Citation Nr: 21076612 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 09-36 192 DATE: December 27, 2021 ORDER 1. Entitlement to service connection for right foot pes planus and arthritis, claimed as a right lower extremity disability and to include as secondary to a service-connected right knee disability, is granted. 2. Entitlement to service connection for left foot pes planus and arthritis, claimed as a left lower extremity disability and to include as secondary to a service-connected right knee disability, is granted. 3. Entitlement to service connection for a left ankle disability, claimed as a left lower extremity disability and to include as secondary to a service-connected right knee disability, is granted. 4. Entitlement to a rating in excess of 10 percent prior to December 14, 2015, in excess of 20 percent from December 14, 2015 to January 24, 2017, and in excess of 30 percent from January 25, 2017, for subluxation and unstable right knee with old partial medial collateral ligament (MCL) tear (right knee instability) is denied. 5. Entitlement to a rating in excess of 10 percent for osteoarthritis of the right knee is denied. REMANDED 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The right foot pes planus and arthritis is proximately due to or aggravated beyond its natural progression by the service-connected right knee disability. 2. The left foot pes planus and arthritis is proximately due to or aggravated beyond its natural progression by the service-connected right knee disability. 3. The left ankle disability, diagnosed as degenerative arthritis, is proximately due to or aggravated beyond its natural progression by the service-connected right knee disability. 4. For the period prior to December 14, 2015 to January 25, 2017, the preponderance of the evidence is against finding that the right knee instability manifested with moderate instability. 5. From December 14, 2015 to January 25, 2017, the preponderance of the evidence is against finding that the right knee instability manifested with severe instability. 6. From January 25, 2017 right knee instability is in receipt of the highest available rating throughout the relevant appeal period. 7. Throughout the period on appeal, the right knee disability was not manifested by ankylosis, a semilunar cartilage condition, flexion functionally limited to 30 degrees or less, extension functionally limited to 10 degrees or more, an impairment of the tibia and fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for service connection for right foot pes planus and arthritis, identified as a right lower extremity disability, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for left foot pes planus and arthritis, identified as a left lower extremity disability, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for a left ankle disability, identified as a left lower extremity disability, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for an increased rating in excess of 10 percent prior to December 14, 2015, in excess of 20 percent from December 14, 2015 to January 24, 2017, and in excess of 30 percent from January 25, 2017, for subluxation and unstable right knee with old partial medial collateral ligament (MCL) tear with right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 5. The criteria for an increased rating in excess of 10 percent for a right knee disability, due to osteoarthritis and limitation of flexion, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1975 to May 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from February 2009 and May 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board remanded these matters in September 2017 and October 2020 for additional development. In consideration of the appeal, the Board is satisfied there was substantial compliance with the remand directives and will proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection 1. Entitlement to service connection for right foot pes planus and arthritis, identified as a right lower extremity disability and to include as secondary to a service-connected right knee disability 2. Entitlement to service connection for left foot pes planus and arthritis identified as a left lower extremity disability and to include as secondary to a service-connected right knee disability 3. Entitlement to service connection for a left ankle disability, identified as a left lower extremity disability and to include as secondary to a service-connected right knee disability Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). The Veteran contends that his current bilateral foot conditions and left ankle disability are related to his military service, due to marching in cold weather and stress. The Veteran also asserts that his current bilateral foot disabilities and left ankle disability are caused and/or aggravated by his service-connected right knee condition. The medical evidence shows current diagnoses of metatarsalgia of the right foot and hallux valgus of both feet, as evidenced by January 2017 and November 2017 VA examinations. Additionally, a February 2021 VA examination notes diagnoses of arthritis and pes planus of both feet. The Veteran was also diagnosed with degenerative arthritis with some limitation of motion of the left ankle at a January 2021 VA examination. Service treatment records are silent for any complaints of, or treatment for, a foot or ankle disability. However, in February 2021, the VA examiner opined that the Veteran's claimed bilateral foot and bilateral ankle disabilities were more likely than not incurred in or caused by the service-connected right knee disability service due to the shift in weightbearing and pressure/stress points. The February 2021 VA examination shows that the Veteran has current bilateral foot disabilities of osteoarthritis and pes planus and a current left ankle disability, diagnosed as degenerative arthritis, and the February 2021 VA examiner opined that these disabilities were at least as likely as not aggravated beyond their natural progress by his service-connected right knee disability. Thus, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current arthritis and pes planus of the bilateral feet and degenerative arthritis of the left ankle are proximately due to and/or aggravated beyond the natural progression by the service-connected right knee disability. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for bilateral arthritis and pes planus and left ankle degenerative arthritis is granted. Increased Rating Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2018). The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. Diagnostic codes provide rating criteria specific to a particular disability. If two diagnostic codes are applicable to the same disability, the diagnostic code that allows for the higher disability rating applies. See 38 C.F.R. § 4.7 (2018). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. See id. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding under 38 C.F.R. § 4.14 do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Additionally, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable diagnostic code. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Post-traumatic arthritis is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are two or more joints affected, each rating shall be combined in accordance with §4.25. Diagnostic Code 5010. The Board notes that the February 7, 2021 amendment did not substantively change the rating criteria for Diagnostic Code 5010, but rather, provided a more medically accurate description of the disability. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76459 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5010). Diagnostic Code 5256 provides a rating for ankylosis of the knee. A rating of 60 percent is warranted for extremely unfavorable, in flexion at an angle of 45 degrees or more. A rating of 50 percent is warranted when flexion between 20 degrees and 45 degrees is present. A 40 percent rating is assigned when flexion between 10 degrees and 20 degrees is present. A 30 percent rating is warranted when favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees is shown. Diagnostic Code 5260 provides a noncompensable rating when flexion is limited to 60 degrees or more. A 10 percent rating is warranted for leg flexion limited to 45 degrees. A 20 percent evaluation is for leg flexion limited to 30 degrees. A 30 percent evaluation is for leg flexion limited to 15 degrees. Diagnostic Code 5261 provides a noncompensable rating when extension is limited to 5 degrees or less. A 10 percent rating is warranted for leg extension limited to 10 degrees. A 20 percent evaluation is for leg extension limited to 15 degrees. A 30 percent evaluation is for leg extension limited to 20 degrees. A 40 percent evaluation is for leg extension limited to 30 degrees. A 50 percent evaluation is for leg extension limited to 45 degrees. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a. For VA purposes, "normal" extension and flexion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71a, Plate II. The Board notes that separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code (Diagnostic Code 5257), without violating the prohibition on pyramiding. Diagnostic Code 5257 is predicated on instability, rather than limitation of motion, therefore, an analysis under DeLuca does not apply. See Johnson v. Brown, 9 Vet. App. 7 (1996). Diagnostic Code 5257 contemplates "other impairment" of the knee including recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where impairment is severe, moderate, or slight, disability evaluations of 30, 20, and 10 percent are assigned, respectively. 38 C.F.R. § 4.71a. The words "slight," "moderate," "severe," and "marked" as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for "equitable and just" decisions. 38 C.F.R. § 4.6. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities, including Diagnostic Code 5257, under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. 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. From February 7, 2021, Diagnostic Code 5257 was amended to separate recurrent subluxation or lateral instability from patellar instability. With recurrent subluxation or lateral instability, a 10 percent rating is assigned for a 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 warranted for one or more of the following: (a) 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) an 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 warranted for unrepaired or failed repair of a 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. With patellar instability, 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. 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 with one of the following: a brace, cane, or walker. 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. Note 1 clarifies that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note 2 clarifies that 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). Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76473 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). A rating of 20 percent under Diagnostic Code 5258 requires cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. A rating of 10 percent under Diagnostic Code 5259 requires the removal of semilunar cartilage, symptomatic. A rating under Diagnostic Code 5262 provides that impairment of the tibia and fibula characterized by malunion with slight knee or ankle disability warrants a 10 percent evaluation, malunion with moderate knee or ankle disability warrants a 20 percent evaluation, and malunion with marked knee or ankle disability warrants a 30 percent rating. Impairment of the tibia and fibula manifested by nonunion with loose motion, requiring a brace, warrants a maximum 40 percent rating. Diagnostic Code 5263 assigns a 10 percent rating for genu recurvatum (acquired, traumatic, with weakness and insecurity in weightbearing objectively demonstrated). In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). 