Citation Nr: 21005871 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 11-15 637 DATE: February 2, 2021 ORDER A disability rating of in excess of 10 percent prior to December 22, 2018 for limitation of the motion of the left knee is denied. A disability rating of 40 percent, but no more, from December 22, 2018 to November 17, 2020 for limitation of motion of the left knee is granted. A disability rating in excess of 40 percent from November 18, 2020 and in excess of 40 percent for limitation of motion of the left knee is denied. A disability rating of 20 percent, but no more, from December 7, 2016 to November 17, 2020 for instability of the left knee is granted. A disability rating in excess of 20 percent for instability of the left knee from November 18, 2020 is denied. A disability rating of 10 percent, but no more, for a meniscal condition of the left knee from March 31, 2009 to December 7, 2016 is granted. A disability rating of in excess of 10 percent prior to June 11, 2019 and in excess of 60 percent from August 1, 2020 for a right knee disability is denied. A disability rating of 10 percent for scarring effective December 5, 2016 is granted. FINDINGS OF FACT 1. Prior to December 22, 2018, the Veteran’s left knee did not manifest ankylosis, “locking” and effusion into the joint as a result of a semilunar cartilage condition, genu recurvatum, a tibial or fibular impairment, a flexion limited to 30 degrees or less; an extension limited to 15 degrees or more; or a flexion limited to 45 degrees or more and an extension limited to 10 degrees or more. 2. From December 22, 2018 to November 17, 2020, the Veteran’s extension was limited to 30 degrees and had a combined disability rating of the left lower extremity of 60 degrees. 3. From November 18, 2020, the Veteran had a combined disability rating of the left lower extremity of 60 degrees. 4. The Veteran manifested moderate instability of the left knee from December 7, 2016. 5. The Veteran did not manifest severe lateral instability or recurrent subluxation of the left knee throughout the period on appeal. 6. The Veteran manifested a semilunar cartilage condition of the left knee throughout the period on appeal from March 31, 2009 to December 7, 2016. 7. Prior to June 11, 2019, the Veteran did not manifest ankylosis, recurrent subluxation or lateral instability, a semilunar cartilage condition, genu recurvatum, a tibial or fibular impairment, a flexion limited to 30 degrees or less; an extension limited to 15 degrees or more; or a flexion limited to 45 degrees or more and an extension limited to 10 degrees or more. 8. From December 5, 2016, the Veteran manifesting an unstable scar of the left knee, but the Veteran did not manifest three or more painful scars, any scars of the head, face, or neck, any scarring with an area of 12 square inches (77 sq. cm) or more, or any other additional disabling effects. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 10 percent prior to December 22, 2018 for limitation of motion of the left knee have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5256, 5258, 5260-5263. 2. The criteria for a disability rating of 40 percent, but no more, from December 22, 2018 to November 17, 2020 for limitation of motion of the left knee have been met. 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Codes 5003, 5256, 5258, 5260-5263. 3. A disability rating in excess of 40 percent from November 18, 2020 and in excess of 40 percent for limitation of motion of the left knee is denied. 38 C.F.R. §§ 4.25, 4.71a, Diagnostic Codes 5003, 5256, 5258, 5260-5263. 4. The criteria for a disability rating of 20 percent, but no more, from December 7, 2016 for instability of the left knee have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257. 5. The criteria for a disability rating in excess of 30 percent for instability of the left knee have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257. 6. The criteria for a disability rating of 10 percent for a meniscal condition of the left knee from March 31, 2009 to December 7, 2016 have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5259. 7. The criteria for a disability rating of in excess of 10 percent prior to June 11, 2019 and in excess of 60 percent from August 1, 2020 for a right knee disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5256-5263. 8. The criteria for a disability rating of 10 percent for scarring effective December 5, 2016 have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7802, 7804-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from October 1982 to February 1993. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) made in December 2009 and in August 2017. These matters are being adjudicated under the legacy appellate framework. The Veteran testified at a personal hearing before the Board regarding the severity of his bilateral knee disabilities in September 2015, and a transcript of the hearing is of record. The November 2018 substantive appeal perfecting the increased rating claim for a scar on the left knee to the Board indicated that the Veteran did not desire hearing. The Veteran’s increased rating claims for bilateral knee disabilities were previously before the Board in February 2016 and March 2018, but, in June 2019, the Board denied both claims. In April 2020 however, the Court of Appeals for Veterans Claims (Court) granted a joint motion for remand (JMR) and vacated the Board’s disposition and remanded the increased rating claims for bilateral knee disabilities back to the Board for further consideration. In October 2020, the Board remanded the Veteran’s knee claims and the Veteran’s scar claim for further development. Further development in substantial compliance with the Court’s and the Board’s previous remand instructions has been completed. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 1. A disability rating of in excess of 10 percent prior to December 22, 2018 for limitation of the motion of the left knee is denied. 2. A disability rating of 40 percent, but no more, from December 22, 2018 to November 17, 2020 for limitation of motion of the left knee is granted. 3. A disability rating in excess of 40 percent from November 18, 2020 and in excess of 40 percent for limitation of motion of the left knee is denied. 4. A disability rating of 20 percent, but no more, from December 7, 2016 to November 17, 2020 for instability of the left knee is granted. 5. A disability rating in excess of 20 percent for instability of the left knee from November 18, 2020 is denied. 6. A disability rating of 10 percent, but no more, for a meniscal condition of the left knee from March 31, 2009 to December 7, 2016 is granted. 7. A disability rating of in excess of 10 percent prior to June 11, 2019 and in excess of 60 percent from August 1, 2020 for a right knee disability is denied. At issue is whether the Veteran is entitled to increased disability ratings for the Veteran’s bilateral knee disabilities. The weight of the evidence indicates that the Veteran is entitled to separate compensable disability rating for a cartilage condition of the left knee, an earlier effective date for the assignment of an instability condition the left knee, and an earlier effective date for the assignment of limitation of extension of the left knee. The Veteran is not otherwise entitled to an increased disability rating. The Veteran first filed for service connection in February 1993, and, in August 1994, the RO granted service connection and assigned a disability rating of 10 percent for the left knee and a noncompensable disability rating of the right knee; both effective the date the claim was received. Thereafter, the Veteran’s right knee disability was increased to 10 percent effective March 20, 2011. In March 31, 2009, the RO filed an increased disability rating, and, in December 2009, the RO denied the Veteran’s increased rating claim. The Veteran appealed. During the pendency of the appeal, the Veteran’s left knee disability was increased to 40 percent effective November 18, 2020. Additionally, the Veteran was assigned a separate compensable disability rating of 20 percent effective November 18, 2020. The Veteran also underwent a total arthoplasty of the right knee on June 11, 2019, and a total disability rating was assigned effective June 11, 2019 and a disability rating of 60 percent was assigned August 1, 2020. See November 2020 Rating Decision Code Sheet. If the Veteran does not undergo a knee replacement, then a knee disability is evaluated under Diagnostic Code 5003 & Diagnostic Codes 5256-5263. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5003 is not raised by the record. Under Diagnostic code 5003 a disability rating of 10 percent may be assigned for an individual major joint (such as either the right or left knee) and a disability rating of 20 percent may be assigned for two major joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The Veteran, however, has already been assigned disability ratings of 10 percent for each knee throughout the period on appeal (from March 31, 2009 to present) as well as a combined disability rating of 20 percent for both knees throughout the period on appeal. See November 2020 Rating Decision Code Sheet; see also 38 C.F.R. § 4.25. Therefore, Diagnostic Code 5055 does not provide an adequate basis for an increased rating claim. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5262 (tibial or fibular impairment) is not raised by the record, because the Veteran has not been diagnosed with a tibial or fibular impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5256, a disability rating of 30 percent is assigned when the knee manifests ankylosis with favorable angle in full extension or in slight flexion between zero and 10 degrees, and a disability rating of 40 percent is assigned when the knee manifests ankylosis in flexion between 10 percent and 20 percent. A disability rating of 50 percent is assigned when the knee manifests ankylosis in flexion between 20 percent and 45 percent, and a disability rating of 60 percent is assigned when the knee manifests ankylosis inf flexion with extremely unfavorable ankylosis at an angle of 45 degrees or more. Under Diagnostic Code 5257, a disability rating of 10 percent is assigned for slight recurrent subluxation and lateral instability, and a disability rating of 20 percent is assigned for moderate recurrent subluxation and lateral instability. A 30 percent is assigned for severe recurrent subluxation and lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5259, a disability rating of 10 percent is assigned when the knee is symptomatic of removal of semilunar cartilage, and, under Diagnostic Code 5258, a disability rating of 20 percent is assigned when the knee manifests dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5258-5259. Under Diagnostic Code 5260, a disability rating of 10 percent is assigned when the knee manifests a flexion limited to 45 degrees, and