Citation Nr: 21077160 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 15-04 211A DATE: December 28, 2021 ORDER A 100 percent disability rating for the service-connected posttraumatic stress disorder (PTSD) with major depressive disorder (MDD) associated with chronic low back strain, for the period on appeal before January 30, 2019, is granted. Special monthly compensation (SMC) at the housebound rate for the period on appeal before January 30, 2019, is granted. A disability rating in excess of 20 percent for the service-connected left knee degenerative arthritis, status post reconstruction anterior cruciate ligament repair (hereinafter left knee disability) on the basis of limited extension, for the period on appeal before September 28, 2020, and in excess of 40 percent from September 28, 2020, is denied. A disability rating in excess of 20 percent for the service-connected right knee degenerative arthritis, status post reconstruction anterior cruciate ligament repair (hereinafter right knee disability) on the basis of limited extension, before July 17, 2014, and in excess of 30 percent on the basis of status post total knee replacement from September 1, 2015, is denied. FINDINGS OF FACT 1. For the period on appeal before January 30, 2019, the Veteran's service-connected PTSD with MDD manifested in a total social and occupational impairment. 2. For the period on appeal before January 30, 2019, the Veteran has a single service-connected disability rated at 100 percent and additional service-connected disabilities independently rated at 60 percent or higher. 3. During the February 2021 Board hearing, the Veteran testified that he is satisfied with the disability ratings for his service-connected knee disabilities. CONCLUSIONS OF LAW 1. The criteria for a 100 percent disability rating for the service-connected PTSD with MDD have been met for the period on appeal before January 30, 2019. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411-9434. 2. The criteria for entitlement to SMC at the housebound rate have been met for the period on appeal before January 30, 2019. 38 U.S.C. §§ 1114(s), 5107; 38 C.F.R. §§ 3.102, 3.350(i). 3. The criteria for entitlement to a rating in excess of 20 percent for the service-connected left knee disability before September 28, 2020, and in excess of 40 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5261. 4. The criteria for entitlement to a rating in excess of 20 percent for the service-connected right knee disability before July 17, 2014, and in excess of 30 percent from September 1, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, DCs 5261, 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1982 to July 2007. This matter is before the Board of Veterans' Appeals (the Board) on appeal from an April 2011 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision increased the disability rating for the service-connected PTSD with depressive disorder from 30 to 50 percent from August 13, 2010, and increased the disability for the service-connected right and left knee degenerative arthritis (hereinafter referred to as right and left knee disabilities) from 0 to 10 each from August 13, 2010. The Veteran's Notice of Disagreement (NOD) was received in June 2011. The Statement of the Case was issued in January 2015, and the Veteran's VA Form 9, substantive appeal to the Board, was received in February 2015. During the pendency of the appeal, the RO issued a rating decision in February 2015 increasing the disability rating for the Veteran's service-connected right knee disability from 10 to 20 percent from August 13, 2010, with a temporary total rating assigned from July 14, 2014, and a 30 percent disability rating from September 1, 2015. The rating decision also increased the disability rating for the service-connected left knee disability from 10 percent to 20 percent from August 13, 2010. The claims were remanded in June 2018 and March 2020. Before the appeal was returned to the Board, the RO issued an October 2020 rating decision, further increasing the disability rating for the service-connected PTSD from 50 percent to 100 percent effective from January 30, 2019; further increasing the evaluation for the service-connected left knee disability from 20 percent to 40 percent effective from September 28, 2020; and, it granted SMC under 38 U.S.C. § 1114(s) from January 30, 2019. As these grants are not considered a full grant of benefits sought on appeal with regard to these issues, they remain in appellate status and before the Board at this time. Most recently, in February 2021, the Veteran appeared before the undersigned Veterans Law Judge (VLJ) for a Board virtual hearing. The transcript is of record. INCREASED RATING Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Ratings Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings, then separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings and is employed for initial or established ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the disability more nearly approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran is currently in receipt of a 10 percent rating for his left knee patellofemoral osteoarthritis based on painful motion. