Citation Nr: 21076385 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 16-61 417 DATE: December 23, 2021 ORDER Beginning February 22, 2016, entitlement to a rating of 30 percent, but no higher, for lumbosacral strain with degenerative changes is granted. Entitlement to a rating of 20 percent, but no higher, prior to February 25, 2020, exclusive of the time period where a temporary total rating has been assigned, for right knee chondromalacia status post arthroscopy with synovectomy, chondroplasty, partial medial meniscectomy, plica excision with osteochondral defect, and calcified tendonitis of suprapatellar tendon and degenerative arthritis is granted. Beginning April 1, 2021, entitlement to a rating in excess of 30 percent for residuals of right knee arthroplasty is denied. FINDINGS OF FACT 1. Beginning February 22, 2016, the Veteran's back disability manifested with forward flexion to 45 degrees at its most limited; there was no ankylosis of the spine; the Veteran experienced functional loss of pain with bending, lifting, and twisting and localized tenderness not resulting in an abnormal gait or abnormal spinal contour. 2. Prior to February 25, 2020 (exclusive of the time period where a temporary total rating has been assigned), the Veteran's right knee was manifested by flexion limited to, at most, 45 degrees and extension limited to, at most, 0 degrees; the Veteran's functional loss due to flare-ups manifested with pain on use impacted prolonged standing, walking, and managing stairs. 3. On February 25, 2020, the Veteran underwent a total left knee arthroplasty, requiring convalescence through March 31, 2021. 4. Beginning April 1, 2021 (the first day of the first month following convalescence), the Veteran's status-post total right knee arthroplasty did not result in chronic residuals consisting of severe painful motion or weakness, or ankylosis, extension limited to 30 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, or nonunion of the tibia and fibula with loose motion and requirement of a brace. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 30 percent rating from February 22, 2016, for lumbosacral strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242-5237. 2. Prior to February 25, 2020, the criteria for a rating of 20 percent for right knee chondromalacia status post arthroscopy with synovectomy, chondroplasty, partial medial meniscectomy, plica excision with osteochondral defect, and calcified tendonitis of suprapatellar tendon and degenerative arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260, 5010-5260. 3. As of April 1, 20121, the criteria for a rating in excess of 30 percent for status-post total right knee arthroplasty have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1972 to October 1992 in the United States Air Force. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated August 2016 and July 2017 issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the Board, in relevant part, denied a rating in excess of 10 percent for the Veteran's right knee disability, denied a rating in excess of 20 percent for his back disability, and denied service connection for sleep apnea. See BVA Decision (February 2019). Thereafter, the Veteran appealed such aspects of the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In December 2019, the Court granted the parties' Joint Motion for Partial Remand (JMPR), which vacated the Board's decision as to such claims and remanded the case for further consideration. See CAVC Decision (December 2019). In June 2020, the Board remanded these claims for action consistent with the JMPR. As noted in the June 2020 Board Remand, during the pendency of the appeal, an April 2020 rating decision recharacterized the Veteran's right knee disability right knee arthroplasty and assigned a 100 percent rating, effective February 25, 2020, and a 30 percent rating, effective April 1, 2021. In November 2020, in relevant part, the Board noted that the Veteran's service-connected right knee disability is currently evaluated as totally disabling (at a 100 percent schedular evaluation) and will remain so until a specified date in the future (April 1, 2021). See November 2020 BVA Decision. The Board recategorized the issue of increased rating for right knee to entitlement to a rating in excess of 10 percent prior to February 25, 2020, exclusive of the time period where a temporary total rating has been assigned, for right knee chondromalacia status post arthroscopy with synovectomy, chondroplasty, partial medial meniscectomy, plica excision with osteochondral defect, and calcified tendonitis of suprapatellar tendon and degenerative arthritis. The Board also remanded the issues on appeal for additional development to include for the purpose of obtaining addendum opinions regarding the etiology of sleep apnea and to determine the nature and severity of the Veteran's thoracolumbar spine and right knee disabilities. In March 2021, the Board remanded the claims for further development as the opinions of record remained inadequate for adjudication purposes. Here, the Board directed that the AOJ obtain the Veteran's VA treatment records for the period from November 2020 to the present; schedule the Veteran for examinations to determine the severity of his service-connected right knee disability and thoracolumbar spine disability; and to obtain an addendum opinion regarding the Veteran's sleep apnea. In a July 2021 rating decision, the AOJ granted service connection for obstructive sleep apnea with an evaluation of 50 percent, effective May 22, 2017. As this grant of service