative arthritis under Diagnostic Code 5003. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the joint involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating 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. In the absence of limitation of motion, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Diagnostic Code 5003. Under Diagnostic Code 5256, a 30 percent rating is warranted for ankylosis of the knee with favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is warranted for ankylosis of the knee with flexion between 10 degrees and 20 degrees. Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words "slight," "moderate," and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. 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. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under Diagnostic Code 5258, a 20 percent rating is warranted for cartilage, semilunar dislocated, with frequent episodes of locking, pain, and effusion into the joint. The 20 percent rating is the only rating available under Diagnostic Code 5258. Diagnostic Code 5259 provides that a 10 percent rating is warranted for surgically removed cartilage that is symptomatic. A semilunar cartilage is one of the menisci of the knee joint. A 10 percent rating is also the highest schedular evaluation allowed under Diagnostic Code 5259. Under Diagnostic Code 5260, limitation of flexion of the knee to 60 degrees warrants a noncompensable rating. Limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating. Limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. Under Diagnostic code 5261, limitation of extension of the knee to 5 degrees warrants a zero or noncompensable rating. Limitation of extension of the knee to 10 degrees warrants a 10 percent rating. Limitation of extension of the knee to 15 degrees warrants a 20 percent rating. Limitation of extension of the knee to 20 degrees warrants a 30 percent rating. Limitation of extension to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. Under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, malunion with slight knee or ankle disability warrants a 10 percent rating; malunion with moderate knee or ankle disability warrants a 20 percent rating; malunion with marked knee or ankle disability warrants a 30 percent rating; and nonunion of the tibia and fibula, with loose motion, requiring brace warrants a maximum 40 percent rating. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. VA's General Counsel has provided guidance concerning increased rating claims for knee disabilities. In VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997), it was held that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that any separate rating must be based upon additional disability. When a knee disability is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or DC 5261 in order to obtain a separate rating for arthritis. In VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998), the VA General Counsel clarified that when a veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. The VA General Counsel has also held that separate ratings could be provided for limitation of knee extension and flexion under Diagnostic Codes 5260 and 5261, as long as both ranges of motion meet the criteria for a compensable rating. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). 1. Entitlement to an initial disability rating in excess of 10 percent for osteoarthritis, left knee, status-post medical meniscectomy based on limitation of flexion, from January 1, 2003 to February 13, 2011, is denied. 2. Entitlement to a separate 20 percent disability rating for osteoarthritis, left knee status-post medial meniscectomy based on frequent episodes of "locking," pain, and effusion into the joint from January 1, 2003 to February 13, 2011, is granted. 3. Entitlement to an initial disability rating in excess of 20 percent osteoarthritis, left knee, status-post medical meniscectomy based on frequent episodes of "locking," pain, and effusion into the joint, from February 14, 2011, to March 24, 2019, is denied. 4. Entitlement to a separate 10 percent disability rating for osteoarthritis, left knee status-post medial meniscectomy based on limitation of flexion, from February 14, 2011, to March 24, 2019, is granted. 5. Entitlement to a separate 30 percent disability rating for osteoarthritis, left knee, status-post medial meniscectomy based on lateral instability from January 1, 2003, to March 24, 2019, is granted. During the time periods listed above, the Veteran's service-connected osteoarthritis, left knee, status-post medial meniscectomy has been rated as 10 percent disabling from January 1, 2003, to June 27, 2007, and from October 1, 2007 to February 13, 2011 under Diagnostic Codes 5259-5003 and 20 percent disabling from February 14, 2011, to March 24, 2019, under Diagnostic Codes 5003-5258. See 38 C.F.R. § 4.71a (hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen). The original 10 percent rating under Diagnostic Codes 5259-5003 from January 1, 2003, to February 13, 2011 was assigned based upon painful motion of the left knee, as limitation of motion of the knee was noncompensable under the appropriate diagnostic code, i.e., DCs 5260 and 5261. From February 14, 2011, to March 24, 2019, the 20 percent rating under DC 5003-5258 was based upon frequent episodes of "locking," pain, and effusion into the joint. The Veteran's left knee disability has also been assigned 100 percent disability ratings under 38 C.F.R. § 4.30 from June 28, 2007, to September 30, 2007 and from March 25, 2019, to April 30, 2020. The provisions of 38 C.F.R. § 4.30, which govern convalescent ratings, direct that the total disability rating will be assigned without regard to other provisions of the rating schedule and that such total rating will be followed by appropriate schedular evaluations. Therefore, to the extent that the medical and lay evidence may support a higher rating for the Veteran's left knee disability or separate ratings based on the diagnostic codes relating to the knee during these time periods, Federal law and regulations prohibit such awards. To evaluate the Veteran's left knee disability, he has been afforded several examinations. Of note, the Veteran was provided a May 2003 VA Joints Examination. The examination report states that the Veteran's left knee has been somewhat troublesome as he cannot squat, and he experiences pain and stiffness during cold weather. His knee has given way once. He takes Advil, he uses a sleeve, and utilizes topical ointment during cold weather. The May 2003 VA examination report states that the Veteran's gait and station are within normal limits. He has extension to 0 degrees and flexion to 130 degrees. The Veteran's left knee is stable to all tests throughout range of motion. McMurray's and pivot shift testing were negative. He does not have effusion, but there are palpable, slightly tender osteophytes along the medial border of his joint line, primarily on the femoral side. The Veteran was assessed with osteoarthritis of the left knee, status post partial medial meniscectomy. The Veteran was also provided a June 2004 VA Joints Examination. The examination report states that the Veteran reported recent private treatment for his left knee that included an injection that resulted in slight improvement. He advised of left knee pain, discomfort, and weakness. Recent X-ray examinations show that he is status post medial meniscectomy with some osteoarthritis of the medial compartment of his left knee. He has been prescribed a knee brace that he uses constantly and apparently shows some improvement. The examination report states that the Veteran has normal range of motion on flexion. He had a negative Lachman test, McMurray's test, and drawer test. The Veteran was also provided with a November 2008 VA Examination. The examination report states that the Veteran is experiencing moderate symptoms that include painful swelling, giving way, and locking of his opposite non-service-connected right knee. He has increased pain and swelling after standing for five or six hours, he has snapping, difficulty entering and exiting motor vehicles, ascending stairs, and he cannot run. He does not experience pain when at complete rest. He requires the use of a hinged elastic Velcro maintained Bledsoe brace. The November 2008 VA examination report states that the Veteran walks with a slight limp and his knee was swollen on examination. He had a positive suprapatellar fluid wave in the left knee. He had extension to 0 degrees and flexion to 110 degrees on maximal effort with a painful endpoint. He had satisfactory stability to varus and valgus strain. He had a negative drawer test, anterior drawer sign, and no suggestion of anterior cruciate ligament instability. He was unable to perform a full squat. He had mild narrowing of the medial joint space. The Veteran was provided with a February 2011 VA Joints Compensation and Pension Examination. The examination report states that his left knee disability has been progressively worsening. He utilizes medication, bracing, and activity limitation. He has left knee deformity, giving way, instability, pain, stiffness, weakness, incoordination, decreased speed, sensitivity to weather, several locking episodes weekly, warmth, redness, swelling, and tenderness as symptoms of inflammation, and joint noises. He does not have episodes of dislocation or subluxation or flare-ups. He can stand for more than one hour, but less than three. He is unable to walk more than a few yards. He utilizes corrective shoes, orthotic inserts, and a brace constantly. The February 2011 VA examination report states that on physical examination, the Veteran has an antalgic gait with poor propulsion. He has callus formation, there is bone loss incidental to arthroscopic procedures. He has bony joint enlargement, crepitus, deformity, edema, tenderness, pain at rest, weakness, and guarding of movement. He has effusion, clicking or snapping, grinding, subpatellar tenderness, and fibrotic feelings of the patellar ligament. He does not have instability, locking, or dislocation. The McMurray's test was positive. The Veteran had extension to 0 degrees and flexion to 90 degrees. There was objective evidence of pain following repetitive motion, but no additional limitations after repetitions of range of motion. There is no joint ankylosis. The Veteran was provided with an October 2019 Knee and Lower Leg Conditions Disability Benefits Questionnaire. The Veteran's medical history is described as chronic knee pain, and decreased range of motion. He takes Motrin 800 milligrams twice daily, participates in physical therapy several times per week, and