Citation Nr: 21075857 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 13-15 155 DATE: December 21, 2021 ISSUES 1. Entitlement to a rating in excess of 10 percent for left knee arthritis for the period prior to January 15, 2020. 2. Entitlement to a rating in excess of 60 percent for left knee arthritis, status post total knee replacement, from March 1, 2021 forward. 3. Entitlement to a rating in excess of 10 percent for right knee chondromalacia patella. 4. Entitlement to a rating in excess of 10 percent for instability of the right knee associated with chondromalacia patella. ORDER Entitlement to an increased rating in excess of 10 percent for left knee arthritis, limitation of extension, for the period prior to June 27, 2019 is denied. Entitlement to an increased rating in excess of 10 percent for right knee chondromalacia, limitation of extension, for the period prior to June 27, 2019 is denied. Entitlement to an increased rating of 40 percent, but no higher, for left knee arthritis, limitation of extension, from June 27, 2019 to January 15, 2020 is granted. Entitlement to an increased rating of 20 percent, but no higher, for right knee chondromalacia, limitation of extension, from June 27, 2019 forward is granted. Entitlement to a separate disability rating of 20 percent for left knee arthritis, limitation of flexion under Diagnostic Code 5260 from June 27, 2019 to January 15, 2020 is granted. Entitlement to a separate disability rating of 10 percent for right knee chondromalacia, limitation of flexion, under Diagnostic Code 5260 from June 27, 2019 forward is granted. Entitlement to a separate disability rating of 10 percent for left knee instability associated with arthritis under Diagnostic Code 5257 for the period prior to June 27, 2019, and for a rating of 20 percent until January 15, 2020 is granted. Entitlement to an increased rating of 10 percent, but no higher, for right knee instability associated with chondromalacia for the period prior to March 9, 2013 is granted. Entitlement to a rating in excess of 10 percent for right knee instability associated with chondromalacia from March 9, 2013 to June 27, 2019 is denied. Entitlement to an increased rating of 20 percent, but no higher, for right knee instability associated with chondromalacia from June 27, 2019 forward is granted. Entitlement to a rating in excess of 60 percent for left knee arthritis, status post total knee replacement, from March 1, 2021 is denied. FINDINGS OF FACT 1. Prior to June 27, 2019 the Veteran's service- connected left and right knee disabilities were manifested by limitation of extension at worst to 10 degrees in both knees, with swelling, weakness and pain on motion. 2. From June 27, 2019 to January 15, 2020, the Veteran's service- connected left knee disability was manifested by limitation of flexion at worst to 30 degrees and limitation of extension at worst to 25 degrees with swelling, weakness and pain on motion. 3. From June 27, 2019 forward, the Veteran's service- connected right knee disability was manifested by limitation of flexion at worst to 50 degrees and limitation of extension at worst to 15 degrees with swelling, weakness and pain on motion. 4. For the period prior to June 27, 2019, resolving doubt in the Veteran's favor, the Veteran's left knee disability was manifested by mild lateral instability. 5. For the period from June 27, 2019 to January 15, 2020 the Veteran's left knee disability was manifested by moderate lateral instability. 6. For the period prior to March 9, 2013, resolving doubt in the Veteran's favor, the Veteran's right knee disability caused mild lateral instability. 7. For the period from March 9, 2013 to June 27, 2019 the Veteran's right knee disability was manifested by mild lateral instability 8. For the period from June 27, 2019 forward the Veteran's right knee disability was manifested by moderate lateral instability. 9. From March 1, 2021, the Veteran's service-connected left knee disability is productive of chronic residuals consisting of severe painful motion or weakness in the affected extremity. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating in excess of 10 percent for service-connected left knee and right knee disabilities, limitation of extension, for the period prior to June 27, 2019 have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Codes 5014-5261. 2. The criteria for entitlement to an increased rating of 40 percent, but no higher, for left knee arthritis, limitation of extension, from June 27, 2019 to January 15, 2020 have been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Codes 5014-5261. 3. The criteria for entitlement to an increased rating of 20 percent, but no higher, for right knee chondromalacia, limitation of extension from June 27, 2019 forward have been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Codes 5014-5261. 4. The criteria for entitlement to a separate disability rating of 20 percent for left knee arthritis, limitation of flexion under Diagnostic Code 5260 from June 27, 2019 to January 15, 2020 have been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 5. The criteria for entitlement to a separate disability rating of 10 percent for right knee chondromalacia, limitation of flexion, under Diagnostic Code 5260 from June 27, 2019 forward have been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 6. The criteria for entitlement to a separate disability rating of 10 percent for left knee instability associated with arthritis under Diagnostic Code 5257 for the period prior to June 27, 2019, and for 20 percent until January 15, 2020 have been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 7. The criteria for entitlement to an increased rating of 10 percent for right knee instability associated with chondromalacia for the period prior to March 9, 2013 have been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 8. The criteria for entitlement to a rating in excess of 10 percent for right knee instability associated with chondromalacia from March 13, 2013 to June 27, 2019 have not been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 9. The criteria for entitlement to an increased rating of 20 percent, but no higher, for right knee instability associated with chondromalacia from June 27, 2019 forward have