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 1. Entitlement to a disability rating in excess of 50 percent for the service-connected PTSD with MDD for the period on appeal before January 30, 2019. During the Board hearing, the Veteran testified that his PTSD manifested in symptoms of the same frequency and severity before January 30, 2019 as they were after January 30, 2019 when he was granted a 100 percent disability rating. The Veteran testified that his symptoms included constant nightmares, anxiety attacks, depression, tinnitus, irritability, bedwetting because of nightmares, hypervigilance, avoidance, illusions, relationship issues, and hearing things. The Veteran's PTSD is rated as 50 percent disabling for the period on appeal before January 30, 2019 under 38 C.F.R. § 4.130, DC 9411-9434. The criteria for rating PTSD are the same for MDD, and are based on the General Formula for Mental Disorders, found at 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. 38 C.F.R. § 4.130, DC 9411. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). When determining the appropriate disability rating to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to ward a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-24 (Fed. Cir. 2004). Rather, there must be a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria under the General Rating Formula. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The analysis should include whether any unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages; and, whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). In March 2011, the Veteran underwent a VA examination for his claim. It was noted that the Veteran was undergoing his second divorce and that he had a relationship with (as well as custody of) his children. The VA examiner indicated that the Veteran reported subjective symptoms which rise to the diagnostic criteria of PTSD, but that his current symptoms could not be distinguished from a current diagnosis of depression. The VA examiner also indicated that the Veteran's PTSD symptoms are no worse than his depressive symptoms, and that it would be impossible to differentiate between the two. It was noted that the Veteran worked as a logistics specialist full time, and that he did not exhibit any psychiatric symptoms that would prevent him or impact his capacity for employment. The Veteran reported irritability, anger outbursts, decreasing in socialization, road rage and involuntary anger outbursts, impaired sleep with nightmares and flashbacks, as well as hyperawareness, continually checking his immediate environment. The Veteran also reported occasional forgetting and difficulty with memory and concentration. He also reported bedwetting. It was noted that the Veteran was groomed and dressed appropriately. He was noted to be alert, oriented, cooperative, with mood and affect restricted. His thought content was normal, and he denied homicidal or suicidal ideations. Memory, concentration, abstract reasoning, judgment, impulse control, and insight were noted to be intact. The Veteran denied being in a romantic relationship and reported having a relationship with his children. The Veteran reported spending all of his time watching television and no longer engaging in active hobbies. It was noted that the Veteran was previously arrested for domestic violence, but that no charges were filed. It was also noted that the Veteran maintained full independence with regard to all activities of daily living. The VA examiner diagnosed the Veteran with chronic PTSD of mild severity and MDD. The Veteran's symptoms were listed as recurring intrusive thoughts, recurring distressing dreams, flashbacks, avoidance, detachment, decreased interest in formerly enjoyable activities, difficulty falling and staying asleep, irritability, difficulty concentrating, hypervigilance, and an exaggerated startle response. The VA examine indicated that these symptoms result in occupational and social impairment with transient or mild symptoms that occasionally impact on work efficiency or ability to socialize during periods of increasing stress as exemplified by impaired sleep, isolation, avoidance of recreation and leisure activities, heightened arousal, flashbacks and mood swings, along with restricted affect. A June 2011 VA mental health consultation note indicates that the Veteran screened positive for PTSD and was referred for diagnostic clarification and treatment planning. The Veteran reported getting irritated quickly, with a history of domestic violence. He also reported being very confrontational, being up during the night, being hypervigilant most of the time, having nightmares, anxiety, and seeing delusions in the mirror. The Veteran indicated that he prefers to be alone, and that he suffers from memory loss. The Veteran's mood was noted to be flat with congruent affect. His thoughts were noted to be goal oriented, with no evidence of delusions. The Veteran denied suicidal and homicidal ideations, hallucinations, and was not considered to be a danger to self or others. It was noted that the Veteran's subjective distress was severe, and that he reported having a huge social impairment, not being the man that he used to be, and being very hostile. It was noted that the Veteran had severe depression with reported delusional behaviors. It was