performs stretches daily. The Veteran reported flare-ups of his left knee as increased pain and swelling that occurs three times per week that are 7-8 out of 10 in severity and last for several hours. His functional impairment is listed as an inability to work outside of an office or driving setting, he has difficulty performing household chores, and cannot accomplish yard work. The October 2019 examination report states that the Veteran does not have pain with weight-bearing, but he has objective evidence of crepitus. Initial range of motion measurements show that he has flexion to 130 degrees and extension to 20 degrees. There was pain noted on the examination during flexion that causes functional loss. He has tenderness on palpation around the patella that is moderate and consistent with left knee osteoarthritis. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional loss of function or range of motion. The October 2019 examination report states that the Veteran has periodic swelling, disturbance of locomotion as the inability to run and difficulty ascending stairs, and interference during standing as increased pain with prolonged standing. The Veteran's muscle strength testing was rated as 5/5 (normal strength) on flexion and 4/5 (active movement with some resistance) on extension. He did not have muscle atrophy, ankylosis, recurrent subluxation, or lateral instability. He has a history of recurrent effusion as he reported frequent swelling of his knees. Joint stability testing did not reveal instability as anterior, posterior, medial, and lateral instability testing was normal. The Veteran has had a meniscal tear of the left knee and a total knee joint replacement on March 25, 2019 with residuals of intermediate degrees of residual weakness, pain, or limitation of motion. The examination report states that the Veteran has scars associated with his left knee disability, but none are painful or unstable, or have an area equal to or greater than 39 square centimeters (6 square inches), or are located on the head, face, or neck. The Veteran regularly uses a brace. He has objective evidence of pain on passive range of motion and when the joint is used in non-weight bearing. The October 2019 examination report indicates that the Veteran has bilateral degenerative or traumatic arthritis and that in terms of functional impairment, he is unable to perform patrol work as a police officer. The Veteran's claims folder contains private treatment records that demonstrate the severity of his left knee disability. A March 2004 private treatment record indicates that the Veteran has a potential anterior cruciate ligament tear, and that physical examination reveals significant swelling with decreased motion of the left knee. An April 2004 private treatment record states that the Veteran has full range of motion and slight patellofemoral crepitus, no instability, and no lateral joint line tenderness. He has tenderness in the medial joint line. An April 2004 MRI report states that the Veteran is status post medial meniscectomy without definite tear, osteoarthritis particular medial compartment with cartilage loss, and some areas of subchondral edema without gross loose body. Generally, the Veteran's private treatment records indicate that he received several Synvisc injections to his left knee. On April 12, 2007, the Veteran was seen at Orthopedics Institute of Central Massachusetts and was shown to have full range of motion and slight patellofemoral crepitus, no instability, and no lateral joint line tenderness. He had tenderness in the medial joint line. On April 25, 2007, the Veteran was evaluated after he experienced a left knee giving way episode. The treatment record states that this event occurred approximately one month ago and that since that time he states his knee feels loose and he cannot trust it. His medical history is significant for two arthroscopic procedures for meniscal pathology within the left knee. He denied any episodes of giving way prior to this injury. On physical examination the Veteran had full extension and flexion to 135 degrees. The assessment was noted as clinical symptoms consistent with a complete tear of the anterior cruciate ligament. An April 2007 private MRI report from UMass Memorial provides that the there is an appearance of a chronic anterior cruciate ligament tear. There is evidence of previous partial meniscectomy of the medial meniscus, without clear-cut cleavage tear of the remnant. There is considerable chondromalacia and degenerative changes noted of medial joint compartment and mild joint effusion is seen. A May 2007 private treatment record from Orthopedics Institute of Central Massachusetts provides that the Veteran has a chronic tear of the anterior cruciate ligament. The Veteran's VA treatment records contain evidence of the severity of his left knee disability. In general, the VA treatment records demonstrate complaints of knee pain, locking, instability, and muscle weakness. In April 2009, the Veteran stated that he wakes with left knee stiffness and that he experiences locking. The Veteran had left knee extension to -20 degrees and flexion to 95 degrees on physical examination. He was assessed with a diagnosis of osteoarthritis of knees, decreased range of motion, and weakness of left quadriceps and hamstrings. The Veteran advised of engaging