a disability rating of 20 percent is assigned when the knee manifests a flexion limited to 30 degrees. A disability rating of 30 percent is assigned when the knee manifests a flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a disability rating of 10 percent is assigned when the knee manifests an extension limited to 10 degrees, and a disability rating of 20 percent is assigned when the knee manifests an extension limited to 15 degrees. A disability rating of 30 percent is assigned when the knee manifests an extension limited to 20 degrees, and a disability rating of 40 percent is assigned when the knee manifests an extension limited to 30 degrees. A disability rating of 50 percent is assigned when the knee manifests an extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5263, a disability rating of 10 percent is assigned when the knee manifests a disability rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5263. If the Veteran undergoes a knee replacement, then a knee disability is evaluated under Diagnostic Code 5055. Under Diagnostic Code 5055, a total disability rating is assigned one year following the implantation of a prothesis. Thereafter, the maximum disability rating that can been assigned is 60 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Veteran has been assigned the maximum disability rating for the right knee from June 11, 2019, because the Veteran was assigned a total disability rating effective the date of the total knee arthroplasty until August 2020; and a disability rating of 60 percent thereafter. See November 2020 Rating Decision Code Sheet. This is the maximum disability rating that can be assigned after a total arthroplasty. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Therefore, the Board shall not consider assigning an increased disability rating for the right knee after June 11, 2019. In March 2009, the Veteran submitted a VA Form 21-4138 commencing his bilateral knee disability. At that time, the Veteran posited that, “(m)y knees give out causing me to fall a lot. . . . My arthritis is getting so bad my back and knees and ankles pop all the time causing severe pain.” The Veteran’s treatment records indicate that the Veteran manifested knee symptomology throughout the period on appeal. In March 2009, the Veteran underwent a VA examination. The Veteran actually underwent this examination prior to the commencement of the period on appeal. Nevertheless, the severity of the Veteran’s knee disabilities just prior to the period on appeal is relevant evidence to the severity of the Veteran’s knee disabilities at the beginning of the period of the appeal; particularly until the Veteran underwent another VA examination in December 2016. Additionally, the Board notes that this potentially gives rise to an earlier effective date for an increased disability rating up to one year prior to the commencement of the appeal. 38 C.F.R. § 3.400(b)(1) (ii)(B). The Veteran reported pain, popping, and grinding. The Veteran also indicated that the right knee was worse than the left; sometimes “going out.” The Veteran reported 25 flare-ups a month. On examination, the Veteran’s flexion was to 140 degrees bilaterally, and the extension was to zero degrees bilaterally. The examiner noted objective evidence of pain on motion, but the examiner did not observe loss of range of motion after repetitive range of motion; and the examiner did not opine that the Veteran manifested additional functional loss. The Veteran was not diagnosed with ankylosis. In August 2009, VA received correspondence from Margaret J. Weston Community Health Centers. Therein, the Veteran’s provider stated that, “(the Veteran) suffers from chronic back pain (involves the entire spine), knee pain, foot pain, and anxiety disorder. These medical conditions prevent (the Veteran) from independently performing some of his activities of daily living and thus he requires assistance.” In June 2011, VA received correspondence from the Veteran’s former representative. Therein, the representative posited that, “(the Veteran) reported pain as well as popping and grinding of both knees. (The Veteran) affirmed that he suffered from consistent, sharp/throbbing pain daily. In fact, (the Veteran) reported that he had fallen on several occasions due to this condition. With regard to (the Veteran’s) left knee impairment, examination revealed positive tenderness to the central patella region as well as guarded posture with standing and walking. With regard to (the Veteran’s) right knee impairment, examination revealed positive tenderness on palpation of the anterior and medial patella. Range of motion testing of (the Veteran’s) bilateral knees revealed flexion 0 to 140 degrees with pain throughout and extension to 0 degrees with pain. The examiner noted moderate pain during repetitive motion. X-ray testing of the right knee revealed moderate degenerative changes. X-ray testing of the left knee revealed moderate osteoarthritis and benign tibial plateau lesion.” In September 2011, VA received correspondence from the Veteran’s fiancé, JT. Therein, JT revealed that, “(the Veteran) is always in excruciating pain. Especially in the mornings before he takes his medicine. He cannot function without his medicine.” The correspondence concluded with, “he needs more compensation, he is a lot worse just in the past year, let alone since 15 years since he got 40 percent. You can look at his knees... and easily tell it more than 40 percent.” In