connection represents a full grant of the benefits sought on appeal, the claim is no longer before the Board. AB v. Brown, 6 Vet. App. 35 (1993) Increased Rating Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. The Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." Fenderson v. West, 12 Vet. App. 119 (1999). Musculoskeletal Disabilities When evaluating musculoskeletal disabilities, VA must consider whether a higher evaluation is warranted, where the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups. See 38 C.F.R. § § 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. Nevertheless, pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Moreover, functional impairment must be supported by adequate pathology. Id. Entitlement to a rating in excess of 20 percent for a thoracolumbar spine disability Initially, the Board notes that in a June 1993 rating decision, the RO granted service connection for lumbosacral strain with a 10 percent rating effective November 1, 1992. In a January 2009 rating decision, the RO increased the rating from 10 percent to 20 percent, effective October 31, 2008, pursuant to Diagnostic Code 5242-5237. The Veteran's non-initial increased rating claim was received on February 22, 2016; therefore, the period on appeal is from that date, plus the one-year "look back" period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for DCs 5235 to 5244, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), spondylolisthesis or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), degenerative arthritis of the spine (DC 5242) (for degenerative arthritis of the spine, see also DC 5003) (prior to Feb. 7, 2021), degenerative arthritis, degenerative disc disease other than IVDS (also, see either DC 5003 or DC 5010) (effective Feb. 7, 2021), IVDS (DC 5243), and complete traumatic paralysis (DC 5244) (effective Feb. 7, 2021). The Board notes that the criteria for rating musculoskeletal disabilities, including disabilities of the spine, have changed once during the period covered by this appeal, effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). When a law or regulation changes during the pendency of a Veteran's appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; VAOPGCPREC 3-2000, 65 Fed. Reg. 33422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the Veteran is entitled to application of the criteria that are most favorable to his claim, except that an award based on the amended regulations may not be made effective before the effective date of the change. The Board notes that, effective February 7, 2021, DC 5242 was amended to include degenerative disc disease other than IVDS. DC 5244 was also added to add paraplegia and quadriplegia. DC 5237, under which the Veteran's chronic lumbar strain and chronic cervical strain is currently rated, was not changed. The Board notes that the spine regulations were also amended to state that Diagnostic Code 5243 governing Intervertebral disc syndrome should only be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; and that Diagnostic Code 5242 should apply to all other disc diagnoses. See 85 Fed. Reg. 76462 (Nov. 30, 2020) (effective 2/7/2021). The Board notes that this change does not impact the evaluation in this case as the Veteran does not have any evidence of incapacitating episodes that would warrant a compensable rating under Diagnostic Code 5243. With respect to arthritis, DC 5010 was clarified to rate post-traumatic arthritis according to limitation of motion, dislocation, or instability. The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent disability rating is assigned for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. The Formula for Rating IVDS Based on Incapacitating Episodes provides for ratings from 10 to 60 percent based on the frequency and duration of incapacitating episodes, defined in Note 1 as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. The maximum 60 percent schedular rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the previous 12 months. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate DC. Note (2) provides that, for VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See also Plate V, 38 C.F.R. § 4.71a. Note (3) provides that, in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4) provides that the rater is to round each range of motion measurement to the nearest five degrees. Note (5) provides that, for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6) provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a. Turning to the evidence of record, a November 2015 VA treatment record showed that the Veteran did not have pain over palpation of the spinous processes of the lumbar spine or sacroiliac joints. The Veteran was afforded a Back (Thoracolumbar Spine) Conditions DBQ in July 2016. Upon examination, the Veteran complained of stiffness, tightness, and achiness affecting the lumbar spine including the midline lumbar region and into the paralumbar regions, and of potential flare-ups of increased pain and decreased range of motion with bending, lifting, and twisting. He denied any radiculopathy symptoms associated with his low back condition. He also denied any loss of time from work or periods of incapacity secondary to the lumbar spine condition over the past year. Range of motion testing found 0 to 90 degrees flexion of the lumbar spine, with flexion limited to 85 degrees after repetitive motion; and 0 to 25 degrees extension, 0 to 25 degrees right and left lateral rotation, and 0 to 25 left and right rotation; all reduced to 20 degrees after repetitive motion. There was no guarding