in private physical therapy, aching knee pain, pain that worsens with standing and improves with sitting, ice, and use of Celebrex in a June 2011 VA treatment record. On physical examination, the Veteran had decreased extension of the left knee. A February 2012 VA MRI report states that the Veteran has an intact anterior cruciate ligament graft with the increased cystic change at the tibial tunnel as compared to study dated March 18, 2009. He has worsening tricompartmental degenerative arthropathy. There are no significant interval changes in morphology and signal of the medial meniscus consistent with previous meniscectomy. The Veteran was fitted with knee braces in February 2012. A December 2012 VA treatment record states that the Veteran's gait is slightly antalgic due to the left knee pain. He has medial joint line tenderness with full extension, but his flexion is limited to about 45 degrees with pain. He does not have swelling, instability, or patellar apprehension. VA treatment records from 2014 demonstrate that the Veteran had full range of motion, complained of episodes of locking, and received a Synvisc injection. A March 2015 VA treatment record also noted that the Veteran's flexion is limited to about 45 degrees with pain. The Veteran had Synvisc injections in February 2016, and March, September, October 2017, and April 2018. VA treatment records in February 2016 and September 2017 note that the Veteran does not have swelling or instability, and he has slightly less than full extension and his flexion is preserved but painful. A left knee imaging study from February 2017 shows that the Veteran has patellofemoral and medial compartment predominant degenerative changes with sequela from prior anterior cruciate ligament repair and he was assessed with bilateral knee osteoarthritis. A December 2017 VA treatment record provides that the Veteran continues to have knee pain, he has no night pain or pain at rest, and he has pain with standing and walking. He did not have knee swelling; he typically takes 800 milligrams of Motrin at night. He is unable to run as he would like, but he goes to the gymnasium every morning. The Veteran received a steroid injection in April 2018 per VA treatment records. An October 2018 VA treatment record provides that the Veteran's left knee has mild varus deformity with crepitus and painless full range of motion with no swelling. A May 2019 VA treatment record states that the Veteran is participating in physical therapy two times per week and completing an in-home program five days per week. He hoped to defer a total left knee replacement until he retired, but he injured his knee while working as a police officer. The Veteran also advised of the severity of his left knee disability. In a January 2005 written statement, the Veteran stated that his knee collapsed in March 2004 while performing a fireman's carry while on duty as a police officer. He stated that he received Synvisc knee injections and underwent three months of physical therapy. He now wears a knee brace while at work. In a May 2007 written statement, the Veteran provided that he experiences left knee buckling and instability. In a February 2009 written statement, the Veteran stated that after a complete anterior cruciate ligament reconstruction surgery, he has limited range of motion and is in constant need of a knee brace. In a July 2009 written statement, the Veteran advised that he has left knee pain, discomfort, swelling after standing for long periods of time, and loss of range of motion. During an October 2009 hearing, the Veteran stated that he is currently undergoing physical therapy for his left knee and he also exercise at a gymnasium. He advised that he had swelling at his last examination in April 2009. He takes Motrin 800 milligrams twice daily and he wears a knee brace daily. He has left knee pain, weakness, fatigability, limited range of motion, difficulty ascending stairs, buckling, and instability with weight bearing and prolonged use. He has functional impairments associated with limitations at work as a police officer and at home because he has difficulty running and fatigability. He has missed work because of his left knee disability. His left knee has worsened since his last examination. During a November 2017 hearing, the Veteran stated that he experiences pain, fatigue, loss of balance, fatigability, swelling, instability, and weakness. He cannot run due to weakness, cannot walk for long periods, and has difficulty standing for long periods of time. He advised that he has reduced range of motion and in particular reduced knee extension with pain. He takes Motrin 800 milligrams every 8 hours, wears a knee brace, ices his knee, and tries to keep his knee as straight as possible. Lay testimony is competent as to matters capable of lay observation or within a person's first-hand experience and may be competent evidence with respect to both the diagnosis of a medical condition and its etiology or cause. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, lay testimony is not competent with respect to determinations that cannot be made based on lay observation alone due to their medical or scientific complexity. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). The Board must determine on a case-by-case basis whether lay testimony is competent on the matter at issue, or whether medical evidence is required. See Davidson, 581 F.3d at 1316; Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011). The Board finds that while the Veteran is competent to advise of his observable left knee symptomatology and resultant functional impairment, he is not competent to determine whether his left knee disability warrants a higher disability rating based on reduced range of motion. Such a determination is based on physical examination findings and knowledge of medical principles and testing and; therefore, it is beyond the realm of competence for a lay person. See Jandreau, 492 F.3d at 1376-77. There is no evidence contained in the Veteran's claims folder that he has the specialized knowledge, training, or medical expertise required to make such a determination. From January 1, 2003 to February 13, 2011, a disability rating in excess of 10 percent for the Veteran's osteoarthritis, left knee, status-post medial meniscectomy is not warranted under Diagnostic Code 5259-5003. A March 2004 private treatment record noted significant swelling and decreased range of motion. An April 2009 VA Physical Therapy Initial Evaluation Consult states that the Veteran has flexion to 95 degrees. During this time period, the Veteran advised that he has weakness, incoordination, tenderness, swelling, cannot squat, and he experiences pain and stiffness during cold weather. Because limitation of motion of the left knee did not meet the criteria for a noncompensable rating under DCs 5260 and/or 5261, the Veteran was assigned a10 percent rating for painful motion. See 38 C.F.R. §§ 4.40, 4.45, 4.59. At no point from January 1, 2003 to February 13, 2011 was the range of motion on extension or flexion reduced to such an extent that the criteria for a 20 percent disability rating under Diagnostic Code 5260 or Diagnostic Code 5261 was satisfied, i.e., extension limited to 15 degrees or flexion limited to 30 degrees. However, the Board finds that a separate 20 percent disability rating is warranted from January 1, 2003 to February 13, 2011, for the Veteran's osteoarthritis, left knee, status-post medial meniscectomy under Diagnostic Code 5258. Diagnostic Code 5258 provides for assignment of a 20 percent disability rating for dislocation of the semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. The Veteran's VA treatment records and private treatment record contain notations of locking, pain, and effusion. Further, an April 2007 private MRI report states that the appearance of chronic anterior cruciate ligament tear is noted, there is evidence of a previous partial meniscectomy of the medial meniscus without clear-cut cleavage tear of the remnant, considerable chondromalacia and degenerative changes of medial joint compartment, and mild joint effusion. The February 2011 examination report states that the Veteran has locking episodes several times per week. As such, a separate 20 percent disability rating is warranted for the Veteran's osteoarthritis, left knee, status-post medial meniscectomy under Diagnostic Code 5258. A 20 percent disability rating is the maximum rating available under Diagnostic Code 5258. In addition, full consideration has been given to the Veteran's statements that he has left knee buckling, instability, and giving way that is contained in his VA treatment records, examination reports, written statements, and hearing testimony. The Veteran is competent to report that which he has personally experienced, such as the above knee symptomatology. See Layno, 6 Vet. App. at 470. Thus, the Board finds that the evidence approximates the criteria for a 30 percent disability rating for severe recurrent lateral instability under Diagnostic Code 5257 from January 1, 2003, to March 24, 2019 under the Diagnostic Code 5257. See 38 C.F.R. § 4.71a. The Board notes that the 30 percent disability rating is the highest schedular evaluation allowed under Diagnostic Code 5257. The evidence demonstrates that the Veteran has had a meniscectomy and a complete ACL tear with total knee replacement of his left knee. The evidence also indicates that he has been prescribed a knee brace. While most objective testing has not revealed lateral instability of the Veteran's left knee, the February 2011 examination report states that the Veteran has giving way and instability. Further, the Board points out that objective evidence of instability is not necessarily required to satisfy the criteria for a rating under Diagnostic Code 5257. English v. Wilkie, 30 Vet. App. 347, 353 (2018). Thus, a 30 percent disability rating under the prior version of Diagnostic Code 5257 for the entire appellate period is granted. The Board also finds that from February 14, 2011, to March 24, 2019, a separate 10 percent disability rating under Diagnostic Code 5260 is warranted. As noted above, the Veteran is now in receipt of a 30 percent disability rating under Diagnostic Code 5257. Again, for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 does not have to be compensable but must meet the criteria for a zero-percent rating. VAOPGCPREC 9-98 (August 14, 1998), 63 Fed. Reg. 56,704 (1998). During this time period, the Veteran had left knee flexion to about 45 degrees with pain per multiple VA treatment records. Thus, the Board finds that the criteria for a 10 percent disability rating under Diagnostic Code 5260 have been met during the above time period. At no point from February 14, 2011, to March 24, 2019, was the range of motion on extension reduced to such an extent that the criteria for a 20 percent disability rating under Diagnostic Code 5260 or a compensable disability rating under Diagnostic Code 5261 satisfied. The Board has also considered the applicability of other potential diagnostic codes during this period on appeal. As the evidence of record fails to demonstrate ankylosis, impairment of the tibia or fibula; or genu recurvatum, the Veteran is not entitled to a higher or separate rating under Diagnostic Codes 5256, 5262, or 5263 respectively. 