Citation Nr: 21075804 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 15-03 725 DATE: December 21, 2021 ORDER Entitlement to a 100 percent disability rating for posttraumatic stress disorder (PTSD) is granted. For the period prior to September 26, 2018, entitlement to a total disability rating due to unemployability (TDIU) due to service-connected right knee disability is granted. For the period beginning September 26, 2018, entitlement to a total disability rating due to unemployability (TDIU) due to service-connected disability is moot. Entitlement to special monthly compensation (SMC) based on housebound status (HB) is granted. Entitlement to a rating in excess of 10 percent for subluxation and instability of the right knee for the period from February 16, 2012 to September 26, 2018 is denied. Entitlement to a rating in excess of 10 percent for limitation of flexion of the right knee for the period from February 16, 2012 to November 20, 2014 is denied. Entitlement to a rating in excess of 40 percent for limitation of extension of the right knee from November 20, 2014 to September 26, 2018 is denied. Entitlement to a rating in excess of 50 percent for a right knee replacement beginning December 1, 2019 is denied. FINDINGS OF FACT 1. The Veteran's PTSD symptoms reflect total occupational and social impairment. 2. The Veteran has at least one disability rated at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more for the period on appeal. 3. The Veteran's service-connected right knee disability rendered the Veteran unable to obtain and maintain substantially gainful employment for the period prior to his knee replacement on September 26, 2018. 4. Beginning September 26, 2018, the Veteran is unemployable due to his PTSD disability but entitlement to TDIU for this period is moot as he is granted a 100 percent for his PTSD disability. 5. For the entire appeal period, the Veteran had a single disability rated 100 percent disabling, PTSD, plus additional disabilities independently rated as 60 percent or more disabling. 6. The Veteran's right knee disability is manifested by only slight subluxation and instability of the right knee for the period from February 16, 2012 to September 26, 2018. 7. The Veteran's right knee is manifested by flexion to 45 degrees for the period from February 16, 2012 to November 20, 2014. 8. The Veteran's right knee is manifest by extension to 40 degrees for the period from November 20, 2014 to September 26, 2018. 9. Beginning December 1, 2019, the Veteran's right knee replacement is manifested by intermediate degrees of residual weakness, pain or limitation of motion. CONCLUSIONS OF LAW The criteria for entitlement to a 100 percent disability rating for posttraumatic stress disorder (PTSD) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 1. For the period prior to September 26, 2018, the criteria for entitlement to a total disability evaluation based on unemployability due to a service-connected disability (TDIU) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25. 2. For the period beginning September 26, 2018, the criteria for entitlement to a total disability evaluation based on unemployability due to PTSD is moot. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25. 3. The criteria for entitlement to SMC based on statutory housebound status for the entire appeal period, are met. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. 4. The criteria for a rating in excess of 10 percent for subluxation and instability of the right knee for the period from February 16, 2012 to September 26, 2018 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 5. The criteria for a higher evaluation than 10 percent for limitation of flexion of the right knee for the period from February 16, 2012 to November 20, 2014 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 6. The criteria for a rating in excess of 40 percent for limitation of extension of the right knee from November 20, 2014 to September 26, 2018 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 7. The criteria for entitlement to an evaluation higher than a 50 percent evaluation for a right knee replacement beginning December 1, 2019 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.159, Part 4, §§ 4.1, 4.2, 4.3, 4.7, 4.15, 4.16, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from September 1989 to May 1996. This matter comes before the Board of Veterans' Appeals (Board) from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Janesville, Wisconsin. This case was most recently before the Board in December 2020. The Board acknowledges that the Veteran was afforded a hearing in May 2016 with another Veteran Law Judge who no longer is employed by the Board. The Veteran was also not informed by letter that he could request a new hearing because this judge was no longer employed at the Board. Despite this, the Veteran's claims for PTSD and TDIU are being granted in full. He is also receiving special monthly compensation for the entire appeal period. The Board finds that this is a full grant of benefits and not allowing a new hearing would not put the Veteran at a disadvantage in terms of benefits. 1. Entitlement to an increased rating in excess of 70 percent for posttraumatic stress disorder (PTSD) The Veteran contends that the severity of his PTSD symptoms warrants a higher evaluation. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The Board concludes that the Veteran's PTSD did more nearly approximate the level of impairment required for a disability rating of 100 percent. VA and private treatment records, the April 2012 VA examination, August 2013 letter from a social worker, November 2014 VA examination, March 2015 opinion, October 2015 opinion, October 2019 VA examination, the Veteran's lay statements and his mother's lay statements show that the Veteran's PTSD was manifested by symptoms associated with a 100 percent rating (suicidal ideation, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living). These symptoms more nearly approximate total social and occupational impairment because the Veteran is unable to maintain a job or have relationships with others due to his irritability and aggression towards others. The Veteran testified that he lives in total social isolation. An August 2013 VA treatment record noted that he had been hospitalized in 2012 after he poured gasoline over his girlfriend and threatened to ignite the gasoline. In October 2013, the Veteran's mother explained how the Veteran was unable to be around people. She explained that when he goes to the grocery store with her, he can only stay inside for ten to fifteen minutes and then he has to go outside and away from people. At that time, the Veteran was living in a trailer owned by his parents. The Veteran's mother reported that he did not take care of his surroundings and did not clean his dishes or put anything away. He was unable to keep a job or a relationship with a significant other. He was married for two years, but it ended in divorce. The Veteran's mother explained that the Veteran is unable to clean-up after himself and lives in a mobile home owned by her and her husband. The October 2015 treating psychiatrist opined that the Veteran's PTSD caused the Veteran to be 100 percent disabled and unemployable. As the most probative evidence of record shows total occupational and social impairment, the maximum 100 percent rating is warranted during the appeal period. Thus, the appeal is granted. 