been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 10. From March 1, 2021 the criteria for the assignment of a disability rating in excess of 60 percent for a left knee disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from February 1974 to February 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an February 2010 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In that rating decision, in pertinent part, the RO denied evaluations in excess of 10 percent for both right and left knee chondromalacia patella. The Veteran appealed the denial of her claims. In an April 2013 rating decision, the RO granted service connection for instability of the right knee and assigned an evaluation of 10 percent effective March 9, 2013. This matter was remanded in July 2015 and February 2021 for further development. Upon review of the Veteran's claim file, the Board finds that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). By the way of an October 2021 rating decision, the RO awarded a 100 percent disability rating from January 15, 2020 to March 1, 2021 for the left knee disability based on 13 months following the implantation of prosthesis, and thereafter, assigned a 60 percent rating. The Board notes that this grant does not award the full benefit sought for the period prior to January 15, 2020 and the period from March 1, 2021. The grant of the increased ratings for the right and left knee disabilities during the course of the appeal does not affect the pendency of the appeal. AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claims are still in controversy and on appeal. Id. Increased Schedular Ratings - General Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. § Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 (musculoskeletal system) or § 4.73 (muscle injury); 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 [or 4.73] criteria."). The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing 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. Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, the United States Court of Appeals for Veterans' Claims (Court) recently addressed what constitutes an adequate explanation for an examiner's inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. The Board also notes recent case law where the Court held that 38 C.F.R. § 4.59 does not solely condition the evaluation based on range of motion measurements for a particular diagnostic code, but rather "it conditions that award on evidence of an actually painful, unstable, or maligned joint or periarticular region and the presence of a compensable evaluation in the applicable diagnostic code." Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Board considers not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C. § 1155 (2012); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Knee Disabilities: Legal Standards The Veteran is currently rated under two separate sets of diagnostic codes for each knee. The left knee is currently rated under Diagnostic Code 5055 with a 60 percent rating from March 1, 2021. For the period on appeal prior to January 15, 2020 the Veteran's left knee was rated under Diagnostic Code 5014-5261 with a 10 percent rating. The Veteran's right knee is currently rated under Diagnostic Code 5014-5261. The Veteran is also separately rated for right knee instability under Diagnostic Code 5257 with a 10 percent rating. This appeal for increased evaluation of the Veteran's knees arrives from a increased rating claim made in April 2009. As such, the Board will consider the medical evidence from one year prior to those dates of the increased rating claim. "The relevant temporal focus for adjudicating an increased-rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim." Hart v. Mansfield, 21 Vet. App. 505, 509 (2007) (discussing 38 U.S.C. § 5110 and 38 C.F.R. § 3.400(o)). In assigning hyphenated diagnostic codes, the number assigned to the residual condition on the basis of which the rating is determined will generally represent injuries. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also VAOPGCPREC 9-04, 69 Fed. Reg. 59990 (2004) (holding that separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned). The rationale is that limitation of flexion and limitation of extension are two distinct impediments, i.e., the symptomatology upon which the separate ratings would be based is not duplicative or overlapping. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability. VAOPGCPREC 23-97 (July 1, 1997). VA's Office of the General Counsel (OGC) opined that it was not pyramiding to assign ratings under DC 5257 (knee instability) and DC 5260/61 based on additional disability. The opinion explained that DC 5257 addressed instability of the knee without reference to limitation of motion, and DC 5060/61 referenced limitation of motion without instability. Id. at para. 2. In other words, the two diagnostic codes addressed different manifestations or symptoms. In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court held that evaluation of a knee disability under Diagnostic Codes 5260 and/or 5261 does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under Diagnostic Code 5258 or 5259, and vice versa. The Court further held that entitlement to a separate evaluation in a given case depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different Diagnostic Code. In the context of evaluating musculoskeletal disabilities based on limitation of motion, a manifestation of disability has not been compensated, for separate evaluation and pyramiding purposes, if that manifestation did not result in an elevation of the evaluation under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the principles set forth in DeLuca v. Brown, 8 Vet. App. 202 (1995). Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). However, based on the medical evidence before the Board, impairment of the tibia and fibula, and genu recurvatum have not been found or associated with the Veteran's knee disabilities and thus will not be considered here. VA's schedule of musculoskeletal rating changes, found in 38 C.F.R. § 4.71a, was modified with the changes in effect on February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). A small modification was also made to Diagnostic Code 5003, which was announced in a corrected final rule. See 85 Fed. Reg. 85523 (Dec. 29, 2020). Pertinent to this particular appeal, Diagnostic Code 5257, other impairment of the knee, has been substantially modified and will be noted below. Also pertinent to this appeal, Diagnostic Code 5003 was modified in its title to now read "Degenerative arthritis, other than post-traumatic." Id. No other changes pertinent to this claim are applicable for this particular appeal. Absent any Congressional intent or directive with regard to new or revised regulations, when a claim originates prior to the effective date of the new language but is decided after the effective date, VA will use the version that provides the Veteran a greater benefit. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under Diagnostic Code 5055, for prosthetic replacement of the knee joint, a 100 percent rating is warranted for one year following implantation of the prosthesis. A 60 percent rating is warranted if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is to be rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5261 (limitation of extension) or 5262 (impairment of the tibia and fibula). The regulation prescribes a minimum rating of 30 percent under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Diagnostic Code 5257 (pre-February 7, 2021) provides ratings for recurrent subluxation and/or lateral instability of the knee. A 10 percent rating is assigned for slight recurrent subluxation and/or instability of the knee. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (prior to Feb. 7, 2021). The new language of Diagnostic Code 5257 that took effect on February 7, 2021 now reads for recurrent subluxation or lateral instability, a 10 percent rating is assigned 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 20 percent rating is assigned for one of the following: (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; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is assigned 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. In addition for Diagnostic Code 5257, a new section on patellar instability has been added that also took effect on February 7, 2021. A 10 percent rating is assigned 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 20 percent rating is assigned 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 30 percent rating is assigned 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. Two new notes for the new Diagnostic Code 5257 are as follows. 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). The remainder of the pertinent diagnostic codes are unchanged and are as follows. Under Diagnostic Code 5260, a non-compensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a non-compensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees, a 40 percent rating will be assigned for limitation of extension to 30 degrees, and a 50 percent rating will be assigned for limitation of extension to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. For Diagnostic Code 5003, degenerative arthritis 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 (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 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, rate as follows: a 10 percent evaluation is assigned for painful or limited motion of a major joint or group of minor joints and may also be applied once to multiple joints if there is no limited or painful motion. A 20 percent is assigned for X-ray evidence that shows involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a. The terms "slight," "marked," "moderate," and "severe" are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element 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. Bilateral Knees Evidence and Analysis The Veteran seeks higher evaluations for her right and left knee disabilities. The right knee is currently evaluated with a 10 percent evaluation, effective from May 5, 2005 under Diagnostic Codes 5014 and 5261. The right knee also has an additional rating with an evaluation of 10 percent under Diagnostic Code 5257 from March 9, 2013. The left knee is currently evaluated prior to January 15, 2020 under Diagnostic Code 5014 and 5261 with a 10 percent rating from March 20, 2006. After her January 2020 left total knee replacement the Veteran received a temporary total evaluation pursuant to 38 C.F.R. §§ 3.400 & 4.30 for 13 months following the total knee replacement, and then a 60 percent evaluation under Diagnostic Code 5055 effective from March 1, 2021. As such, then, the Board will evaluate Diagnostic Codes 5014 and 5261 prior to January 15, 2020 for the Veteran's left knee disability, and then under Diagnostic Code 5055 from March 1, 2021 forward. The Veteran's first examination pertinent to the increased rating claim occurred in December 2008. The Veteran reported that since her last VA examination she had been told that she had arthritis in her knees with increased pain, decreased range of motion and mobility. She reported being on methocarbamol and Tylenol and was also seeing on orthopedics specialist. The Veteran reported constant moderate pain which she rated a 6 out of 10, without locking but with feelings of instability and swelling. The examiner diagnosed bilateral moderate chondromalacia. Both right and left knee flexion were measured out to 90 degrees with objective evidence of pain. Both right and left knee extension were measured to 10 degrees with objective evidence of pain. There was no additional loss of range of motion after repetitive use of either knee. The examiner noted that the examination of the knees was stable with Lachman, drawers, varus and valgus stressing. The Veteran experienced tenderness on palpation with minimal pressure. She also experienced grade 2 moderate crepitus bilaterally. The McMurray test was normal. The Veteran received a new VA knee examination in March 2013. The examiner diagnosed bilateral knee chondromalacia. The Veteran reported that during flare ups she could not walk a block without stopping. Also, during flare ups she reported difficulty with doing routine household chores, using stairs and driving. Both right and left knee flexion were measured out to 80 degrees with objective evidence of pain. Both right and left knee extension were measured to 10 degrees with objective evidence of