6. Entitlement to a disability rating in excess of 60 percent for total left knee arthroplasty (previously rated as osteoarthritis, left knee, status-post medial meniscectomy) from May 1, 2020, forward is denied. From May 1, 2020, forward, the Veteran's service-connected total left knee arthroplasty has been rated as 60 percent disabling under Diagnostic Code 5055. For the reasons discussed below, the Board finds that a higher disability rating is not warranted. Under Diagnostic Code 5055, a 30 percent rating is warranted as a minimum rating for knee replacement. With intermediate degrees of residual weakness, pain, or limitation of motion, the condition is rated by analogy to Diagnostic Code 5256, 5261, or 5262. A 60 percent rating is warranted for knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. Under the former criteria, in effect prior to February 7, 2021, a maximum rating of 100 percent is warranted for one year following implantation of prosthesis. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The current criteria reduces that time period to 4 months. As the Veteran's most recent March 2019 knee replacement according to the occurred before the regulation change, the more favorable former criteria apply. The Board adds that the other criteria outlined in Diagnostic Code 5055 did not change on February 7, 2021, although several Notes were added to clarify what types of surgery qualify for ratings under 5055, and to direct that additional ratings under other musculoskeletal diagnostic codes may not be assigned for that joint, unless otherwise directed. In particular, Note (1) provides that when an evaluation is assigned for joint resurfacing or the prosthetic replacement of a joint under Diagnostic Codes 5051-5056, an additional rating under §4.71a may not also be assigned for that joint, unless otherwise directed. To evaluate the Veteran's left knee disability, he was provided an August 2020 Knee and Lower Leg Conditions Disability Benefits Questionnaire. The Veteran advised that his ability to flex his left knee has diminished recently. He has pain in both knees, especially after standing for long periods of time, swelling, an inability to knee and retrieve objects from the floor. He takes 800 milligrams of Ibuprofen, wears a flexible brace when not working, and wears a hinged brace with stabilizers when working a detail that requires standing. He has been unable to participate in physical therapy recently, but exercises at the gymnasium when he is able. He reported flare-ups of fatigue and catching that occurs a few times per week and particularly after a long day at work, the severity is 7 out of 10, and it is alleviated by rest and sitting. Concerning functional impairment, the Veteran cannot run or walk for long distances and he must be careful to avoid tripping. The August 2020 examination report states that the Veteran does not have pain with weight bearing and there is no objective evidence of crepitus. Initial range of motion testing showed the Veteran had flexion to 100 degrees and extension to 0 degrees. Pain was noted on flexion that causes functional loss. The Veteran has stiffness of his joint, pain with flexion, and abduction and adduction of his left leg causes quadricep soreness. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional loss of function or range of motion. The August 2020 examination report states that the Veteran had strength of 4/5 (active movement with some resistance) on flexion and extension. He did not have muscle atrophy, ankylosis, or recurrent subluxation. The Veteran has slight lateral instability. Joint stability testing did not reveal instability as anterior, posterior, medial, and lateral instability testing was normal. The Veteran does not have and has never had recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He has had a meniscus condition but has no current symptoms. He had total knee replacement in March 2019, and his residuals are noted as intermediate degrees of residual weakness, pain, or limitation of motion. The examination report states that the Veteran has scars associated with his left knee disability, but none are painful or unstable, or have an area equal to or greater than 39 square centimeters (6 square inches), or are located on the head, face, or neck. He uses a brace constantly. There is no objective evidence of pain on passive range of motion testing or when the joint is used in non-weight bearing. The Veteran was also afforded a Knee and Lower Leg Disability Benefits Questionnaire in May 2021. The examination report states that the Veteran's left knee disability has worsened as he has a diminished ability to bend his left knee following his March 2019 total knee