Citation Nr: 21076814 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 10-21 181 DATE: December 27, 2021 ORDER A rating in excess of 10 percent for left knee patellofemoral syndrome (left knee disability) from September 1, 2010 based upon limitation of flexion is denied. A compensable rating for left knee disability based upon limitation of extension from September 1, 2010 to May 30, 2017 is denied. A rating in excess of 10 percent for left knee disability based upon limitation of extension from May 30, 2017 to December 28, 2020 is denied. A rating in excess of 20 percent for left knee disability based upon limitation of extension from December 28, 2020 to June 3, 2021 is denied. A 50 percent rating for left knee disability based upon limitation of extension is granted from June 3, 2021, subject to the law and regulations governing the award of monetary benefits. FINDINGS OF FACT 1. The Veteran's left knee has been manifested by pain throughout the pendency of this case. 2. From September 1, 2010 the Veteran's left knee has not been manifested by flexion limited to 30 degrees or less to include with repeated use over time and/or during flare-ups. 3. From September 1, 2010 to May 30, 2017, the Veteran's left knee was not manifested by extension limited to 10 degrees or more to include with repeated use over time and/or during flare-ups. 4. From May 30, 2017 to December 28, 2020, the Veteran's left knee was not manifested by extension limited to 15 degrees or more to include with repeated use over time and/or during flare-ups. 5. From December 28, 2020 to June 3, 2021, the Veteran's left knee was not manifested by extension limited to 20 degrees or more to include with repeated use over time and/or during flare-ups. 6. From June 3, 2021, the Veteran's left knee has extension limited to more than 45 degrees. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for service-connected left knee disability based upon limitation of flexion from September 1, 2010 have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 2. The criteria for a compensable rating for service-connected left knee based upon limitation of extension from September 1, 2010 to May 30, 2017 have not been met. to include with repeated use over time and/or during flare-ups. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2020). 3. The criteria for a rating in excess of 10 percent for service-connected left knee disability based upon limitation of extension from May 30, 2017 to December 28, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 4. The criteria for a rating in excess of 20 percent for service-connected left knee disability based upon limitation of extension from December 28, 2020 to June 3, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 5. The criteria for a rating of 50 percent for service-connected left knee disability based upon limitation of extension are met from June 3, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from March 1991 to June 1995. This matter is before the Board of Veterans' Appeals (Board) originally on appeal from a January 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied a rating in excess of 10 percent for the service-connected left knee disability. This case was previously before the Board in February 2015, April 2016, May 2017, and October 2018. In a February 2015 decision, the Board denied a rating in excess of 10 percent for the service-connected left knee disability. The Veteran appealed the Board's February 2015 decision to the United States Court of Appeals of Veterans Claims (Court). By a February 2016 Order, the Court, pursuant to a joint motion for partial remand (JMPR), vacated that portion of the Board's February 2015 decision which denied a rating in excess of 10 percent for service-connected left knee disability from September 1, 2010, pursuant to Diagnostic Codes 5260 and 5261. The Court dismissed the appeal of the issue of entitlement to a rating in excess of 10 percent for a left knee disability prior to September 1, 2010, and the issue of entitlement to a rating in excess of 10 percent for the left knee disability under an alternative diagnostic code, including Diagnostic Codes 5256, 5257, 5258, 5262, or 5263. In April 2016 and May 2017, the Board remanded the claims for additional development. While the matter was in remand status, the RO, in an August 2017 rating decision, assigned a separate 10 percent rating for limitation of extension of the left knee, effective May 30, 2017. In October 2018, the Board again remanded the Veteran's left knee claims for additional development, to include a new examination which provided an opinion as to the extent of limitation of motion during flare-ups. Such an examination and opinion was accomplished in a December 2020 examination, VA medical opinions in March 2021 and April 2021, and in a September 202 VA examination. For the reasons discussed in greater detail below the Board finds the findings and opinions expressed for limitation of motion of the left knee during such are adequate for resolution of this case. Accordingly, there has been at least substantial compliance with the Board's remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). During the period this case was last on remand, the RO issued a rating decision in April 2021 that assigned a 20 percent rating for limitation of extension of the left knee effective December 28, 2020. As an additional matter, the Board notes that new and additional evidence and medical records were added to the Veteran's claims folder after the case was last adjudicated below via an April 2021 Supplemental Statement of the Case (SSOC). The Veteran waived initial consideration of such evidence by the agency of original jurisdiction (AOJ) in September 2021. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. Pursuant to the terms of the JMPR which was the basis for the Court's February 2016 Order, the adjudication of this appeal is based upon Diagnostic Code 5260 (limitation of flexion) and 5261 (limitation of extension). In VAOPGCPREC 9-2004 VA's Office of General Counsel held in that separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same joint. The Board notes that full range of motion of the knee consists of 0 degrees extension and 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. The law mandates resolving any reasonable doubt regarding the degree of disability in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If different disability ratings are warranted for different periods of time over the life of a claim, "staged" ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). As discussed in the Introduction, the Veteran has already been assigned such "staged" ratings for his left knee in this case. The Veteran's left knee has been manifested by complaints of pain throughout the pendency of this case, and resulting functional impairment such as limitation of motion. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated by the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). The Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that significant changes were made to the criteria for evaluating orthopedic disabilities under 38 C.F.R. § 4.71a, effective February 7, 2021. See 85 Fed. Reg. 76460 (Feb 7, 2021). However, no changes were made to Diagnostic Codes 5260 and 5261 which are the focus of this appeal. The Board further notes that in its prior decision of February 2015, it addressed whether an extraschedular rating was warranted for the left knee pursuant to 38 C.F.R. § 3.321(b)(1). The Court has set out a three-part test, based on the language of these regulator provisions, for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). As noted, the JMPR limited the present appeal to the limitation of motion of the left knee, which is explicitly addressed by the schedular criteria. Accordingly, consideration of an extraschedular rating is not warranted in this case. 1. Entitlement to a rating in excess of 10 percent for service-connected left knee patellofemoral syndrome based upon limitation of flexion from September 1, 2010 Diagnostic Code 5260 provides for limitation of flexion of the leg. Where flexion is limited to 60 degrees, a noncompensable (zero percent) rating is provided; when flexion is limited to 45 degrees, 10 percent is assigned; when flexion is limited to 30 degrees, 20 percent is assigned; and when flexion is limited to 15 degrees, 30 percent is assigned. 38 C.F.R. § 4.71a. During the pendency of this appeal from September 1, 2010 the Veteran has had limitation of flexion, as well as flare-ups of pain. Nevertheless, at no point has it been demonstrated his left knee would have flexion limited to 30 degrees or less to include with repeated use over time or during flare-ups. In pertinent part, the Veteran reported daily throbbing pain at a September 2010 VA examination that he described as 7/10. He also reported a pulling sensation and infrequent swelling. He reported difficulty getting up from a squatting position; as well as with prolonged walking, standing, driving, and going up stairs. In addition, he reported he did have a brace, but it did not help. On physical examination, he had flexion to 135 degrees with end of range pain, and it was not additionally limited following repetitive use. An August 2012 VA examination noted the left knee had flexion to 120 degrees, with pain throughout range of motion. At a September 2014 VA examination, the Veteran reported daily knee pain, worse at night. He also reported that his knees get hot, and that he was not able to kneel on his left side. Further, he reported that when he stands his knees click and pop. He reported flare-ups, during which it was hard to walk or do anything. On physical examination, his left knee had flexion to 100 degrees with pain beginning at 60 degrees. There was no change after repetitive-use testing. At a March 2016 VA examination, the Veteran reported pain and popping of both knees, left worse than the right. He reported prolonged standing or walking, and climbing stairs, made the pain worse. He also indicated he could not run, kneel, or squat due to his knees. On range of motion testing, he had flexion to 90 degrees. There was pain with weight bearing. There was no additional loss of motion after repetitive use testing. The examiner also stated that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repeated use over time nor flare-ups. At an October 2016 VA examination, the Veteran reported