pain. There was no additional loss of range of motion after three repetitions for either knee. The examiner noted that after repetitive use the Veteran would experience less movement than normal, pain on movement and disturbance of locomotion in both knees. The examiner noted tenderness or pain to palpation for joint line or soft tissues for both knees. Muscle strength testing was 5/5 and joint stability testing was normal in both knees. Medial lateral instability was noted to be 1+ in the right knee and normal in the left knee. There was no evidence of recurrent patellar sublation or dislocation in either knee. The examiner noted that the Veteran did not have any meniscal condition or had not had surgical procedures for a meniscal condition. The examiner noted that the Veteran had a prior arthroscopic cartilage debridement off the knees in 2006, though there were no residual signs or symptoms. The Veteran reported that she regularly used a cane due to knee pain. VA and private treatment records reflect that the Veteran had sought ongoing treatment for her bilateral knee disabilities. Notably, a private treatment record from June 2014 indicates that she reported that she was continuing to have discomfort in both knees. She also reported that she had fallen several times since her last visit. An August 2016 private treatment note indicates that the examiner noted that the Veteran experienced decreased range of motion in both knees as well as swelling and crepitation present in both. The Veteran received another VA knee examination in December 2016. The examiner continued a diagnosis of bilateral knee chondromalacia. The examiner also diagnosed right knee instability. The Veteran reported that during flare ups it was like "fire in [her] knees" and she couldn't walk. The Veteran described functional loss as amounting to tremendous pain with walking and requiring her to use a cane. Right knee flexion was measured to 90 degrees and right knee extension was measured to zero degrees. Left knee flexion was measured to 60 degrees and left knee extension was measured to zero degrees. The examiner noted pain on the examination of both knees during flexion, extension and weightbearing, that caused functional loss. There was objective evidence of pain throughout upon mild palpation and tenderness of both knees. There was no evidence of crepitus in either knee. The Veteran was not able to perform repetitive testing after three repetitions. The examiner noted that the Veteran experienced other contributing factors of her disability including swelling, disturbance of locomotion, interference with sitting and with standing. The examiner also explained that the Veteran became very stiff with her knees in one position, that walking was painful, she was unable to climb stairs, unable to squat, crouch or crawl and unable to bathe or dress herself. Muscle strength testing was 4/5 in the right knee and 3/5 in the left knee. The examiner noted that while the Veteran did experience reduced muscle strength the examiner believed that the diffuse pain was due to the Veteran's synovitis secondary to her rheumatoid disease. No muscle atrophy or ankylosis was noted in either knee. The examiner noted that there was no history or recurrent subluxation or lateral instability in either knee. The examiner noted a history of recurrent effusion, with tenderness and swelling throughout the knees bilaterally though the examiner also noted that the Veteran did not have a meniscus condition. The examiner did however also acknowledge that the Veteran had a meniscotomy in approximately 2004 and experienced residuals of pain. The examiner noted that joint stability testing was normal. The Veteran did use a cane at all times, but the examiner explained the cane was not used for reasons of her service-connected chondromalacia. In her remarks, the examiner explained that the Veteran's restricted range of motion, including active and passive, with pain, swelling, loss of strength in knee flexion and extension was believed to be due to the Veteran's rheumatoid disease and not due to her service-connected chondromalacia. A February 2019 private treatment rehabilitation order form reflects that the Veteran was diagnosed with complex tears of the left and right knee lateral meniscus as well as a complex tear of the medial right knee meniscus. The Veteran was afforded another VA knee examination in June 2019. At that time the examiner diagnosed right knee strain and left knee degenerative arthritis. The Veteran reported that she was in pain if she sat or stood too long. She also reported taking Humira and using hot packs for pain relief. The Veteran reported severe flare ups in the right knee which occurred 3 to 5 times a week and would last several hours. She reported that the flare ups were precipitated by standing too long, walking and getting out of chairs after sitting too long. She reported that her right knee flare ups were alleviated by heat packs. The Veteran reported that her left knee flare ups were very severe, occurred 4-5 times a week and would last several hours. She reported that the left knee flare ups were precipitated by her left foot dropping (due to her status post-stroke), sitting for too long, or for no other reason. She reported that the left knee flare ups were alleviated by elevating her legs, rest and warm packs. The Veteran reported loss of functional loss as being the loss of motion in her knees, as well as her toes going numb in both feet. During the June 2019 examination, right knee flexion was measured to 100 degrees and extension was measured to 15 degrees. The examiner noted pain on extension of the right knee which did not contribute to functional loss. Left knee flexion was measured to 75 degrees and extension was measured to 25 degrees. There was pain noted on flexion and extension of the left knee that caused functional loss. There was evidence of pain on weight bearing in both knees as well as pain on palpation. There was no evidence of crepitus in either knee. The Veteran was not able to perform repetitive use testing. The examiner estimated that after repeated use over time right knee flexion would measure to 75 degrees and extension would measure to 15 degrees. After repeated use over time of the left knee the examiner estimated