2. For the period prior to September 26, 2018, entitlement to a total disability rating due to unemployability due to service-connected disabilities 3. For the period beginning September 26, 2018, the criteria for entitlement to a total disability evaluation based on unemployability due to PTSD The Veteran seeks a TDIU. He contends that his service-connected PTSD and right knee disability render him unemployable. See May 2015 statement. A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3)disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table). The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., their history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether they are capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has the following disabilities that are service-connected: PTSD (rated 50 percent from March 2007 and 70 percent from February 2012); right knee disability (rated as 40 percent from November 2014 to September 26, 2018, rated 100 percent from September 2018 to December 2018 and rated 50 percent from December 2019 to present); irritable bowel syndrome (rated 30 percent from September 2015 to present); back disability (rated as 10 percent from May 1996 to March 2016 and 20 percent from March 2016 to present); right knee disability (rated as 10 percent from March 2007 to February 2012.); chronic hepatitis B (rated as 10 percent from March 2007 to September 2015); right knee instability (rated as 10 percent from February 2012 to September 2018); right knee flexion (rated 10 percent from February 2012 to November 2014); tinnitus (rated as 10 percent from June 2013 to present); neuropathy of right lower extremity (rated as 10 percent from March 2015 to present) radiculopathy of the left lower extremity (rated as 10 percent from March 2015 to present); left knee disability (rated as 10 percent from August 2015); lumbar radiculopathy of the right lower extremity (rated as 10 percent from March 2016); lumbar radiculopathy of left lower extremity (rated as 10 percent from March 2016); neuropathy of the right great toe (rated as noncompensable); hearing loss (rated as noncompensable); inguinal hernia (rated as noncompensable); migraines disability (rated as noncompensable); and scar on right knee (rated as noncompensable). Based on the forgoing, the Veteran has at least one disability rated at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more for the period on appeal. Accordingly, the Board may consider the claim for a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). For the reasons that follow, the Board finds that a TDIU is warranted. The Veteran has a high school diploma. He reported that he last worked in 2007 in construction. The Veteran attended truck driving school in 2003 and 2004. For the period prior to September 26, 2018, the Veteran's ability to secure and follow a substantially gainful occupation is impacted by the physical effects of his knee disability. The Veteran did not receive a total knee replacement until September 26, 2018. In June 2012, a physician noted that the Veteran's knee pain precluded work. During his hearing in May 2016, the Veteran reported that his right knee locks in place. He reported instability of his right knee and excruciating pain. He wore a knee brace every day. The January 2016 examiner opined that the Veteran knee disabilities impacted his ability to work because of difficulty with prolonged standing and ambulation. He used a brace and a cane at the time of the examination. A February 2012 treatment record noted that knee pain precluded gainful employment. The Board acknowledges that the Veteran is also unemployable due to his PTSD, but the evidence demonstrates that the severity of his knee disability alone also renders him unemployable. The Veteran's ability to secure and follow a substantially gainful occupation is impacted by his knee disability. Given the foregoing, the Veteran's service-connected right knee precludes him from the ability to secure and follow a substantially gainful occupation consistent with his education, skills, training, and work history. Accordingly, a TDIU is warranted for the period prior to September 26, 2018. The Veteran received a right knee replacement on September 26, 2018. The evidence does not show that he is rendered unemployable due to his right knee after his knee replacement. As the Veteran is already in receipt of a 100 percent evaluation for PTSD, the issue of TDIU is rendered moot. After September 26, 2018, the Veteran is already in receipt of special monthly compensation based on housebound status based on 100 percent for PTSD and additional disabilities that are rated as 60 percent or more. See also Buie v. Shinseki, 24 Vet. App. 242, 250 (2011) (discussing VA's "well-established" duty to maximize a claimant's benefits). 4. Entitlement to special monthly compensation based on housebound status VA shall pay special monthly compensation (SMC) at the housebound rate when a Veteran has a single service-connected disability rated at 100 percent and additional service-connected disabilities that total at least 60 percent. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). The Board finds that an inferred issue of entitlement to SMC at the housebound rate has been raised. The Veteran has been granted a 100 percent evaluation for his PTSD per this decision. Prior to September 26, 2018, the Veteran is considered unemployable due to right knee disability. As the Veteran's TDIU is based on a different disability than his PTSD, for which he is receiving a 100 percent rating, the Veteran's TDIU is considered an additional disability that is rated as 60 percent or more. Therefore, the requirements under 38 U.S.C. § 1114 (s) and 38 C.F.R. § 3.350 (i) have been met prior to September 26, 2018. After September 26, 2018, the Veteran is continuing to receive a 100 percent evaluation for his PTSD, and he is receipt of service-connected disabilities that total at least 60 percent. Therefore, after September 26, 2018, special monthly compensation requirements are met. INCREASED RATING 1. Entitlement to a higher evaluation than 10 percent for subluxation and instability of the right knee for the period from February 16, 2012 to September 26, 2018 The Veteran contends that he is entitled to a higher rating because he has instability of his right knee that is more severe than the currently assigned 10 percent. The Veteran's subluxation and instability of his right knee is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. Under 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. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for right knee subluxation and instability. The Board has carefully considered the Veteran's reports about instability. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that the subluxation and instability symptoms have varied and do not suggest the presence of symptoms more nearly approximating moderate severity. The May 2012 Knee and Lower Leg Disability Benefits Questionnaire (DBQ) noted normal stability. The examiner noted that the Veteran had slight patellar subluxation/dislocation on the right. The November 2014 Knee and Lower Leg DBQ noted slight lateral instability of the right knee. The January 2016 Knee and Lower Leg DBQ noted no joint instability. The Board has considered if another evaluation is warranted under a separate diagnostic code, but has found none. The Veteran is already evaluated under limitation of flexion and limitation of extension during this period. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for subluxation and instability of the right knee. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a higher evaluation than 10 percent for limitation of flexion of the right knee for the period from February 16, 2012 to November 20, 2014 The Veteran contends that he is entitled to a higher rating for limitation of flexion of his right knee for this period because his limitation of flexion is more severe than the 10 percent rating assigned for this period. The Veteran's right knee is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Here, flexion was to 90 degrees when examined in April 2012. Painful motion began at 45 degrees. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for limitation of flexion of the right knee disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The Board has considered if another evaluation is warranted under a separate diagnostic code, but has found none. The Veteran is already evaluated under instability and limitation of extension during this period. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the right knee for the period from February 16, 2012 to November 20, 2014. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a higher evaluation of 40 percent for limitation of extension of the right knee from November 20, 2014 to September 26, 2018 The Veteran contends that his limitation of extension of his right knee is more severe than the currently assigned 40 percent rating for the period from November 20, 2014 to September 26, 2018. The Veteran's right knee is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5261, for limitation of extension of the leg. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for limitation of extension of the right knee. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due pain, standing and sitting more than 20 minutes, cold and humid weather, going downstairs and walking on uneven ground. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating extension limited to 45 degrees. The November 2014 examination noted extension to 40 degrees even after repetitive use testing and during flare-ups. In January 2016, the Veteran reported frequent flare-ups that made movement difficult. Upon examination, extension was to 0 degrees. There was pain noted on flexion and on extension. Extension was to 0 degrees even after repetitive use testing and flare-ups. The Board acknowledges that the January 2016 was inadequate as it did not test passive range of motion, but no further testing can be done for this appeal period, and the Veteran has since gotten a total knee replacement. The Board based its decision on the evidence included in the record for this specific period on appeal. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Here, the Veteran's right knee disability is rated for instability, flexion and extension. The Board does not find that any other diagnostic code is applicable. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 40 percent for a right knee disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to a higher evaluation than 50 percent for a right knee replacement beginning December 1, 2019 Diagnostic Code 5055 provides criteria for evaluating impairment arising from the prosthetic replacement of a knee joint. For one year following the implantation of a knee prosthesis, a 100 percent disability rating is assigned. Thereafter, the minimum disability rating which may be assigned, post-knee replacement is 30 percent. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, adjudicators are instructed to rate by analogy to Diagnostic Codes 5256 (knee ankylosis), 5261 (limitation of leg extension), or 5262 (impairment of the tibia and fibula). In December 2019, the Veteran's was afforded a Knee Disability Benefits Questionnaire (DBQ). The examiner noted that flexion was to 120 degrees and extension was to 0 degrees. There was pain on flexion and extension. There was pain and lack of endurance after repetitive use testing, but flexion was to 120 after repetitive use testing. He reported that he had pain and lack of endurance during a flare-up. There was no instability after joint stability testing. The examiner noted chronic pain and loss of motion as a residual of his right knee replacement but did not specify by degrees. No passive range of motion testing was completed during the examination for the right knee. Due to the inadequacies in this examination, the Veteran was afforded a new examination in April 2021. During the April 2021 Knee DBQ, the Veteran reported that he has flare-ups every day due to walking, standing, or sitting. Flexion was to 80 degrees. He had no instability. The examiner opined that the Veteran's right knee was manifested by intermediate degrees of residual weakness, pain, or limitation of motion. The Board acknowledges that the Veteran had pain during flexion and extension range of motion testing, but there is no indication that he had severe painful motion or weakness. A July VA treatment record noted that the Veteran had no issues with both of his total knee replacements. The physician noted that there was no significant discomfort on passive patella-femoral motion. For this reason, the Board finds that a rating higher than 50 percent for a right knee replacement is not warranted. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tahirih S. Samadani, 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.