also noted that his wife helped with everything and was his fiduciary. An August 2011 VA treatment note indicates that the Veteran was on Venlafaxine with a relatively good response. The Veteran reported that in the past few months he did not like to be around people, isolated himself, had a startle response for any minor noise, had sleeping problems, experienced irritability, got angry easily, had decreased libido, and depressed mood with suicidal plants without any plan or intent. The Veteran reported constant arguments with his wife which escalated to violence and police being called several times. It was noted that the Veteran was abusive towards other family members and would punch walls. It was also noted that the Veteran had nightmares 4-5 times per week, flashbacks, auditory hallucinations, paranoia, and recurrent traumatic thoughts. There were no psychiatric hospitalizations noted. His appearance, speech, and behavior were noted to be normal. His mood was noted to be anxious, depressed, irritable, and angry. There were no evidence hallucinations noted, and the Veteran's denied suicidal and homicidal ideations. He was noted to be oriented with normal insight and judgment. The Veteran's VA treatment notes from this time period had similar contentions. In February 2013, the Veteran underwent a VA examination for his claim. The VA examiner concluded that the Veteran's symptoms manifest in an occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood. It was noted that the Veteran was separated from his wife, with a pending divorce, and that he did not have any friends. The Veteran denied participating in any leisurely activities. He reported living with his cousin, who took care of him. He was noted to work part time from home. The Veteran reported nightmares, anxiety, no sleep, nights sweats, and bedwetting. The Veteran denied physical aggression but reported his wife calling the police on him several times. He also reported a verbal interaction with one of her friends. The Veteran's symptoms were listed as depressed mood, anxiety, panic attacks that occur weekly or less often, near-continuous depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, impairment of long term and short term memory, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, impaired impulse control, difficulty in establishing and maintaining effective work and social relationships, and disorientation of time or place. The Veteran was deemed capable of managing is own affairs. The VA examiner noted that the Veteran appears to be functioning poorly as the result of his psychiatric disorders, isolating himself. The VA examiner also noted that by the Veteran's report his symptoms have been this level of severity since onset. In October 2015, the Veteran underwent a VA examination for his claim. He reported living alone in an apartment and being twice divorced. He reported being close to his adult children but not having any friends. The Veteran reported having two jobs since the army, currently working for the government, and missing a lot of time due to service-connected disabilities. He also reported not working well in groups and having a lot of confrontations. He reported that his supervisor is a veteran and is understandable. The Veteran reported going to church, but sitting in the back. He also reported watching football, sports, and fishing. It was noted that the Veteran was receiving mental health treatment through the VA and was on Abilify, venlafaxine, gabapentin, Percocet, and had nightmares 3 to 5 times per week. He reported his treatment not helping, and having dreams of people shooting at him and combat. The Veteran reported hypervigilance, and checking all of the windows in his apartment. He reported daily thoughts about war and avoiding loud noises, as well as certain music and movies. His symptoms were listed as depressed mood, chronic sleep impairment, disturbances of motivation and mood, and inability to establish and maintain effective relationships. It was noted that the Veteran was alert, pleasant, well groomed, with an appropriate speech. The Veteran denied homicidal ideations, but reported previous suicidal thoughts with no attempts, most recent thoughts being several years ago. It was noted that the Veteran did not have delusions but did not trust people. The VA examiner noted that the validity of this evaluation is difficult to determine, and that neuropsychological testing documents likely over-reporting of psychological symptoms, which was also the VA examiner's impression from the VA examination. The VA examiner concluded that the Veteran's PTSD with MDD manifested in occupational and social impairments with reduced reliability and productivity. A December 2017 VA treatment note indicates that the Veteran has nightmares, anxiety, insomnia, and ongoing medical problems. It was noted that the Veteran spends most of his days taking naps and watching TV. The Veteran reported having nightmares 3 to 4 times per week, bed wetting, and night sweats. His mood was noted to be depressed, with reported irritability and low frustration tolerance. The Veteran reported memory problems and denied suicidal and homicidal ideations. It was noted that his wife was his caretaker, including helping him with his medications. The