that flexion would measure to 50 degrees and extension would measure to 25 degrees. During a flare up of the right knee the examiner estimated that flexion of the right knee would measure to 50 degrees and extension would measure to 15 degrees. During a flare up of the left knee the examiner estimated that flexion would measure to 30 degrees and extension would measure to 25 degrees. The examiner noted that the Veteran would experience less movement than normal, weakened movement, swelling, instability of station, disturbance of locomotion and interference with sitting and standing. Muscle strength was measured at 4/5 for the right knee and 3/5 for the left knee. The examiner noted that only in the left knee was the reduction in muscle strength due entirely to the service-connected disability. The examiner noted that there was no muscle atrophy in either knee. No ankylosis was noted. The examiner noted a history of moderate instability bilaterally as well as a history of recurrent effusion. Joint stability testing was not able to be completed because the Veteran was in too much pain. The examiner noted that the Veteran had experienced meniscus, with frequent episodes of joint effusion in both knees. The Veteran reported occasional use of a wheelchair and constant use of a brace and walker. The Veteran reported that she used the brace on her left lower leg due to her stroke. In August 2019 VA sought a medical opinion to clarify whether the Veteran's diagnosis rehabilitation treatment for tears of her left and right medial meniscus was related to her service- connected chondromalacia. The examiner opined that the Veteran's new diagnoses were related to joint aging and overuse and were less likely than not related to her service-connected chondromalacia. Private treatment records reflect that on January 15, 2020 the Veteran underwent a left total knee replacement surgery. The Veteran was most recently afforded a VA examination in April 2021. The examiner noted a diagnosis of bilateral knee instability as well as bilateral knee degenerative arthritis. The examiner also diagnosed right knee chondromalacia. The examiner noted that the Veteran had arthroscopies and knee replacements in 2017 and 2018. The Veteran reported that prior to her left knee replacement she had received multiple cortisone injections and that she experienced pain 8 out of 10 on a pain scale "all the time". The Veteran reported that she takes 2 Aleve pills 4 times a day by mouth every day since 2020 and has tried heating pads and ice packs with minimal relief. The Veteran reported instability of the left knee, stating that her knee would just give out. During active range of motion testing of the right knee, flexion was measured to 140 degrees and extension was measured to zero degrees, with objective evidence of pain. Passive range of motion testing of the right knee measured flexion to 130 degrees and extension to 5 degrees. There was no additional loss of range of motion after 3 repetitions or after repeated use over time. Active and passive range of motion of the left knee was measured to 35 degrees on flexion and 40 degrees on extension with objective evidence of pain. The examiner noted that during range of motion testing of the left knee the Veteran grimaced and cried out in pain. The Veteran was not able to perform range of motion testing after 3 repetitions out of fear of pain. The Veteran was not observed after repeated use over time of the left knee, but the examiner estimated that after repeated use flexion would measure to 25 degrees and extension would measure to 50 degrees. There was objective evidence of pain on palpation to only the left knee. There was no evidence of crepitus in either knee. The Veteran denied flare ups of the right knee. She reported almost daily left knee flare ups that were sharp, hot, throbbing and lasted for hours. She reported that the flare ups were caused by standing, walking and performing activities of daily living. She also reported that during flare ups she could not do anything and she had to go to bed. The examiner estimated that during flare ups, left knee flexion would measure to 25 degrees and extension would measure to 60 degrees. The examiner noted that the Veteran experienced less movement than normal, weakened movement, swelling, disturbances of locomotion and interference with sitting and standing due to her left knee. No muscle atrophy noted in either knee. The examiner found objective evidence of ankylosis of the left knee, with the severity being extremely unfavorable, in flexion at an angle of 45 degrees or more. The examiner noted that there was recurrent subluxation or instability in both knees, though the Veteran did not have a ligament tear. The Veteran was prescribed the use of a cane for ambulation. The Veteran has recurrent patellar instability only in the left knee with no history of a surgical repair, though she was prescribed a cane and walker for ambulation with left knee patellar instability. The examiner noted that the Veteran did not have a meniscus condition in either knee. The examiner also noted that the Veteran has chronic residuals consisting of severe painful motion or weakness related to her total left knee joint replacement. 1. Entitlement to an increased rating in excess of 10 percent for left knee arthritis, limitation of extension, for the period prior to June 27, 2019. 2. Entitlement to an increased rating in excess of 10 percent for right knee chondromalacia, limitation of extension, for the period prior to June 27, 2019. For the Veteran's right and left knee disabilities the Board finds that the Veteran's symptoms most closely approximate the 10 percent rating for the period prior to June 27, 2019. This is based on the worst finding of range of motion in extension for the right and left knees of 10 degrees each, as noted in the March 2013 VA examination. The Board recognizes the Veteran's complaints of swelling, weakness and pain on motion of both knees. While the Board notes a variety of measurements of ranges of motion in this period on appeal, the Veteran's worst measurements in extension of both knees are indicative of a 10 percent rating. To warrant the next higher rating above the current 10 percent for painful motion based on limitation of extension, a 20 percent rating, knee extension during this period would have to be limited to 15 degrees or greater, which has not been shown during this period. 