Citation Nr: 21076389 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 13-27 589 DATE: December 23, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for right knee instability from June 30, 2009 to April 13, 2012 is denied. Entitlement to a disability rating of 30 percent for right knee instability from April 14, 2012 to December 28, 2014 is granted, subject to the laws and regulations regarding governing payments. Entitlement to a disability rating in excess of 10 percent for right knee degenerative joint disease from June 30, 2009 to June 15, 2014 is denied. Entitlement to a disability rating of 20 percent for right knee degenerative joint disease from June 16, 2014 to August 25, 2014 is granted, subject to the laws and regulations governing monetary payments. Entitlement to a disability rating in excess of 20 percent for right knee degenerative joint disease from August 26, 2014 to December 28, 2014 is denied. Entitlement to a separate 20 percent rating for right knee semilunar cartilage dysfunction, is granted, from April 14, 2011 to December 28, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 60 percent from February 1, 2016 for right knee status post total replacement is denied. FINDINGS OF FACT 1. From June 30, 2009 to April 13, 2012, the severity of the Veteran's right knee instability was at worst moderate. 2. From April 14, 2012 to December 28, 2014 the severity of the Veteran's right knee instability was severe. 3. From June 30, 2009 to June 15, 2014, the Veteran's right knee flexion was not limited to less than 30 degrees. 4. From June 14, 2014 to December 28, 2014, the Veteran's right knee flexion was limited to 30 degrees. 5. From April 14, 2011 to December 28, 2014 the Veteran had a semilunar cartilage dysfunction manifested by symptoms of locking of the right knee and joint effusion. 6. From February 1, 2016, the Veteran's right knee status post total replacement included chronic residuals consisting of severe pain motion and weakness. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent, from June 30, 2009 to April 13, 2012, for right knee instability are not 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 5257. 2. The criteria for an evaluation of 20 percent, from April 14, 2012 to December 28, 2014, for right knee instability are 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 5257. 3. The criteria for a rating in excess of 10 percent, from June 30, 2009 to June 15, 2014 for right knee degenerative joint disease are not 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 5010-5260. 4. The criteria for a rating of 20 percent, from June 15, 2014 to August 25, 2014 for right knee degenerative joint disease are 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 5010-5260. 5. The criteria for a rating in excess of 20 percent, from August 25, 2014 to December 28, 2014 for right knee degenerative joint disease are not 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 5010-5260. 6. From April 14, 2011 to December 28, 2014, the criteria for a separate evaluation of 20 percent for semilunar cartilage dysfunction of the left knee are 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 5258. 7. The criteria for an evaluation in excess of 60 percent, from February 1, 2016, for right knee status post total knee replacement, are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 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 October 1981 to October 1982. This matter comes to the Board of Veterans' Appeals (Board) from a November 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned in a September 2016 Board hearing. A transcript of the hearing is of record. The appeal was remanded to the Agency of Original Jurisdiction (AOJ) in September 2017 and January 2019 for additional development. The Board notes that the Veteran was awarded a 100 percent disability rating due to covalence of his total right knee replacement from December 29, 2014 to January 31, 2016. This total disability rating is not on appeal, rather the period prior and after the Veteran's total disability rating. Further, the RO granted a 20 percent disability rating from August 26, 2014 to December 28, 2014 and a 60 percent disability rating from February 1, 2016. However, these issues remain on appeal and before the Board as this action does not constitute a full grant on benefits on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (where a claimant has filed a notice of disagreement as to a RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part 4. 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. See 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. See 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14. However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. Id. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. The rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent they are sufficient to warrant changes in evaluation based on the applicable rating criteria. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). For increased-rating claims, where a claimant seeks a higher evaluation for a previously service-connected disability, it is the present level of disability that is of primary concern, and VA considers the level of disability for the period beginning one year prior to the claim for a higher rating. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); see also 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2). 