he had knee pain all the time, which varied from a dull pain to a sharp pain depending on the activities. Further, the knee pain was aggravated by prolonged standing, walking and climbing stairs which are all tasks that were required at work. If he was driving a long distance, his knee will start to ache. Daily pain was rated as 8/10. He reported flare-up if he squats, and he was unable to get back up due to severe pain. Additionally, stepping down on the knee (i.e., a curb) caused sudden increase in pain. Flare ups were rated as 10/10 with duration up to 4 hours. On range of motion testing, the left knee had flexion to 40 degrees. There was pain with weight bearing. There was no change with repetitive-use testing. As with the March 2016 VA examination, the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repeated use over time nor flare-ups. At a May 2017 VA examination, the Veteran reported a gradual onset of increasing knee pain in 1992. He reported the left knee pops all the time, the pain wakes him at night, and the pain was constant. He also reported difficulties with prolonged walking, standing, sitting, squatting, lifting and climbing. On range of motion testing, the left knee had flexion to 75 degrees. There was no change with repetitive use testing. The examiner stated the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repeated use over time nor flare-ups. Further, the examiner stated he could not estimate the additional limitation during repeated use over time or flare-ups without resort to speculation. In addition, it was noted that passive motion was the same as active motion; and there was no evidence of pain in weight bearing nor non-weight bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). At an October 2017 VA examination, the Veteran reported increased pain and discomfort in his knees; as well as difficulty standing, sitting, climbing stairs, and getting comfortable in the evening when sleeping. On range of motion testing, the left knee had flexion to 70 degrees. There was no additional limitation following repetitive-use testing. Further, the examiner stated the examination was medically consistent with the Veteran's statements describing functional loss with repeated use over time and flare-ups. However, the examiner stated he could not estimate the extent of additional loss of motion during such in terms of degrees without resort to speculation. Passive motion was the same as active motion. In addition, there was pain in weight bearing and non-weight bearing. The Board acknowledges that the JMPR which was the basis for the Court's February 2016 Order in this case essentially contended the VA examinations at that point of the appeal did not adequately address the extent of additional limitation of motion during flare-ups. Similarly, the Board found that the May 2017 and October 2017 VA examinations were inadequate to the extent they did not provide an adequate explanation as to why any additional limitation of motion during a flare-up could not be quantified in degrees. However, there is no finding that the initial range of motion findings on these examinations were inadequate. Further, as discussed below opinions were provided regarding the extent of additional limitation of motion based, at least in part, on the information and findings contained in these examinations. At an August 2019 VA examination the Veteran reported knee pain was 9/10, dull ache pain. He was unable to get comfortable. He also reported flare-ups 2 to 3 times per week where his knees lock, and the pain increases. However, he described the severity as moderate, and that it lasted a few minutes. On range of motion testing the left knee had flexion to 90 degrees, with no change after repetitive use testing. The examiner stated the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repeated use over time nor flare-ups. Moreover, the examiner stated he had no basis to offer additional losses of function or motion during repeated use over time or during a flare-up. The examiner also stated there was no objective evidence of left knee pain in weight bearing, but there was in non-weight bearing and passive motion. At a December 2020 VA examination, the Veteran reported his current symptoms consisted of pain, stiffness, and falls. He also reported flare-ups of the left knee during which he experienced increased pain, and could not get comfortable. Further, he reported the flare-ups occurred 3 to 4 times per week, during which the severity was sever, and lasted from 30 minutes to 1 hour. On range of motion testing, the left knee had initial flexion to 100 degrees which was additionally limited to 95 degrees after repetitive-use testing. Moreover, the examiner stated the examination was medically consistent with the Veteran's statements describing functional loss with repeated use over time and flare-ups; and estimated flexion would be to 95 degrees during such. In addition, there was objective evidence of left knee pain in weight bearing, non-weight bearing, and passive motion. The March 2021 VA medical opinion based upon review of the record, another VA examiner opined that the additional loss of flexion during flare-ups would be to 130 degrees at the time of the 2010 VA examination; 90 degrees at 2014 VA examination; 60 degrees at the 2014 VA examination; 65 degrees at the 2017 VA examination; and 80 degrees at the 2019 VA examination. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, the examiner did not specify which of the 2016 or 2017 VA examinations these estimates were in reference to, nor was an opinion expressed regarding the August 2012 VA examination. In a subsequent April 2021 VA medical opinion, the same VA examiner estimated that at the time of the August 2012 VA examination the Veteran would have flexion during flare-ups to 90 degrees; 60 degrees for both the March and October 2016 VA examinations, and 65 degrees at the time of both the May and October 2017 VA examinations. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Here, the Board notes the Veteran has not challenged the qualifications of the VA examiner who provided the March 2021 and April 2021 opinions. The examiner was familiar with the medical history of his left knee from review of the claims folder, and specifically noted the opinions were in reference to the aforementioned VA examinations. Further, the examiner's opinions regarding the extent of additional limitation of motion during flare-ups was not expressed in speculative or equivocal language. The Board acknowledges that the Veteran's representative asserted in a July 2021 statement that the examiner did not specify the mechanism used for ascertaining the estimates he retrospective opinions. However, the examiner did indicate that these estimates were based upon the findings and information contained in the examinations themselves. Moreover, he has not provided any evidence which demonstrates he would have greater limitation of motion in terms of degrees than that which was provided in the March 2021 and April 2021 opinions. As such, the Board finds the examiner had sufficient rationale in support of these opinions. In light of the foregoing, the Board finds that the March 2021 and April 2021 opinions regarding estimated loss of motion during flare-ups are adequate for resolution of this case. The Board further notes the Veteran reported constant knee pain at a June 2021 VA examination. On range of motion testing, the left knee had flexion to 80 degrees. Passive motion was the same as active motion. Pain was noted in active motion, weight bearing, and non-weight bearing; but it was indicated not in passive motion. Further, it was noted that it was too painful to perform repetitive-use testing. However, the examiner did estimate that with repeated use over time and during flare-ups the left knee would have flexion limited to 75 degrees. No inaccuracies or deficiencies have been alleged by the Veteran regarding the findings of the December 2020 and June 2021 VA examinations, to include the estimated loss of motion during flare-ups. In pertinent part, the representative criticized the retrospective opinions in July 2021, but did not specifically object to the opinions expressed regarding the December 2020 and June 2021 examination findings and opinions. Regardless, the respective examiners did indicate the opinions were based upon the findings and information provided on the examinations themselves. In pertinent part, the December 2020 VA examiner noted the opinion was based upon factors such as pain and weakness. Further, the June 2021 VA examination report itself reflects the estimated range of motion for repeated use and flare-ups was to be based on a review of all procurable information - to include the Veteran's statement on examination, case-specific evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. Absent evidence to the contrary, the Board finds that examiner's opinion would be consistent with such instructions, and the Veteran has not explicitly contended such was not the case. Accordingly, the Board finds these opinions are also adequate for resolution of this case. The Board further notes the Veteran has not reported the left knee has increased in severity since the most recent examination of June 2021. In short, none of the aforementioned VA examinations reflect the Veteran's left knee had flexion limited to 30 degrees or less at any time during the pendency of this case, to include during repeated use over time or during flare-ups. Moreover, the Veteran has not contended, nor does the record otherwise reflect, he would have flexion limited to the extent necessary for a rating in excess of 10 percent but for the use of medication. See Jones v. Shinseki, 26 Vet. App. 56 (2012). Therefore, the Board finds the preponderance of the evidence is against a rating in excess of 10 percent for left knee flexion, to include on the basis of "staged" rating(s). Consequently, this aspect of the appeal is denied. In making the above determination, the Board was cognizant the Veteran submitted a private medical statement dated in August 2021 from a Dr. PF regarding his knees. Dr. PF stated the Veteran had osteoarthritis of the knees, right worse than the left; that it was a chronic and progressive condition; and that the certain prognosis is that it would get worse over time and eventually require orthopedic intervention. However, nothing in this statement reflects the Veteran would have greater limitation of motion of the left knee during the period of this appeal beyond what was discussed in the aforementioned VA examinations. As such, this statement does not affect the Board's adjudication under Diagnostic Code 5260, nor the following adjudication below under Diagnostic Code 5261. 