4. Entitlement to a disability rating in excess of 10 percent prior to December 14, 2015, in excess of 20 percent from December 14, 2015 to January 24, 2017, and in excess of 30 percent from January 25, 2017, for subluxation and unstable right knee with old partial medial collateral ligament (MCL) tear. The Veteran seeks an increased rating for his right knee instability, which is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257. As noted above, prior to February 2021, instability of the knee was rated under Diagnostic Code 5257 based upon the severity of the disability, slight moderate, or severe. According to Merriam Webster's Collegiate Dictionary (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. (a) Prior to December 14, 2015 The Veteran contends that he is entitled to a rating in excess of 10 percent for his right knee disability prior to December 14, 2015. The Veteran was afforded a VA examination in December 2008. The examiner confirmed a diagnosis for degenerative joint disease since 1973. The Veteran stated that he had knee pain, weakness, and guarding of movement. The examiner documented that the Veteran did not experience flare-ups. The Veteran exhibited 0 to 120 degrees of flexion and 0 degrees of extension. Repetitive use testing (with at least three repetitions) showed no change in flexion or extension, compared to the initial range of motion. There was no evidence or history of recurrent patellar subluxation or dislocation. The examination did not document ankylosis, or a history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that a brace and/or assistive device (e.g., cane(s), crutch(es), walker) was not used for ambulation. The Veteran was afforded another VA examination in November 2009. The Veteran stated that he had knee pain, at rest and when ambulating, and swelling in the right knee. The examiner documented the Veteran did not experience flare-ups. The Veteran exhibited 5 to 120 degrees of flexion and -5 degrees of extension. The examiner noted mild medial instability at 30 degrees. Repetitive use testing (with at least three repetitions) showed no change in flexion or extension, compared to the initial range of motion. There was no evidence or history of recurrent patellar subluxation or dislocation. The examination did not document ankylosis, or a history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that a brace and/or assistive device (e.g., cane(s), crutch(es), walker) was not used for ambulation. The Veteran was afforded a VA examination in February 2011. The Veteran stated that he had knee pain, stiffness, chronic swelling, and painful "clicking and popping." The Veteran did not report flare-ups that were incapacitating. The Veteran exhibited 0 to 120 degrees of flexion, with complaints of pain from 90 to 120 degrees, and 0 degrees of extension. The examiner noted medial instability. There was no evidence or history of recurrent patellar subluxation or dislocation. The examination did not document ankylosis, or a history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that a brace was used for ambulation. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for subluxation and unstable right knee with old partial medial collateral ligament (MCL) tear disability. The Board has carefully considered the Veteran's reports about instability. However, overall, the lay and medical evidence indicates that the instability symptoms have been mild and do not suggest the presence of symptoms more nearly approximating moderate severity. At the December 2008 VA examination, the examiner specifically documented that the Veteran did not have objective evidence of instability. The November 2009 VA examination specifically documented only mild medial instability. Finally, at the February 2011 VA examination, though the examiner documented a fair amount of instability to valgus stress, the examiner also documented that muscle strength was normal, and there was no anterior or posterior instability, nor was there instability with varus stress. Thus, the Board finds the 10 percent rating currently assigned adequately address the instability to valgus stress given that the Veteran does not have more severe instability impacting the knee on varus stress or anteriorly or posteriorly. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Here, a separate rating under Diagnostic Code 5260 has been granted for limitation of flexion of the right knee. This is discussed in more detail below. A rating under Diagnostic Code 5256 is not for application in this case because the evidence of record is against a finding of ankylosis. Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland's Illustrated Medical Dictionary (28th Ed. 1994) at 86). The clinical evidence reflects that the Veteran's right knee was negative for ankylosis of the joint. Thus, a rating under Diagnostic Code 5256 is not warranted. With respect to Diagnostic Code 5259, the record during the period on appeal does not document evidence of any semilunar cartilage condition. Therefore, Diagnostic Code 5259 does not apply. A rating under Diagnostic Code 5261 is not for application because the evidence of record is against a finding that the limitation of motion of the right knee equates to limitation of extension of the leg to 0 to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The VA examination reports show that the Veteran had 0 degrees of extension, which is greater than that required for a separate compensable rating, even with consideration of any functional impairment. 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 202. Additionally, the evidence documents that the Veteran's right knee extension has not been limited. VA examinations document extension to 0 degrees throughout the period on appeal. Furthermore, a rating under Diagnostic Code 5262 is not warranted because the evidence does not reflect that the Veteran has malunion or nonunion of the tibia and fibula. Similarly, a rating under Diagnostic Code 5263 is not warranted because the evidence does not show that he had exhibited genu recurvatum at any point during the appeal period. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent, for the period prior to December 14, 2015, for subluxation and unstable right knee with old partial medial collateral ligament (MCL) tear. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. (b) From December 14, 2015 to January 24, 2017 The Veteran contends that he is entitled to a rating in excess of 20 percent for his right knee instability from December 14, 2015 to January 24, 2017. The Veteran was afforded a VA knee examination in December 2015. The Veteran stated that he had knee pain and that his knee "gives way repeatedly" with increased pain with walking, standing, and climbing stairs. The Veteran denied flare-ups. The Veteran exhibited 0 to 110 degrees of flexion and 0 degrees of extension. The examiner noted pain on weightbearing, tenderness to palpation, and evidence of crepitus. Repetitive use testing (with at least three repetitions) showed no change in flexion or extension when compared to the initial range of motion. There was no evidence or history of recurrent patellar subluxation or dislocation. The examiner noted normal findings for anterior instability (Lachman test), posterior instability (Posterior drawer test), and lateral instability. Medial instability of 5-10 millimeters at 30 degrees was documented. The examination did not indicate ankylosis, or a history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that a brace was used constantly for ambulation. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for right knee instability during this period on appeal. The Board has carefully considered the Veteran's reports about instability. However, overall, the lay and medical evidence indicates that the instability symptoms have varied and do not suggest the presence of symptoms more nearly approximating severe recurrent subluxation or lateral instability. Rather, the medical evidence, to include VA treatment records and a VA examination, does not suggest severe instability, as shown with normal findings for anterior instability (Lachman test), posterior instability (Posterior drawer test) and lateral instability. Further, the examiner documented medial instability of 5-10 millimeters at 30 degrees, rather than the more severe 10-15 millimeters. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The evidence does not show a dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, and thus, a rating under Diagnostic Code 5258 is not warranted. With respect to Diagnostic Code 5259, the record during the period on appeal does not contain any evidence of any semilunar cartilage condition. Therefore, Diagnostic Code 5259 does not apply. As the Veteran has not experienced ankylosis of his right knee, impairment of his tibia or fibula, medial tibial stress syndrome or shin splints, or genu recurvatum, the associated diagnostic codes, Diagnostic Codes 5256, 5262, and 5263, do not apply. Additionally, the evidence suggests that the Veteran's right knee extension has not been limited. VA examinations document extension to 0 degrees throughout the appeals period. As such, a separate rating under Diagnostic Code 5261 is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent, for the period from December 14, 2015 to January 25, 2017 for right knee instability, and the appeal is denied. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. (c) From January 25, 2017 The Veteran was afforded a VA knee examination in January 2017. The Veteran reported constant pain, made worse with prolonged standing and walking, as well as swelling, recently falling, and feeling as though the knee will "fall out of place" while driving. The examiner documented that the Veteran did report flare-ups but only documented symptoms of flare-ups in the left knee. The Veteran exhibited 0 to 110 degrees of flexion and 0 degrees of extension. The examiner noted pain on weightbearing and evidence of crepitus. Repetitive use testing (with at least three repetitions) showed no change in flexion or extension, compared to the initial range of motion. There was no evidence or history of recurrent patellar subluxation or dislocation. The examiner noted normal findings for anterior instability (Lachman test) and posterior instability (Posterior drawer test). The examiner documented slight lateral instability and medial instability was documented as 5-10 millimeters at 30 degrees, rather than the more severe 10-15 millimeters. The examiner did not document ankylosis or a history of recurrent subluxation or lateral instability but did note recurrent effusion. The examiner noted that an assistive device was not used for ambulation. The Veteran was afforded a VA knee examination in November 2017. The Veteran stated that he had worsening pain, looseness, and decreased mobility, including poor balance and nearly falling. The examiner documented that the Veteran did report severe flare-ups occurring two to three times per week. The Veteran exhibited 0 to 110 degrees of flexion and 0 degrees of extension. The examiner noted pain on weightbearing, tenderness to palpation, and evidence of crepitus. Repetitive use testing (with at least three repetitions) showed no change in flexion or extension, compared to the initial range of motion. There was no evidence or history of recurrent patellar subluxation or dislocation. The examiner noted normal findings for anterior instability (Lachman test), posterior instability (Posterior drawer test) and lateral instability. Medial instability of 0-5 millimeters at 30 degrees, rather than the more severe 10-15 millimeters, was documented. The examination did not document ankylosis or a history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that a brace was used occasionally for ambulation. The Veteran was