Veteran's mental health status examination was the same as before. The remainder of the Veteran's VA treatment records contained similar findings. Based on a review of the entire record, the Veteran's overall disability picture more nearly approximates total occupational and social impairment for the entire period on appeal before January 30, 2019. In this case, the Veteran's longstanding PTSD symptoms have been of such severity and frequency, as to warrant a 100 percent disability rating. These symptoms include persistent anger outbursts, irritability, anxiety, depression, chronic sleep impairment, mild memory loss and concentration problems, difficulty establishing and maintaining work and personal relationships, impaired impulse control, occasional delusions, occasional suicidal ideations, and domestic violence. The Veteran's depression, irritability, anxiety, and depression appear to be the most consistent and severe of his symptoms, causing a total impairment in his family relations, with periods of domestic violence and reported abuse towards more than one family member. The record illustrates that the Veteran's symptoms caused a total impairment with respect to employment, family relations, and overall functioning. With respect to employment, the Veteran was noted to have trouble with groups, was easily irritable, confrontational, and did not get along well with others. While the Veteran was noted to be employed, his supervisor was also a veteran and accordingly accommodated the Veteran's psychiatric problems. Moreover, the record indicates that the Veteran missed a large amount of time from work. Thus, while the Veteran continued to be employed, the record indicates that his disability manifested in a total occupational impairment, as the Veteran's anger and irritability prevented him from being around others. With respect to family relations, the Veteran's psychiatric symptoms resulted in a history of domestic violence and police arrests. The Veteran is twice divorced, and has reported his anger, irritability, and anxiety, resulting in previous domestic violence and abuse towards more than one family member. Indeed, the Veteran's psychiatric symptoms have consistently manifested in an inability to maintain any sort of relationships, professional or personal. Although the March 2011, February 2013, and October 2015 VA examination reports did not find total occupational and social impairment, they did not specifically address the Veteran's reported delusions, history of suicidal ideations without plan, and history of domestic violence. Moreover, in determining the proper disability rating to assign, the overall assessment of the Veteran's disability is considered, not merely the clinical impressions at the time of the select few VA examinations. 38 C.F.R. § 4.126. The Veteran's VA treatment records indicate that he suffers from psychiatric symptoms on a daily basis and spends most of his time watching TV and taking naps. They also contain symptoms such as delusions and suicidal ideations with no plan. The February 2013 VA examination report indicates that the Veteran has been functioning poorly for many years due to his psychiatric disability. In other words, the overall assessment indicates a total occupational and social impairment. While the record shows isolated periods when the Veteran's symptoms are better, overall symptoms remained consistent and did not show sustained improvement throughout the period on appeal. In essence, the records reflect that the Veteran's symptoms may wax and wane from one day to the next; however, the Veteran's overall disability picture is manifested by longstanding symptoms of such type, severity, and frequency as to more nearly approximate a disability rating of 100 percent for his service-connected PTSD for the period on appeal before January 30, 2019. Staged ratings have been considered and are not warranted in this matter as the overall disability picture has been relatively consistent for the entire period on appeal. In this regard, the Veteran's service-connected psychiatric disorder is already assigned a 100 percent rating from January 30, 2019 onward, and the totality of the evidence does not show that the overall severity of the disability is much different before January 30, 2019 than it is after that date. For the forgoing reasons, an increased disability rating of 100 percent for the service-connected PTSD with MDD is warranted for the entire period on appeal before January 30, 2019. 