replacement. For treatment, the Veteran takes pain medication, participates in physical therapy, and occasionally uses a brace. He reports flare-ups that are described as moderate in severity, throbbing in nature that occurs several times per week and last for several hours at a time. His flare-ups are caused by standing on his feet for prolonged periods of time and are alleviated by rest and sitting. Concerning functional impairment, the Veteran's left knee causes him difficulty with running and walking long distances. He has a history of frequent effusion of the knee after standing for long periods of time. The May 2021 examination report states that on initial active range of motion testing, the Veteran's left knee had flexion to 8 degrees and extension to 5 degrees with pain exhibited on both. The Veteran's passive range of motion was the same as his active range of motion with pain noted on flexion and extension. The Veteran had pain on active motion, passive motion that causes functional impairment as his inability to fully extend on flexion leads to difficulty kneeling completely. He did not have pain on weight bearing or non-weight bearing. The Veteran's range of motion contributes to a functional loss as he cannot kneel completely. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the joint or associated soft tissue. The May 2021 examination report provides that the Veteran was able to perform repetitive-use testing with at least three repetitions and there is no additional loss of function or range of motion after three repetitions. On repeated use over time, pain significantly limits functional ability and limits the Veteran's flexion to 75 degrees and extension to 5 degrees. During flare-ups, pain significantly limits functional ability and limits the Veteran's flexion to 70 degrees and extension to 5 degrees. The Veteran has interference with standing and activity triggers a pain flare-up. The May 2021 examination report demonstrates that the Veteran does not have muscle atrophy, ankylosis, recurrent subluxation or persistent instability. He had a complete ligament tear and successful repair. He does not require a prescription for a cane, walker, crutches, or brace for ambulation or for ambulation with patellar instability. He does not have recurrent patellar instability or surgical repair of the knee for patellar instability. He does not have and has never been diagnosed with recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment. He has been diagnosed with a meniscus condition but does not have current symptoms. He had a total knee replacement in November 2019. He uses a brace occasionally as a normal mode of locomotion, although occasional locomotion by other methods may be possible. Diagnostic studies have shown that the Veteran has degenerative arthritis. His left knee disability causes difficulty during standing for long periods of time, walking long distances, and running. He has swelling when standing for long periods of time. The Veteran's left knee disability causes him to take more frequent breaks and he transferred to a more sedentary position as police officer. The examination report states that the Veteran has considerable left knee pain after his total knee replacement surgery. The Veteran's recent VA treatment records demonstrate that his left knee is stiff, but he denies current pain, he ices his knee several times daily, and uses CBD cream. He was previously unable to walk due to pain. (Continued on the next page) The Board notes that a 60 percent rating is the highest schedular rating available for residuals following knee replacement under Diagnostic Code 5055 and contemplates the entire symptomatology associated with the Veteran's left knee. Indeed, such rating would not be exceeded by any weakness, pain, or limitation of motion as rated by analogy under Diagnostic Codes 5256, 5261, or 5262. See 38 C.F.R. § 4.71a. As the Veteran has already been assigned this disability rating from May 1, 2020, the Board need not consider whether a higher rating is available during this period. Importantly, the "amputation rule" provides that the combined rating for disabilities of an extremity cannot exceed the rating for amputation at the elective level. 38 C.F.R. § 4.68. In relation to amputations of the lower extremity, a 60 percent disability rating is assigned if there is an amputation of the thigh, above the knee, at the middle or lower third. 38 C.F.R. § 4.71a, Diagnostic Code 5162. Amputation of a leg with defective stump and thigh amputation recommended or amputation not improvable by prosthesis controlled by natural knee action may also be assigned a 60 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Codes 5163 and 5164. A higher disability rating of 80 percent requires amputation in the upper third of the thigh. The evidence of record does not indicate that such an amputation has been approximated by the Veteran's functional limitations as described above. Thus, considering the "amputation rule" pursuant to 38 C.F.R. § 4.68 and 38 C.F.R. § 4.71a, Diagnostic Codes 5161, 5162, 5163, 5164, a 60 percent disability rating is the maximum assignable disability rating for the Veteran's left knee arthroplasty from May 1, 2020, forward. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mussey, Sean 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.