2. Entitlement to a compensable rating for service-connected left knee based upon limitation of extension from September 1, 2010 to May 29, 2017 Diagnostic Code 5261 provides for limitation of the extension of the leg. When there is limitation of extension of the leg to 5 degrees, a zero percent rating is assigned; when the limitation is to 10 degrees, a 10 percent rating is assignable; when the limitation is to 15 degrees, 20 percent is assigned; when extension is limited to 20 degrees, 30 percent is assigned; when extension is limited to 30 degrees, 40 percent is assigned; and when it is limited to 45 degrees, 50 percent is assigned. 38 C.F.R. § 4.71a. During the period from September 1, 2010 to May 29, 2017, the Veteran's left knee was not manifested by extension limited to 10 degrees or more to include with repeated use over time and/or during flare-ups. In pertinent part, the record reflects that despite the Veteran's complaints of pain his left knee had normal extension to zero degrees on the VA examinations conducted in September 2010, August 2012, September 2014, March 2016, and October 2016. There was no change following repetitive-use testing. The Board also notes that the March 2021 and April 2021 VA opinions on retrospective motion concluded that the left knee would still have zero degrees extension during flare-ups at the time of the aforementioned VA examinations. As detailed above, the Board has found these opinions to be adequate for resolution of this case. Nothing in the other evidence of record pertinent to this period reflects the Veteran's left knee would have extension limited to 10 degrees or more, to include with repeated use over time, during flare-ups, and/or but for the use of medication. In light of the foregoing, the Board finds the preponderance of the evidence is against the assignment of a compensable rating for left knee extension prior to May 29, 2017 to include as additional "staged" rating(s). Therefore, this aspect of the appeal is denied. 3. Entitlement to a rating in excess of 10 percent for service-connected left knee disability based upon limitation of extension from May 30, 2017 to December 28, 2020 During the period from May 30, 2017 to December 28, 2020, the Veteran's left knee was not manifested by extension limited to 15 degrees or more to include with repeated use over time and/or during flare-ups. In pertinent part, the May 2017 VA examination found the left knee had extension to 10 degrees, while the October 2017 and August 2019 VA examinations showed normal extension to zero degrees. There was no change with repetitive-use testing. Further, the March 2021 and April 2021 VA retrospective opinions reflect the May 2017 VA examination reflects extension would be limited to 10 degrees during flare-ups, and zero degrees at the subsequent October 2017 VA examination. Nothing in the other evidence of record pertinent to this period reflects the Veteran had or would have left knee extension limited to the extent necessary for a rating in excess of 10 percent, to include during repeated use over time, flare-ups, and/or but for the use of medication. Accordingly, the preponderance of the evidence is against this appellate claim, and it is denied. 4. Entitlement to a rating in excess of 20 percent for service-connected left knee disability based upon limitation of extension from December 28, 2020 During the period from December 28, 2020 to June 3, 2021, the Veteran's left knee was not manifested by extension limited to 20 degrees or more to include with repeated use over time and/or during flare-ups. In pertinent part, the December 2020 VA examination reflects the left knee had extension limited to 15 degrees, with no change after repetitive use testing. Further, the examiner opined the left knee would have extension limited to 15 degrees with repeated use over time and during flare-ups. Therefore, the preponderance of the evidence is against a rating in excess of 20 percent for this period, and this aspect of the appeal is denied. The Board notes, however, that VA examination conducted June 3, 2021 reflects initial left knee extension to 55 degrees, and opined it would be to 50 degrees with repeated use over time and during flare-ups. Although this opinion indicates the Veteran would have better extension during repeated use and flare-ups, the Board cannot ignore that, regardless, these results reflect his left knee extension would be to 45 degrees or more particularly in light of the reasonable doubt provisions. See 38 C.F.R. §§ 4.3, 4.7. Therefore, he is entitled to a rating of 50 percent for the (CONTINUED ON NEXT PAGE) period from June 3, 2021. As this is the maximum rating available, no further discussion of left knee extension is warranted. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). James Springer Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board John Kitlas, 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.