2. Entitlement to SMC at the housebound rate before January 30, 2019. SMC at the housebound rate is payable if the Veteran has a single service-connected disability rated as 100 percent and an additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). Pursuant to this decision, the Veteran's PTSD with MDD is now rated as 100 percent disabling for the period on appeal prior to January 30, 2019. As such, the first element of entitlement to SMC at the housebound rate is shown. The Veteran's other numerous additional service-connected disabilities involve different anatomical segments or bodily systems, and they are independently ratable at 60 percent or higher, to include: sleep apnea, rated as 50 percent disabled from August 20, 2009; degenerative arthritis of the left knee, rated as 20 percent disabling from August 13, 2010; migraine headaches, rated as 10 percent disabling from August 1, 2017, and as 30 percent disabling from July 20, 2015; right knee arthritis, rated as 20 percent disabling from August 13, 2010, as 100 percent disabling from July 17, 2014, and as 30 percent disabling from September 1, 2015; continuous fecal leakage, rated as 30 percent disabling from March 17, 2016; right lower extremity radiculopathy, rated as 20 percent disabling from July 20, 2015; left lower extremity radiculopathy, rated as 20 percent disabling from July 20, 2015; back strain, rated as 10 percent disabling from August 1, 2007, and as 20 percent disabling from January 12, 2017, acute cervical spine fracture, rated as 10 percent disabling from August 1, 2007; right ankle disability, rated as 10 percent disabling from April 2, 2009; tinnitus, rated as 10 percent disabling from May 13, 2015; eczema, rated as 10 percent disabling from July 20, 2015; and duodenal ulcer, rated as 10 percent disabling from February 18, 2018. Thus, the criteria for SMC at the housebound rate have been met prior to January 30, 2019. 3. Entitlement to a disability rating in excess of 20 percent for the service-connected left knee disability before September 28, 2020, and in excess of 40 percent thereafter. 4. Entitlement to a disability rating in excess of 20 percent for the service-connected right knee disability before July 17, 2014, and in excess of 30 percent from September 1, 2015. The Veteran's service-connected left knee disability is rated as 20 percent disabling from August 13, 2010, and as 40 percent disabling from September 28, 2020 under 38 C.F.R. § 4.71a, DC 5261. His right knee disability is rated as 20 percent disabling from August 13, 2010 under 38 C.F.R. § 4.71a, DC 5261, as 100 percent disabling from July 17, 2014 under 38 C.F.R. § 4.30, and as 30 percent disabling from September 1, 2015 under 38 C.F.R. § 4.71a, DC 5055 (prosthetic knee replacement). Under Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For purpose of rating a disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Under DC 5260, a 10 percent rating is assigned when flexion of the knee is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. Full 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. Limitation of extension is rated separately under DC 5261. A noncompensable rating is assigned when extension is limited to 5 degrees, a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is assigned when extension is limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 50 degrees. Separate ratings under DC 5260 for limitation of flexion of the leg and DC 5261 for limitation of extension of the leg may be assigned for disability of the same joint. VAOPGCPREC 09-04. Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. Under 38 C.F.R. § 4.71a, DC 5257, which considers "other" knee impairment, including recurrent subluxation or lateral instability, 10, 20 and 30 percent evaluations are assigned for slight, moderate, and severe impairment, respectively. 38 C.F.R. § 4.71a, DC 5257. The words "moderate" and "marked" are not defined in the rating schedule but rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "slight" and "moderate" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. § 4.2, 4.6. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, respectively, while cautioning that any such separate rating must be based on additional, and non-overlapping, symptomatology. VAOPGCPREC 23-97, 62 Fed. Reg. 63, 604 (July 1, 1997; revised July 24, 1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (August 14, 1998). Several other DCs under 38 C.F.R. § 4.71a pertain to knee disabilities in addition to those above. They include DC 5256 for ankylosis of the knee; DC 5258 for dislocated semilunar knee cartilage with frequent episodes of "locking," pain, and effusion into the joint; DC 5259 for symptomatic removal of the semilunar knee cartilage; DC 5262 for impairment of the tibia and fibula; and DC 5263 for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). The Court has explained there is no absolute prohibition of separate evaluations under 38 C.F.R. § 4.71a, Code 5257 or 5260/5261 and a meniscal Code, i.e., Codes 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Veteran had his right knee surgically replaced June 17, 2014. He was under a period of convalescence until September 1, 2015. Then, effective September 1, 2015, his right knee disability must be evaluated as directed in Diagnostic Code 5055. Diagnostic Code 5055 assigns a 100 percent disability rating for one year following implantation of a prosthetic replacement of the knee joint. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. For intermediate degrees of residual weakness, pain or limitation of motion, the knee should be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating is 30 percent. During the pendency of the appeal, the rating criteria for evaluating musculo-skeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 83 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 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 claims under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021, applying the criteria that is more favorable to the Veteran. Diagnostic Code 5257 was amended effective February 7, 2021. Under the amended criteria, Diagnostic Code 5257 evaluates other impairment of the knee of recurrent subluxation or instability or recurrent patellar instability. With respect to recurrent subluxation or instability, a 10 percent disability rating is warranted for the following: 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 disability rating is warranted for the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability and a medical provider prescribes a brace and/or assistive decide (e.g., cane(s), crutch(es), walker) for ambulation or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent disability rating is warranted 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. Regarding recurrent patellar instability, a 10 percent disability 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 disability 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 30 percent disability 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. Diagnostic Code 5055 was also amended effective February 7, 2021. However, the only changes to the provision were to add knee resurfacing, to shorten the time period for a 100 percent rating from one year to four months, and to limit the minimum 30 percent rating for knee replacements but not knee resurfacing. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055). The criteria for rating degenerative arthritis were not amended. During the February 2021 hearing, the Veteran testified that he is satisfied with the current ratings for his service-connected knee disabilities. Specifically, he indicated that the current ratings accurately represent the severity of his service-connected knee disabilities. Left knee For the period on appeal before September 28, 2020, a rating in excess of 20 percent for the service-connected left knee disability is not warranted. Additionally, from September 28, 2020, a rating in excess of 40 percent is not warranted. In this case, in order to warrant a rating in excess of 20 percent, the record would need to show limitation of extension to 20 degrees, flexion to 45 degrees or more, ankylosis, moderate recurrent subluxation or lateral instability, dislocated semilunar cartilage with episodes of locking, or tibial and/or fibular impairment prior to September 28, 2020. In order to warrant a rating in excess of 40 percent, the record would need to show limitation of extension to 45 degrees, flexion to 45 degrees or more, or ankylosis from September 28, 2020 and thereafter. As noted above, the Veteran testified that he is satisfied with the ratings for his service-connected knee disabilities. Thus, the preponderance of the evidence does not support a finding of left knee limitation of extension to 20 degrees, flexion to 45 degrees or more, ankylosis, moderate recurrent subluxation or lateral instability, dislocated semilunar cartilage with episodes of locking, or tibial and/or fibular impairment prior to September 28, 2020. Further, the preponderance of the evidence does not support a finding of left knee extension to 45 degrees, flexion to 45 degrees, or ankylosis from September 28, 2020, and thereafter. New amended criteria have been considered after February 7, 2021 and would not warrant a higher rating. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Right knee For the period on appeal before July 17, 2014, a rating in excess of 20 percent for the service-connected right knee disability is not warranted. Additionally, a rating in excess of 30 percent from September 1, 2015 is not warranted. In this case, in order to warrant a rating in excess of 20 percent, the record would need to show limitation of extension to 20 degrees, flexion to 45 degrees or more, ankylosis, moderate recurrent subluxation or lateral instability, dislocated semilunar cartilage with episodes of locking, or tibial and/or fibular impairment prior to July 17, 2014. In order to warrant a rating in excess of 40 percent from September 1, 2015, the record would need to show limitation of extension to 45 degrees, extremely unfavorable ankylosis at the angle of 45 degrees or more, or chronic residuals consisting of severe painful motion or weakness. As noted above, the Veteran testified that he is satisfied with the ratings for his service-connected knee disabilities. Thus, the preponderance of the evidence does not support a finding of right knee limitation of extension to 20 degrees, flexion to 45 degrees or more, ankylosis, moderate recurrent subluxation or lateral instability, dislocated semilunar cartilage with episodes of locking, or tibial and/or fibular impairment prior to July 17, 2014. Further, from September 1, 2015, the preponderance of the evidence does not support a finding of right knee limitation of extension to 45 degrees, extremely unfavorable ankylosis at the angle of 45 degrees or more, or chronic residuals consisting of severe painful motion or weakness. Accordingly, a higher rating under Diagnostic Code 5055 from September 1, 2015 is not warranted. New amended criteria have also been considered after February 7, 2021 and would not warrant a higher rating. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kuksova, Kseniya 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.