or muscle spasm, radicular pain, IVDS, or ankylosis, and the examiner noted that the examination was not conducted during a flare-up. The Veteran had localized tenderness, but it did not result in an abnormal gait or abnormal spinal contour. The examiner added that as the Veteran was not experiencing a flare up at the time of the examination or being seen following repeated use over a period of time, an opinion regarding functional ability during a flare-up or following repeated use over a period of time could not be rendered. Imaging studies were performed and revealed moderate to advanced multilevel degenerative disc disease most pronounced at L5-S1; moderate to advanced multilevel facet degenerative changes greatest at L4/L5 and Ls/S1; and mild retrolisthesis L3 on L4 and L5 on S1. The examiner noted that the Veteran's thoracolumbar spine condition did not impact his ability to work. The Veteran was provided another Back (Thoracolumbar Spine) Conditions DBQ in June 2020. As to whether the Veteran reported flare-ups or functional loss, no response was provided. Range of motion testing revealed flexion from 0 to 45 degrees, extension from 0 to 10 degrees, left and right lateral flexion from 0 to 20 degrees, and left and right lateral flexion from 0 to 20 degrees. Pain was noted on exam which caused functional loss in forward flexion and extension; however, there was no loss of range of motion in any plane. In a June 2020 addendum opinion, an examiner stated that the Veteran reported daily flare-ups of his back with activities, that caused reduced range of motion, pain, and lack of endurance. Concerning his back, the examiner reported that the Veteran had pain with active range of motion. The examiner stated that passive range of motion could not be performed. No specific joints or opposing joint were affected with the back. The Veteran had pain with weight bearing in the back, but not with weight-bearing. In a May 2021 Back (Thoracolumbar Spine) Conditions DBQ, the examiner noted a diagnosis of lumbosacral strain/lumbosacral strain with degenerative changes, which he noted to have progressed/worsened since onset. The Veteran stated that his current symptoms included intermittent sharp lower back pain worse with bending and twisting and improved with rest and medication. The Veteran did not report flare-ups of the thoracolumbar spine. Range of motion testing revealed forward flexion to 80 degrees and 30 degrees in all remaining planes of motion. The Veteran exhibited pain on forward flexion, extension, and on left lateral flexion. Passive range of motion testing performed. While the examiner noted that there was no evidence of pain, the examiner also checked the boxes "Active motion, Passive motion, and Does not result in/cause functional loss." There was no objective evidence of crepitus or localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive use testing with at least three repetitions, not resulting in any additional loss of function or range of motion after three repetitions. The Veteran did not have localized tenderness, guarding, or muscle spasm of the thoracolumbar spine. There were no additional factors contributing to disability. Muscle strength testing, reflex exam, sensory exam, and straight leg testing were normal. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The Veteran did not have ankylosis of the spine or any neurologic abnormalities. The Veteran did not have IVDS. The Veteran did not use an assistive device. Imaging studies were not performed in conjunction with the examination. As to functional impact, the examiner noted that the Veteran's back disorder would impact any occupation requiring heavy lifting, bending, and twisting. In a September 2021 addendum opinion, the examiner stated that "there would be no discernible change in the active or passive range of motion during a flare." The examiner further reported that the Veteran did not endorse flares at the time of the examination and, when asked about flares, he denied a substantial change from the baseline. The examiner further noted that the July 2015 DBQ showed that the Veteran reported that he had not missed time from work and did not experience periods of incapacity secondary to his back over the past year, and which was also true for the May 2021 examination. Thus, the examiner concluded that the Veteran maintained normal strength without any muscle atrophy or any other signs to suggest a risk of increased disability during any flare. The evidence above shows that the Veteran's his limitation of motion was noted to be 45 degrees of flexion at its worst after considering additional limitation based on repetitive use, which equates to a 20 percent rating, but it does not meet the criteria of 30 degrees or less of forward flexion required for a higher 40 percent rating. 