afforded a final VA knee examination in March 2021. The Veteran reported that he experienced pain, decreased range of motion, and a decrease in strength in his right knee. The examiner documented that the Veteran reported daily flare-ups caused by activity and the weather that caused difficulty in walking or standing for longer periods of time. The Veteran did not report instability in the right knee. The Veteran exhibited flexion to 110 degrees and 0 degrees of extension. The examiner noted pain on weightbearing, tenderness to palpation, and evidence of crepitus. Repetitive use testing (with at least three repetitions) showed no change in flexion or extension, compared to the initial range of motion. The Veteran described 0 to 105 degrees of flexion and 0 degrees of extension during flare-ups. There was no evidence or history of recurrent patellar subluxation or dislocation or muscle atrophy. The examiner did not document ankylosis or a history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that a brace was used constantly for ambulation. However, the examiner did not find that any supportive device had been prescribed by a physician. The Board has carefully reviewed the evidence of records, but as the Veteran is already in receipt of the highest schedular rating for other impairment of the knee, there is no basis to award a higher evaluation under Diagnostic Code 5257. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. However, the evidence shows that the Veteran reported that his knee did not give out and no other evidence reflects evidence of locking or giving way. Therefore, a separate rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint under Diagnostic Code 5258 is not warranted. With respect to Diagnostic Code 5259, the record during the period on appeal does not contain any evidence of any semilunar cartilage condition; therefore, Diagnostic Code 5259 does not apply. As the Veteran has not experienced ankylosis of his right knee, impairment of his tibia or fibula, medial tibial stress syndrome or shin splints, or genu recurvatum, Diagnostic Codes 5256, 5262, and 5263 do not apply. Additionally, the evidence documents that the Veteran's right knee extension has not been limited. VA examinations document extension to 0 degrees throughout the appeals period. As such, a separate rating under Diagnostic Code 5261 is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent, for the period from January 25, 2017 and thereafter for right knee instability is denied. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 5. Entitlement to a disability rating in excess of 10 percent for osteoarthritis of the right knee. The Veteran contends that he is entitled to a higher rating because his right knee condition has worsened in severity since his previous evaluation. The Veteran's right knee osteoarthritis is currently rated under Diagnostic Code 5010-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Based on the evidence of record, as discussed above, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for osteoarthritis of the right knee with limitation in flexion. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that the Veteran has limitations upon walking, standing, and climbing stairs, as well as constant pain and flare-ups would not result in limitation of motion more nearly approximating flexion limited to 30 degrees, as required for the higher 20 percent rating. The Board also considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of the right knee joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, the Veteran consistently complained of pain and tenderness of the right knee. However, the VA examinations reflect that, despite these complaints, the Veteran still demonstrated range of right knee motion, of, at worst, 105 degrees of flexion in January 2017, December 2017, and February 2021, respectively. In addition, he was consistently able to complete repetitive motion testing at all three examinations without any additional loss of range of motion. Pain, weakness, etc., were not shown to otherwise limit the range of motion in the Veteran's right knee such that a high disability rating would be warranted at any time. Thus, the Board finds the 10 percent rating currently assigned adequately reflects these limitations. The Board has also considered the other Diagnostic Codes pertaining to the knee. However, as fully assessed above, separate ratings under other diagnostic codes for the entirety of the period on appeal are denied. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the Veteran's osteoarthritis of the right knee. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to TDIU is remanded. The record as presently developed does not include sufficient evidence upon which to adjudicate the Veteran's TDIU claim. Namely, no disability evaluations have been assigned to the now service-connected right and left foot disabilities, granted herein, since the Board does not assign disability ratings or effective dates in the first instance. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Therefore, it must be remanded to the AOJ for readjudication after the AOJ assigns the proper disability rating and effective date for the grant of service connection for right and left foot disabilities and the left ankle disability. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, adjudication of the TDIU claim will be held in abeyance pending the assignments of both a disability rating and effective date for now service-connected right and left foot disabilities and left ankle disability. The matters are REMANDED for the following action: Upon effectuating the grants of service connection for the for right and left foot disabilities and the left ankle disability, readjudicate the Veteran's TDIU claim based on a review of the entire evidentiary record. A. KENINGER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael J. O'Connor, 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.