3. Entitlement to an increased rating of 40 percent, but no higher, for left knee arthritis, limitation of extension, from June 27, 2019 to January 15, 2020. 4. Entitlement to an increased rating of 20 percent, but no higher, for right knee chondromalacia, limitation of extension from June 27, 2019 forward. For the Veteran's right knee disability, based on limitation of extension under Diagnostic Codes 5014 and 5261, the Board finds that a rating of 20 percent, but no higher from June 27, 2019 to January 15, 2020 has been met or approximated based on the worst finding of range of motion in extension limited to 15 degrees at the June 2019 VA examination. While the Board notes a variety of measurements of ranges of motion in the period on appeal, the Veteran's worst measurement in extension of the right knee is indicative of a 20 percent rating. To warrant the next higher rating above the current 20 percent for painful motion based on limitation of extension, a 40 percent rating, knee extension would have to be limited to 30 degrees or greater. This has not been shown during this period, even with consideration of additional loss of motion due to pain during flare ups and with repeated use over time. For the Veteran's rating for her left knee disability for limitation of extension under Diagnostic Codes 5014 and 5261, the Board finds that a rating of 40 percent, but no higher, from June 27, 2019 to January 15, 2020 is met or approximated based on the worst finding of range of motion in extension limited to 25 degrees at the June 2019 VA examination. While the Board notes a variety of measurements of ranges of motion in the period on appeal, the Veteran's worst measurement in extension is indicative of a 40 percent rating. To warrant the next higher rating above the current 40 percent for painful motion based on limitation of extension, a 50 percent rating, knee extension would have to be limited to 45 degrees or greater. This has never been shown during this period, even with consideration of additional loss of motion due to pain during flare ups and repeated use over time. Additionally, the Board has considered the statements regarding flareups by the Veteran, but based on the medical evidence, even with estimates of motion loss in terms of degrees during periods of flare-ups, the criteria for higher evaluations based on range of motion have not been met or approximated. Sharp v. Shulkin, 29 Vet. App. 26 (2017). 5. Entitlement to a separate disability rating of 20 percent for left knee arthritis, limitation of flexion under Diagnostic Code 5260 from June 27, 2019 to January 15, 2020. 6. Entitlement to a separate disability rating of 10 percent for right knee chondromalacia, limitation of flexion, under Diagnostic Code 5260 from June 27, 2019 forward. For this Veteran, based on VA medical evidence, the Board finds that an additional, separate rating for the Veteran's right and left knee disabilities under Diagnostic Code 5260 for limitation of flexion is warranted. As it relates to the right knee the Board finds that a rating of 10 percent, but no higher, effective from June 27, 2019, the date of the VA examination where the appropriate medical symptoms and facts were obtained, is warranted. As it relates to the left knee, the Board finds that a rating of 20 percent, but no higher, effective from June 27, 2019 to January 15, 2019 is warranted. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C. § 1155 (2012); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993) (emphasis added). During the Veteran's September 2019 VA examination for her knees, the examiner estimated limitation of flexion at its worst to 50 degrees in the right knee during flare ups and to 30 degrees at its worst in the left knee during flare ups. The Board notes the additional symptomatology of the limitation of motion in flexion of each knee was observed and recorded in the VA examination of June 27, 2019, and thus considers that date to be the effective date of the additional rating for instability based on the facts found in that examination. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400; see Lyles v. Shulkin, 29 Vet. App. 107 (2017). As to the degree of limitation of flexion of the right knee, the Board assigns a 10 percent rating under Diagnostic Code 5260 based on the worst finding during this period of flexion to 50 degrees. While the Board notes a variety of measurements during the period on appeal, the Veteran's worst measurement in flexion of the right knee is indicative of a 10 percent rating. To warrant the next higher rating above the current rating for painful motion, a 20 percent rating, knee flexion would have to be limited to 30 degrees or less. This has not been shown during this period, even with consideration of additional loss of motion due to pain during flare ups. As to the degree of limitation of flexion of the left knee, the Board assigns a 20 percent rating Diagnostic Code 5260 based on the worst finding during this period of flexion to 30 degrees. While the Board notes a variety of measurements during the period on appeal, the Veteran's worst measurement in flexion of the right knee is indicative of a 20 percent rating. To warrant the next higher rating above the current rating for painful motion, a 30 percent rating, knee flexion would have to be limited to 15 degrees or less. This has not been shown during this period, even with consideration of additional loss of motion due to pain during flare ups. Additionally, the Board has considered the statements regarding flareups by the Veteran, but based on the medical evidence, even with estimates of motion loss in terms of degrees during periods of flare-ups, the criteria for higher evaluations based on range of motion have not been met or approximated. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board has also considered the effective date of increase in light of Swain v. McDonald, 27 Vet. App. 219 (2015). Under 38 C.F.R. § 3.400(o)(2), an increase in disability compensation is assigned from the "[e]arliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred if a complete claim or intent to file a claim is received within 1 year from such date, otherwise, date of receipt of claim." In Swain, the CAVC held assigning the effective date of an increased rating is not a mechanical exercise of applying the date of the VA examination that warranted the increase. Id. at 223-24. Rather, the Board must review all relevant evidence of record to determine when the increase in the disability can be ascertained. Id. The Board finds the assignment of June 27, 2019 as the effective date of the additional ratings for limitation of flexion for each knee based on the VA examination of that date that first found and factually ascertained, and is consistent with the guidance of Swain. As such the Board finds that the assignment of a separate disability rating of 20 for the left knee and a 10 percent rating for the right knee under Diagnostic Code 5260 for limitation of flexion is warranted. 7. Entitlement to a separate disability rating of 10 percent for left knee instability associated with arthritis under Diagnostic Code 5257 for the period prior to June 27, 2019, and for 20 percent from June 27, 2019 to January 15, 2020. 8. Entitlement to an increased rating of 10 percent for right knee instability associated with chondromalacia for the period prior to March 9, 2013. 9. Entitlement to a rating in excess of 10 percent for right knee instability associated with chondromalacia from March 9, 2013 to June 27, 2019. 10. Entitlement to an increased rating of 20 percent, but no higher, for right knee instability associated with chondromalacia, from June 27, 2019 forward. For this Veteran, based on VA medical evidence, the Board finds that an additional, separate rating for the Veteran's left knee disability under Diagnostic Code 5257 for instability at a rating of 10 percent, effective December 9, 2008, the date of the VA examination where the appropriate medical symptoms and facts were ascertained. The Board also finds that for the period from June 27, 2019 until January 15, 2020, a 20 percent rating for left knee instability should be assigned. For the Veteran's right knee, based on the medical evidence the Board finds that an increased rating of 10 percent for the period prior to March 9, 2013 and 20 percent from June 27, 2019 forward have been met or approximated. The Board assigns the effective date of December 9, 2008, the date of the VA examination where the appropriate medical symptoms and facts were ascertained. As explained above, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C. § 1155 (2012); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993) (emphasis added). During the Veteran's December 2008 examination, which is within the one- year lookback period, the Board notes that the Veteran reported that her knees had become worse since the last VA examination and that she was experiencing symptoms of instability. The Board has considered the findings regarding objective evidence of knee instability versus subjective reporting of instability by the Veteran in this case. See English v. Wilkie, 30 Vet. App. 347, 353 (2018) (holding that the Board cannot categorically favor objective stability test results over lay reports of instability). Here, the Board notes that the December 2008 VA examiner first recorded the Veteran's complaints of instability in her knees, though joint stability testing revealed normal results in both knees. The Veteran has reported consistent symptoms of her knee disabilities in lay statements and to her examiners on multiple occasions over the period on appeal. Notably, in a June 2014 treatment note the Veteran reported to her private treatment provider that she had fallen several times since her last visit. The Veteran is competent to report pain on motion, instability, and limitation of movement. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Moreover, the Board finds her credible, as his reports are internally consistent and there is no evidence to the contrary. Caluza v. Brown, 7 Vet. App. 498 (1995). As such the Board notes that as the Veteran's reported symptomology of instability of her knees was recorded during the VA examination of December 9, 2008, the Board considers that date to be the effective date of the additional rating for instability based on the facts found in that examination. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400; see Lyles v. Shulkin, 29 Vet. App. 107 (2017). As to the degree of instability, for the period prior to June 27, 2019, the Board assigns a rating under Diagnostic Code 5257 for instability, characterized as mild for each knee, with a rating of 10 percent, based on the statements from the Veteran that she experienced feelings of instability in her knees. The Board notes that during the March 2013 examination right knee joint stability testing revealed 1+ when tested for medial-lateral instability. Although the March 2013 and December 2016 examiners did not note the presence of anterior, posterior, medial or lateral instability in the left knee, nevertheless the Board has given the Veteran the benefit of the doubt that she has experienced some instability during this time in her left knee. Her previous lay statements corroborate evidence of instability in both knees. That being said, the Board finds that the Veteran's instability is slight, at worst in both knees, for the period prior to June 27, 2019. For the period from June 27, 2019 to January 15, 2020 for the left knee, and from June 27, 2019 forward for the right knee the Board assigns 20 percent ratings for each knee for instability characterized as moderate based on the findings of the June 27, 2019 VA examination. The Board notes that the Veteran was unable to complete joint stability testing at that time due to pain. However, during that examination she did report symptoms of instability of station. The examiner indicated that there was objective evidence of moderate instability bilaterally. As such, the Board finds that the Veteran's bilateral knee instability was moderate for the period from June 27, 2019. The weight of the evidence is against a higher, 30 percent disability rating during this period, because objective testing on examination and the lay evidence of record does not support a finding of severe instability of either the left or right knee at any point. 