38 C.F.R. § 4.71a, DC 5237. Further, there is no evidence of ankylosis of the spine, so a higher rating is not warranted on this basis either under DC 5237. Yet, with regard to functional loss, the Veteran reported that his low back pain manifested with flare-ups and decreased range of motion with bending, lifting, and twisting. See July 2016 and May 2021 VA examinations. Additionally, the 2016 examiner reported that the Veteran had localized tenderness, but not resulting in an abnormal gait or abnormal spine contour. Here, this evidence indicates a worsening based on functional loss. As a result, the Board finds that a 30 percent rating is warranted for the Veteran's low back disability for the period beginning on February 22, 2016 (the date of the increased rating) based on functional loss. A rating in excess of 30 percent, however, is not warranted as there is no evidence of favorable or unfavorable ankylosis of the thoracolumbar spine or evidence of incapacitating episodes or its functional equivalent. Entitlement to a rating in excess of 10 percent prior to February 25, 2020, excluding periods of temporary total evaluations, for a right knee disability The Board acknowledges that the ratings criteria for the musculoskeletal system was updated during the appeal period, effective February 7, 2021; that new criteria will be address in a separate section below. Diagnostic Code 5010 instructs VA to rate traumatic arthritis as degenerative arthritis by refence to Diagnostic Code 5003. Diagnostic Code 5003 pertains to degenerative arthritis and provides that when 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71A, Diagnostic Codes 5260 and 5261. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5260 provides for a zero percent evaluation where flexion of the leg is only limited to 60 degrees. For a 10 percent evaluation, flexion must be limited to 45 degrees. A 20 percent evaluation is warranted where flexion is limited to 30 degrees. A 30 percent evaluation may be assigned where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 provides for a zero percent evaluation where extension of the leg is limited to five degrees. A 10 percent evaluation requires extension limited to 10 degrees. A 20 percent evaluation is warranted where extension is limited to 15 degrees. A 30 percent evaluation may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent evaluation, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees a 50 percent evaluation may be assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5256, ankylosis of the knee in a favorable angle in full extension, or in slight flexion between 0 and 10 degrees warrants a 30 percent evaluation. Ankylosis of the knee in flexion between 10 and 20 degrees warrants a 40 percent evaluation, while ankylosis in flexion between 20 and 45 degrees warrants a 50 percent evaluation. Extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Under Diagnostic Code 5257, a 10 percent rating is assigned when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent evaluation for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides for a 20 percent rating for a dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the knee joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides for a maximum 10 percent rating for symptomatic residuals of removal of a semilunar cartilage. 38 C.F.R. § 4.71a. Finally, under Diagnostic Code 5055, for a total knee replacement with prosthesis, a 100 percent evaluation is assigned for 1 year following implantation of the prosthesis. After that year, a minimum rating of 30 percent disabling is assigned. With intermediate degrees of residual weakness, pain or limitation of motion, the rater is directed to evaluate as analogous to Diagnostic Codes 5256, 5261, or 5262. The minimum evaluation is 30 percent. The highest evaluation is 60 percent, which 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, the disability will be rated by analogy to Diagnostic Codes 5256, 5261 or 5262. 38 C.F.R. § 4.71A, Diagnostic Code 5055. The Board notes that Diagnostic Codes 5262 and 5263 governing evaluations for impairment of the tibia and fibula and genu recurvatum are not applicable as the Veteran does not have any of these conditions. Thus, these provisions will not be further addressed. 38 C.F.R. § 4.71a, Diagnostic Codes 5262, 5263. From March 1, 2016 to April 18, 2019, the Veteran's right knee was rated 10 percent pursuant to Diagnostic Code 5003-5260. From April 19, 2019 to February 24, 2020, the Veteran's right knee was rated 10 percent pursuant to Diagnostic Code 5010-5260. Turning to the evidence of record for this period, the Veteran underwent right knee surgery in January 2016. VA treatment records, dated May 2016, show that the Veteran complained of daily knee pain without swelling. In a July 2016 VA Knee and Lower Leg Conditions DBQ, the examiner noted a diagnosis, in relevant part, of right knee chondromalacia status post right knee arthroscopy. The Veteran reported symptoms to include pain, some weakness, catching, swelling, and discomfort into the right knee. The examiner noted that the Veteran has had ongoing problems with the right knee and had somewhat of an altered gait and change in biomechanics. The Veteran also stated that he has undergone injections into the knees in the past with little or no benefit. The Veteran stated that he is unable to kneel or squat primarily due to the right knee. He reported that changes in the weather, as well as increased weight bearing ambulation or any attempts at kneeling and squatting can potentially flare-up the condition causing increased pain and decreased range of motion and difficulty with weight bearing. He did not use any sort of cane, but he did utilize a brace to the right knee on an occasional basis. Upon examination, the Veteran reported flare-ups of the knee resulting in increased pain; decreased range of motion; difficulty with prolonged weight-bearing; difficulty with stairs and inclines; and difficulty with squatting/kneeling. The Veteran also reported having functional loss/impairment, to include pain, stiffness, and decreased range of motion. Range of motion testing of the right knee showed flexion to 125 degrees and extension to 0 degrees. Pain was noted on exam which caused functional loss on flexion. There was evidence with pain with weight bearing. There was also objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was also objective evidence of crepitus. As to the right knee, the Veteran was able to perform repetitive use testing with at least three repetitions, and there was additional functional loss and pain after repetition. Range of motion testing after repetition included flexion to 120 degrees and extension to 0 degrees. The examiner stated that he was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. The exam was not conducted during a flare-up. There were no additional contributing factors of disability. Muscle strength testing was normal. There was no ankylosis of the right knee. There was no joint instability. The Veteran was noted to have a meniscus condition, to include a right knee meniscal tear and frequent episodes of joint pain and effusion of the right knee. The examiner noted that the Veteran underwent right knee surgery in January 2016. The Veteran used a brace on an occasional basis. Imaging studies were performed and which showed, in relevant part, osteochondral defects bilateral medial compartments of each knee and questionable trace right knee effusion. The examiner noted that the Veteran's condition did not impact his ability to perform any occupational task. In a June 2020 Knee and Lower Leg Conditions DBQ, the examiner noted that range of motion testing showed flexion to 45 degrees and extension to 0 degrees. The examiner noted that pain and lack of endurance significantly limited functional ability with repeated use over a period of time. The examiner did not determine whether the Veteran had flare-ups. Muscle strength testing, joint stability tests were not performed. The examiner did not provide a response as to whether the Veteran had ankylosis, additional conditions, meniscal conditions, or surgical procedures. The examiner did not determine whether there was any functional impact. In a June 2020 addendum opinion, the examiner stated that the Veteran had his right knee replaced locally earlier in the year, and, therefore "questions about the right knee/ROM/flares/functional concerns are best estimates based on what he could perform today, since he essentially has a 'new' knee." The examiner also stated that there was no manner in which to estimate what the Veteran could or could not do/perform in terms of range of motion in the right knee, prior to his knee replacement. Additionally, the examiner noted that the Veteran's right knee pain could significantly limited functional ability during flares. The Veteran reported flares occurring two times per week with his right knee, which caused reduced range of motion, pain, and lack of endurance. He reported that he was not having a flare upon examination. Concerning the right knee, the examiner noted that the Veteran had pain with active and passive ranges of motion. He had pain with weight-bearing in the right knee and mild pain with non-weight bearing in the right knee. The opposing joint was not examined. In a May 2021 Knee and Lower Leg DBQ, the examiner noted a diagnosis of right knee/right knee arthroplasty. The Veteran reported that his condition improved since onset. He also reported "wear and tear to his knees from working as a mechanic with lots of lifting and kneeling." His current symptoms included intermittent knee pain with overuse. The Veteran also reported that he underwent a right knee replacement. Active and passive range of motion testing revealed flexion to 140 degrees and extension to 0 degrees. As to the right knee, there was no evidence of crepitus or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive-use testing with at least three repetitions, and there was no additional loss of function or range of motion after three repetitions. The Veteran was not being examined immediately after repeated use over time or during a flare-up. There were no additional factors contributing to disability. The Veteran did not have muscle atrophy, ankylosis, or joint instability in the right knee. The Veteran did not have a tibial or fibular impairment or meniscal condition. Specific to the right knee, the examiner noted that the Veteran had a total knee joint replacement in 2020, a meniscectomy in 2016, and an arthroscopic ligament repair in 2016. The Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms. The examiner noted that the Veteran did not use an assistive device. Imaging studies had not been performed. The examiner stated that the Veteran's condition did not cause functional impact. In a May 2021 medical opinion, an examiner stated that based on DBQs from 2015 to 2020, the Veteran "went from right knee range of motion after repeated use of 1-120 in 2015 to 0-45 in 2020 just prior to knee replacement." The examiner also noted that the Veteran underwent an increase in pain frequency and intensity and that the records show a progression in severity that appears to have "grave effect on function culminating in surgical replacement of the joint." The examiner also stated that in 2015, the Veteran recalled having difficulty with kneeling and navigating stairs and inclines with intermittent flare-ups causing increased pain and swelling to the right knee. The Veteran also reported a worsening of symptoms with increased frequency and intensity of knee pain and greater difficulty with ambulating and squatting or kneeling to the point where functioning was very difficult. He reported a dramatic decrease in his ability to even bend the knee over time, adding to decreased function. Based on the above evidence, the Board finds that a 20 percent rating, but no higher, is warranted for the period from March 1, 