1. Knee Disability Prior to December 29, 2014 The Veteran contends his right knee is more severe than currently rated. The appellate period for this appeal begins on June 30, 2009 one year prior to the Veteran's claim for an increased rating for his right knee disability. Between June 30, 2009 and December 28, 2014, the Veteran's right knee is rated 20 percent for right knee instability rated under Diagnostic Code 5257. The Veteran's right knee was also rated 20 percent from August 26, 2014 to December 29, 2014 and 10 percent prior to August 26, 2014 under Diagnostic Code 5260 for his right knee degenerative joint disease. Disabilities of the knee are rated under Diagnostic Codes 5256 to 5263. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides that a 10 percent rating is warranted for flexion limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides that a 10 percent rating is warranted for extension limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 50 degrees. 38 C.F.R. § 4.71a. For comparison, normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrant a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. When the knee disability affects the meniscus, a 20 percent rating is warranted when there is dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. A 10 percent rating is warranted when there has been removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Separate ratings can be assigned for the above knee disabilities (Diagnostic Codes 5257, 5258, 5259, 5260, and 5261) when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. As an initial matter, the Board notes that the evidence in this case does not reflect and the Veteran does not allege that he has tibia or fibula impairment, genu recurvatum, or ankylosis. As such, those diagnostic codes are not for application. 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 rating. Ankylosis of the knee in flexion between 10 and 20 degrees warrants a 40 percent rating. Ankylosis of the knee in flexion between 20 and 45 degrees warrants a 50 percent rating. Extremely unfavorable ankylosis of the knee, in flexion at an angle of 45 degrees or more warrants a 60 percent rating. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011) (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). Moreover, when evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202 (1995); Burton, 25 Vet. App. at 5. Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance," as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the United States Court of Appeals for Veterans Claims (Court) held that VA examiners must provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination. The Court has also issued the opinion of Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016), which clarifies additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. A review of the record reveals that, while the most recent VA examination in December 2019 satisfies the requirements of Correia and Sharp, the prior VA examinations in August 2010, November 2012 and June 2014 do not satisfy the requirements of Correia or Sharp. Nevertheless, the Board finds that a remand to satisfy the requirements of Correia and Sharp is not warranted here, since remanding for another VA examination would not remedy the inadequacies of the evidence prior to December 2019, and there is adequate evidence of record to address the guidance in those cases. For these reasons, the Board finds that VA examinations are in substantial compliance with applicable law and regulations, and that there is no prejudice to the Veteran in proceeding to a decision without a remand under the circumstances. During the pendency of the Veteran's increased rating claim on appeal, the rating criteria for evaluating certain musculoskeletal disabilities including disability os the knees were amended, effective on February 7, 2021. The change added certain diagnostic codes and amended the rating criteria for several diagnostic codes listed under 38 C.F.R. § 4.71a. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. As of February 7, 2021 and as it pertains to this claim, under the amended criteria, Diagnostic Code 5055 notes that at the conclusion of the 100 percent evaluation period, residuals of a knee replacement surgery are to be evaluated under Diagnostic Codes 5256 through 5262. The amendments did not change the criteria under Diagnostic Codes 5256, 5258, 5259, 5260, or 5261. However, under the revised criteria, Diagnostic Code 5257 for recurrent subluxation and instability now provides a 30 percent rating 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 or 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. A 20 percent rating is warranted for 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 10 percent rating is warranted 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. For patellar instability under the revised Diagnostic Code 5257, a 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. The Board finds, however, that increased ratings in excess of that either currently assigned or assigned pursuant to this decision for instability of the right knee would not be in order under the revised criteria of Diagnostic Code 5257. In August 2010, the Veteran underwent a VA right knee examination. During the examination, the Veteran reported constant pain, popping, episodes of discoloration and weakness with lack of endurance. The Veteran reported redness, heat, and swelling during flare-ups and requires drainage of effusion. The Veteran reported he had flare-ups 3 to 3 times a year and it is caused by precipitated by prolonged standing, walking, or strenuous activity. The Veteran used a cane and knee brace during flare-ups. The Veteran described his functional impairment as difficulty driving his manual transmission car with his knee "locking up." The Veteran stated he