11. Entitlement to a rating in excess of 60 percent for left knee arthritis, status post total knee replacement, from March 1, 2021 forward. For the Veteran's left knee, from March 1, 2021, the Board finds that an evaluation in excess of 60 percent has not been met or approximated under Diagnostic Code 5055 or 38 C.F.R. § 4.30 as noted and appropriate. The Board does note that the Veteran had a total left knee replacement on January 15, 2021. As such, pursuant to Diagnostic Code 5055, the RO awarded a temporary total evaluation for thirteen months following the implantation of the prosthesis pursuant to Diagnostic Code 5055 to March 1, 2021, at which time the Veteran was assigned a 60 percent rating for her right knee. Pursuant to Diagnostic Code 5055, a 60 percent rating is the maximum rating for chronic residuals consisting of severe painful motion or weakness following a one-year period of convalescence. 38 C.F.R. § 4.71a, Diagnostic Code 5055. For the period from March 1, 2021 the record shows chronic residuals consisting of severe painful motion or weakness for the left knee. Thus, the Board finds a rating in excess of 60 percent for total left knee replacement is not more nearly approximated under Diagnostic Code 5055. A higher evaluation of 100 percent under Diagnostic Code 5055 is only warranted for one year following prosthetic replacement of the knee joint. 38 C.F.R. § 4.71a. Thus, the Veteran is now receiving the highest schedular rating available for left knee replacement. Accordingly, the Veteran's entitlement to an increased rating above 60 percent from March 1, 2021, thereafter, is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Conclusion The Board notes that evidence of the record has indicated that the Veteran has diagnoses related to a meniscal disability which would warrant consideration under Diagnostic Codes 5258 and 5259. See 38 C.F.R. § 4.71a. However, as explained above in June 2019 the VA examiner opined that the Veteran's symptoms of her meniscal disability were less likely than not related to her service-connected chondromalacia. The Board finds the opinion of the VA examiner to be highly probative as the examiner provided a conclusion based on a review of the Veteran's complete history including her private treatment records. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, the Board finds that a separate rating under Diagnostic Codes 5258 and 5259 are not warranted in this case. The Board has considered other diagnostic codes for the Veteran's bilateral knee disabilities, to include ankylosis (Diagnostic Code 5256), malunion/nonunion of the tibia and fibula (Diagnostic Code 5262), and genu recurvatum (Diagnostic Code 5263), and found them to not apply to the Veteran's bilateral knee disabilities picture in this period. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. In reaching the above conclusions, the Board has not overlooked the Veteran's statements and testimony with regard to the severity of her service-connected bilateral knee disability. In this regard, the Veteran was competent to report on factual matters of which she had firsthand knowledge, e.g., swelling and pain on motion. See Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). Lay evidence was provided by the Veteran through submitted statements, treatment records and during the course of her VA examinations. However, with respect to the Rating Schedule, where the criteria set forth therein require medical expertise to diagnose or observe, which the Veteran has not been shown to have or where these types of findings are not readily observable by a lay person, the Board has afforded greater probative weight to objective medical findings and opinions provided by the Veteran's treatment reports and her VA examination reports. See Woehlaert, 21 Vet. App. at 456 (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In conclusion, for the period prior to June 27, 2019, the preponderance of the evidence is against the finding that an evaluation in excess of 10 percent for the Veteran's left and right knee disabilities based on limitation of extension is warranted. For the left knee, for the period from June 27, 2019 to January 15, 2020, an increased rating of 40 percent based on limitation of extension and a separate disability rating of 20 percent based on limitation of flexion is warranted. For the left knee a separate disability rating of 10 percent for the period prior June 27, 2019, and for 20 percent from June 27, 2019 to January 15, 2020 based on instability is warranted. From March 1, 2021 the criteria for the assignment of a disability rating in excess of 60 percent for a left knee disability, status post total knee replacement is not warranted. For the right knee, for the period from June 27, 2019 forward, an increased rating of 20 percent based on limitation of extension and a separate disability rating of 10 percent based on limitation of flexion is warranted. An increased disability rating of 10 percent for the period prior to June 27, 2019 and from 20 percent from June 27, 2019 forward for the Veteran's right knee disability based on instability is warranted. The Board has also considered whether the Veteran or the record has raised the question of referral for an extraschedular rating adjudication under 38 C.F.R. § 3.321 (b) for any period for the initial rating issue on appeal. See Thun v. Peake, 22 Vet. App. 111 (2008). After review of the lay and medical evidence of record, the Board finds that the question of an extraschedular rating has not been made by the Veteran or raised by the record as to the Veteran's left and right knee disabilities. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record); Yancy v. McDonald, 27 Vet. App. 484, 494 (2016), citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007) (holding that when 38 C.F.R. § 3.321(b)(1) is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted"). All potentially applicable diagnostic codes have been considered, and there is no basis to assign an alternative evaluation for the Veteran's bilateral knee disabilities other than that discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). (Continued on next page.) Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Nettey, Associate 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.