2016 to February 24, 2020. Specifically, throughout this period, a rating in excess of 10 percent is not warranted under DC 5260 as limitation of right knee flexion was not limited to 45 degrees or less. Additionally, limitation of right knee extension was not limited to at least 10 degrees for his right knee; thus, a higher rating under DC 5261 is not applicable. Also, the Veteran has not at any time been found to have a meniscus (semilunar cartilage) condition manifested with locking and effusion; ankylosis; genu recurvatum or a tibia/fibula impairment, so DCs 5256, 5258, 5262, and 5263 are not applicable and a higher rating under any of these provisions is not warranted at any time during the appeal period. The Veteran also did not report right knee instability, and this is not shown in the evidence, so a separate rating under DC 5257 is not applicable. As there is no evidence of incapacitating exacerbations, a rating in excess of 10 percent is not warranted under DC 5003. With respect to functional loss, however, the Veteran has reported that his right knee pain was aggravated with prolonged sitting, standing, and ambulation. Additionally, in the May 2021 opinion, the Veteran recalled that from 2015, he had difficulty with kneeling, squatting, ambulating, and navigating stairs and inclines due to his right knee disorder. He also recalled that he had intermittent flare-ups causing increased pain and swelling to the right knee. While the evidence does not show limitation of motion or other symptoms warranting an increase, the Board finds that a 20 percent rating adequately compensates the Veteran for his functional loss. Accordingly, the Board finds that a 20 percent rating, but no higher, is warranted for functional loss of the Veteran's right knee for the period from March 1, 2016 to February 24, 2020. The Veteran is in receipt of a 100 percent rating, per Diagnostic Code 5055, for the period from April 25, 2020 to March 31, 2020. As of April 1, 2021, the Veteran was assigned the automatic 30 percent disability under Diagnostic Code 5055. The Board must consider whether the Veteran is entitled to a higher rating. Prior to the regulatory change, Diagnostic Code 5055 provides that a minimum 30 percent rating is warranted for knee replacement (prosthesis). A 60 percent rating is warranted for knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. Both the 30 percent and 60 percent criteria were relatively unaffected by the February 7, 2021 regulatory changes. Prior to the February 7, 2021 regulatory changes, however, a maximum rating of 100 percent is warranted for one year following implantation of the prosthesis. From February 7, 2021, a 100 percent rating is warranted for 4 months following implantation of prosthesis or resurfacing. At the conclusion of the 4 month period, resurfacing is to be evaluated under diagnostic codes 5256 through 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055. In addition, ratings between 30 and 60 percent can be assigned with intermediate degrees of residual weakness, pain, or limitation of motion, rated by analogy to Diagnostic Codes 5256 (ankylosis), 5261 (limitation of flexion), or 5262 (impairment of the tibia and fibula). Id. In light of the evidence of record, the Board finds that the residuals of the Veteran's right total knee replacement more nearly approximate the currently assigned 30 percent rating. At the May 2021 VA examination, the Veteran reported that his condition improved. He did not report flare-ups of the knee or lower leg, nor did he endorse having any flare-ups or functional loss or impairment. The Veteran also did not report or have a history of instability, recurrent subluxation, or frequent effusion. The examiner also noted that the Veteran had normal range of motion in all planes. He was able to perform repetitive-use testing with at least three repetitions. There were no additional factors contributing to disability. The Veteran did not have muscle atrophy, ankylosis (or its functional equivalent), or joint instability of the right knee. The Veteran did not require an assistive device. The Veteran did not have a tibular or meniscal condition of the right knee. Additionally, the Veteran's right knee disorder did not impact his ability to perform any occupational task. Based on this evidence, the Board finds that the Veteran has not suffered from chronic residuals consisting of severe painful motion or weakness in the affected extremity, as required for a higher rating under DC 5055. Again, the Board notes that DC 5055 contemplates rating intermediate degrees of symptoms by analogy under 5256, 5261, or 5262. DC 5256 considers ankylosis of the knee and such has not been shown. DC 5261 contemplates limitation of extension of the leg, and the Veteran's right knee extension has not been shown to be limited such that rating his disability under that code would result in a higher evaluation. There is also no impairment of the tibia and fibula manifested by nonunion with loose motion requiring a brace has been shown to warrant rating under DC 5262. It is also noted that separate ratings under DCs 5256 to 5263 cannot be assigned in conjunction with a rating under DC 5055 as that would result in separate ratings for the same symptoms, known as pyramiding, which is prohibited. See 38 C.F.R. §§ 4.14, 4.71a. Therefore, a disability rating in excess of 30 percent for residuals of right knee arthroplasty is not warranted for the period beginning April 1, 2021. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hanson, Tiffany 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.