could stand for up to 2 hours at a time but standing that long often exacerbated pain and swelling in the knee. The Veteran was unable to walk up and down stairs as it aggravated his knee. The Veteran reported he was only to help with light household chores. The Veteran stated he used to enjoyed running and walking for exercise but now had to change to swimming to avoid strain on the knee joint. Upon examination the Veteran had flexion of 5 to 90 degrees with pain through extension with minus 5 degrees medial and lateral collateral ligaments. The varus and valgus stress elicited some instability in the lateral collateral ligament with considerable pain during testing anterior and posterior cruciate ligament. The anterior and posterior drawer tests were negative with minimal pain and medial and lateral meniscus. The McMurray's test elicited considerable pain and clinking with both medial and lateral meniscus testing. Upon repetitive active range motion testing there was increased pain, weakness and lack of endurance with pain having the most functional impact. There was a 10 degree loss of range of motion with flexion and an additional 5 degree loss with extension. The examiner noted there was probable positional apparent lateral patellar subluxations. In April 2011, the Veteran's private doctor submitted a private opinion regarding a March 2011 examination. The private doctor stated that the Veteran had severe end stage traumatic osteoarthritis of the right knee. The Veteran had moderate subluxation and lateral instability. The Veteran had crepitus indicative of loss of cartilage, with evidence of severe knee joint effusion and pain. The Veteran had symptomatic degenerative semilunar cartilage tear and/or absence of said cartilage. In April 2012, the Veteran underwent another VA right knee examination. During the examination the Veteran reported near constant pain, stiffness, giving way, clicking, and popping. The Veteran reported flares-ups that impacted the function of the knee. The Veteran reported he had could not climb stairs, squat or stoop, heavy leaving, or prolong standing, sitting, or walking. Upon range of motion testing the Veteran had flexion of 100 degrees, with pain at starting at 10 degrees. The examiner found no limitation of extension. The Veteran was unable to perform repetitive-use testing. The examiner found the Veteran had additional limitation of range of motion following repetitive use testing. The examiner found the Veteran had additional functional loss in the knee. The examiner found the Veteran had less movement than normal and pain on movement. The examiner found the Veteran had pain on palpation. The examiner was unable to test the Veteran's right knee stability. The examiner did find there was no evidence or history of recurrent patellar subluxation or dislocation. The examiner found the Veteran's right knee disability impacted his ability to work. The examiner noted the Veteran had increased pain at the end of each day. The Veteran reported that he was able to perform his job duties, but he had to take frequent breaks. In November 2012, an addendum opinion was provided by the April 2012 VA examiner. The examiner noted that she had checked the box concerning limitation of range of motion of the knee following repetitive use testing. The examiner explained that repetitive use, anterior instability, posterior instability, and medial-lateral instability testing were not performed as the Veteran stated he was unable to perform these tests due to pain. In June 2014, the Veteran underwent another VA right knee examination. The Veteran reported increased knee pain with at rest and constant pain. The Veteran stated he had pain was mild to severe. The Veteran stated that knee pain radiated up and down his leg that mostly involved the medial and lateral aspect of his knee. The Veteran reported pain medication did not alleviate his pain. The Veteran reported flare-ups that impacted the function of his knee. The Veteran reported that his knee would get so painful that his leg buckles and he would fall. Upon range of motion testing, the Veteran had 60 degrees of flexion with evidence of painful motion occurring at 30 degrees. The Veteran had normal right knee extension. The Veteran was able to perform repetitive use testing with 3 repetitions. The Veteran had 60 degree of flexion after repetitive-use testing. There was no loss of range of motion in extension after repetitive-use testing. The examiner found the Veteran had additional functional loss in the knee. The examiner found the Veteran had less movement than normal, weakened movement, swelling, instability of station, disturbance of locomotion, and pain on movement. The examiner found the Veteran had pain on palpation. The examiner was unable to test the Veteran's stability in his right knee. The examiner found the Veteran evidence or history of recurrent patellar subluxation or dislocation. The examiner found the severity was moderate. The Veteran used assertive devices regularly of a brace and cane. The examiner found the there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by amputation with prosthesis. The examiner found the Veteran's right knee impacted his ability to work. The examiner found the Veteran was unable to do any job that required kneeling, squatting, or prolonged walking. The examiner noted the Veteran worked as a teacher and used a cane to walk around the classroom. The examiner noted the Veteran hollered loudly with pain range of motion passive and active. The examiner found pain and weakness could greatly limit range of motion during a flareup but was unable to estimate degrees without directly observing. The examiner noted that the Veteran had no decrease in range of motion with repeated repetitions. During the appellate period the Veteran's private and VA treatment records indicate that the Veteran's range of motion was in line with the VA examinations. With the exception of in an August 26, 2014 private treatment record that noted the Veteran's flexion was limited to 30 degrees. The treatment records prior to December 29, 2014 all indicated that the Veteran had some locking, popping, crepitus, and pain. In September 2016, the Veteran testified at a Board hearing. The Veteran testified that prior to his total knee replacement he received Synvisc and steroid injections and wore a brace. The Veteran stated that he had swelling in his knee to the point that he lost a lot of mobility. The Veteran stated that during a VA examination, the VA examiner exceeded the mobility of knee and it broke a 6-millimeter section of the bone. The Veteran stated the same VA examiner provided the next examination and she did not touch his knee. The Veteran stated if the weather changed his knee would swell and the pain would increase exponentially. The Veteran stated his knee was not moderate but severe at the point he got the surgery. The Veteran testified that his instability prior to the knee replacement surgery was severe and he had very limited motion. The Veteran explained that the examiner forced his knee to go beyond what the normal range of motion his knee was able to do. Initially, the Board finds that from June 30, 2009 to April 13, 2012 period the Veteran's right knee instability is classified as moderate. The Board notes that the Veteran contends that in the period prior to his surgery, his knee instability was severe not moderate. The Board finds such statement competent and credible and provides probative weight. However, the Board finds that the August 2010 VA examiner and the private doctor's April 2011 opinion that the Veteran's instability was considerate moderate is more probative than the Veteran's statement. These opinions are based on medical examination of the Veteran's knee designed to determine the severity of the stability of the knee. However, the Board finds from April 14, 2012, the Veteran's knee instability is severe, since the only evidence is the Veteran's statement that his stability was severe. Notably no VA examiner was able to determine the severity of the Veteran's instability. Thus, a 30 percent disability rating is warranted from April 14, 2012 to December 28, 2014. The Board finds that the Veteran is entitled to a separate disability rating of 20 percent under Diagnostic Code 5258 from April 14, 2011. The Board notes that the that there is evidence of semilunar cartilage with joint effusion and locking. Notably, the Veteran's statements in his August 2011 of joint effusion combined with the April 2011 private doctor that noted loss of cartilage, with evidence of severe knee joint effusion and pain and the Veteran had symptomatic degenerative semilunar cartilage tear and/or absence of said cartilage. As such from April 14, 2011 to December 28, 2014 a separate 20 percent disability is warranted. The Board notes that symptoms associated with the Veteran's semilunar cartilage dysfunction, including specifically locking and joint effusion, do not necessarily overlap with the painful and limited motion currently rated under Diagnostic Code 5261. See VAOPGCPREC 23-97 (July 1997) and VAOPGCPREC 9- 98, (August 1998) (holding that separate ratings may be assigned for arthritis of the knee with limited motion and instability of the knee and/or cartilage impairment with associated locking and effusion); Esteban, 6 Vet. App. at 261-62 (separate ratings are permissible so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition). As these symptoms do not necessarily overlap with limitation of motion, a separate rating under Diagnostic Code 5258 does not violate the rule against pyramiding. See 38 C.F.R. § 4.14. In regard to the Veteran's forward flexion, prior to August 26, 2014 a disability rating in excess of 10 percent disability rating for the Veteran's loss of range of motion for flexion is not warranted. The evidence does not demonstrate that the Veteran's loss of range of motion prior to June 16, 2014 was limited to 30 degrees. The evidence in the record demonstrates that at worst during this period his loss of range of motion was limited to 60 degrees. In regard to the Veteran's forward flexion from June 16, 2014 to December 29, 2014 the Board finds a 20 percent disability rating is warranted a disability rating in excess of 20 percent is not warranted. The evidence does not demonstrate that the Veteran's flexion was limited 15 degrees. The worst level of flexion is noted in the Veteran's August 2014 private treatment records was 30 degrees. As such a higher disability rating is not warranted. The Board takes into account the June 2014 VA examiner's finding that the Veteran's range of motion would be significantly worse during a flare-up and therefore grants a 20 percent disability rating from the June 2014 rating decision. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to right knee pain with prolonged walking, standing, bending of the right knee, use of stairs, and pain during repetitive use over time. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation would not result in symptoms more nearly approximating any limitation of motion to 30 degrees of flexion, prior to June 16, 2014 or in limitation of 15 degrees in thereafter. As noted above the June 2014 VA examiner noted that during a flare-up the Veteran's range of motion would be significantly be limited during a flare-up and the Board had increased the Veteran's disability rating based on that assumption. It is possible that the Veteran's knee flexion could be more severe thereby allowing for a higher rating for flexion. However, from June 16, 2014, the Veteran's right knee disability combines to a total of disability rating of 60 percent. Because such a rating would exceed the maximum 60 percent allowable under the "amputation rule." See 38 C.F.R. § 4.25, 4.68, 4.71a, Diagnostic Codes 5162 to 5164. Under the "amputation rules" the combined rating for disabilities of an extremity may not exceed the rating for the amputation at the elective level, were the amputation to be performed. 38 C.F.R. § 4.68. As 60 percent is the maximum disability rating the Veteran can receive under the amputation rule for a knee disability, no higher disability rating is available. Therefore, despite the possibility of a higher disability rating for his loss of range of motion during a flare-up a higher rating would not be available. In summary, the Board finds that June 30, 2009 to April 13, 2012 a disability rating in excess of 20 percent is denied, and a disability rating of 30 percent from April 14, 2012 to December 28, 2014 is granted for the Veteran's right knee instability. A separate 20 percent disability rating from April 14, 2011 to December 28, 2014 for right knee semilunar cartilage dysfunction is granted. A disability rating in excess of 10 percent from June 30, 2009 to June 15, 2014 for loss of range of motion for the right knee is denied. A disability rating of 20 percent from June 16, 2014 to August 25, 2014 for the loss of flexion in the right knee is granted. Finally, from August 26, 2014 to December 28, 2014 a disability rating in excess of 20 percent for loss flexion in the right knee is denied. 2. Knee Disability from February 1, 2016 From February 1, 2016, the Veteran has a disability rating of 60 percent for his right knee status post total replacement under Diagnostic Code 5055. Prior to February 7, 2021, Diagnostic Code 5055 allows for rating residuals of knee replacement by analogy to Diagnostic Codes 5256 (ankylosis), 5261 (limitation of extension), and 5262 (impairment of the tibia and fibula) below the 60 percent level, it does not allow for the application of analogous ratings if the requirements for a 60 percent rating have been satisfied. To the contrary, at that point, and beyond the first year after surgery, the Diagnostic Code simply provides for a single 60-percent rating that contemplates chronic residuals consisting of severe painful motion or weakness in the affected extremity. This is consistent with the amputation rule, as noted below, which allows for a maximum rating of 60 percent for disabilities affecting the middle and lower thirds of a lower extremity. See 38 C.F.R. §§ 4.68, 4.71a, DCs 5160-5164. Simply put, prior to February 7, 2021, Diagnostic Code 5055 does not allow for a schedular rating in excess of 60 percent beyond the one-year period following implantation of prosthesis, by analogy or otherwise. From February 7, 2021, the Board notes that under the new rating criteria, Diagnostic Code 5055 provides a 100 percent rating for the four months following implantation of a knee prosthesis for a service-connected knee disability. Thereafter, the rating criteria remains the same with the exception that a separate evaluation for resurfacing after the conclusion of the 100 percent evaluation period may be warranted. Here, there is no evidence the Veteran's left knee has undergone resurfacing since his total left knee replacement. Thus, as it pertains to this specific Veteran, the old and new rating criteria are the same. The Veteran's medical records are notable for right knee replacement surgery in December 2014. As noted above, the RO assigned a 30 percent disability rating under Diagnostic Code 5055, for the right knee disability from February 1, 2016. In the July 2020 rating decision, the RO granted a 60 percent disability rating from February 1, 2016 consistent with the December 2019 VA examination. As noted, former Diagnostic Code 5055 does not provide for a schedular rating in excess of 60 percent, other than a 100 percent rating for the one-year period following implantation of a prosthesis. Therefore, there is no basis in the law for awarding a schedular rating in excess of 60 percent for the disability. Additionally, a disability rating greater than 60 percent is not available for the Veteran's right knee, including the associated scar, because such a rating would exceed the maximum 60 percent allowable under the "amputation rule." See 38 C.F.R. § 4.25, 4.68, 4.71a, Diagnostic Codes 5162 to 5164. Under the "amputation rules" the combined rating for disabilities of an extremity may not exceed the rating for the amputation at the elective level, were the amputation to be performed. 38 C.F.R. § 4.68. As 60 percent is the maximum disability rating the Veteran can receive under the amputation rule for a knee disability, no higher disability rating is available and a discussion of ratings under other potentially applicable Diagnostic Codes is not warranted. (Continued on the next page) The Board therefore finds that the criteria for a higher rating for the Veteran's status-post total right knee replacement have not been met at any time during the rating period. As a preponderance of the evidence is against the assignment of a higher rating, the benefit-of-the-doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. at 49. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert Batten 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.