September 2015, the Veteran testified at a personal hearing before the Board. At that time, the Veteran averred that, “I got to concentrate, try to concentrate on what I’m doing because my knees will pop. I’ll go out and I’ll fall[.]” With regard to the extent of range of motion, the Veteran testified that, “not very much motion at all. The, the VA in Augusta said that I need to have both my knees replaced.” The Veteran testified that, “since 2009 I noticed way back that I was having to walk different. . . . I was using my right knee, I mean like three times more, differently and harder than my left knee to seek from the pain. . . . [M]y left, or my right knee is, is just as hurting as bad as the left knee.” The Veteran testified that he could walk approximately 30 feet before knee-related pain would lead to a need to sit down. The Veteran testified that he wore knee braces and utilized a cane for mobilization. See Transcript. The Veteran underwent another VA examination on December 6, 2016. At that time, the VA provider noted diagnoses for anterior cruciate ligament tear and degenerative arthritis. The Veteran did not report flare-ups, but he did report constant pain. The VA provider recorded 120 degrees of right knee flexion and 0 degrees of extension. The VA provider recorded 120 degrees of left knee flexion and 0 degrees of extension. The VA provider did not note pain with weight bearing, tenderness or pain on palpation, or crepitus. The Veteran did not demonstrate functional loss after repetitive testing. The VA provider did not observe pain, weakness, fatigability or incoordination during repetitive use. The VA provider did not note a history of recurrent subluxation or lateral instability. A history of recurrent effusion was not noted. The VA provider performed stability testing, and the Veteran demonstrated normal anterior, posterior, medial, and lateral instability. The VA provider noted that the Veteran utilized a cane for locomotion. Imaging studies revealed that the Veteran endured degenerative or traumatic arthritis. It was noted that a June 2015 MRI revealed a probable chronic ACL tear; the posterior cruciate and collateral ligaments are intact; the patellar and quadriceps tendons are unremarkable; there is advanced tricompartmental DJD findings in the medial compartment with extensive full-thickness cartilage loss; multiple loose bodies; and, degenerative changes of the proximal tibiofibular articulation. The Veteran was not diagnosed with ankylosis of the knees. In March 2018, the Board remanded the Veteran’s knee claims. At that time, the Board concluded that neither the December 2016 VA examination nor any VA treatment records associated with the Veteran’s claims file utilized range of motion testing of passive motion, weight-bearing, and nonweight-bearing situations. Therefore, none of the medical evidence of record at that time satisfied the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016) and 38 C.F.R. § 4.59. The Veteran underwent another VA examination on December 21, 2018. The Veteran did not report flare-ups but did report constant knee pain. The VA provider reported 115 degrees of right knee flexion and 0 degrees of extension. The VA provider reported 115 degrees of left knee flexion and 0 degrees of extension. The Veteran did not demonstrate objective evidence of pain with weight bearing, tenderness or pain on palpation, or crepitus of the right knee. After three repetitions, the Veteran did not demonstrate additional functional loss. The VA provider noted that aging, natural deconditioning, hyperalgesia due to chronic pain medication usage, and increased body mass index also contributed to the Veteran’s current disabilities. The VA provider did not observe pain, weakness, fatigability or incoordination during repetitive use. The Veteran demonstrated 3/5 muscle strength during flexion and extension bilaterally; however, the VA provider noted that aging, natural deconditioning, and chronic obstructive pulmonary disease (COPD) contributed to the reduction in strength. The VA provider observed no gross deformity, misalignment, drainage, tenderness, edema, redness, spasms, abnormal movement, guarding of movement, fatigue, lack of endurance, atrophy, incoordination, instability, or pertinent abnormal weight bearing. During the examination, the Veteran reported pain with active range of motion (mostly during flexion). The Veteran did not report pain with passive range of motion. During the examination, the Veteran did not demonstrate pain with non-weight bearing, passive range of motion, or pain with weight bearing. The VA provider commented that, “an opinion regarding if, when and to what extent, in degrees, further ‘repetitive use’ or reported ‘flare-ups’ could significantly limit functional ability, is not one with literature support, but instead based on clinical information including history and physical findings. More definitive loss of function, due to flare-ups, cannot be determined without resorting to mere speculation.” The VA provider did not observe ankylosis. A history of recurrent subluxation, lateral instability, or recurrent effusion were not noted. The VA provider did not perform joint stability testing due to risk of injury or perceived injury by the Veteran. The Veteran did not demonstrate recurrent patellar dislocation, ‘shin splints’ (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran reported regular use of a brace and cane for his service-connected bilateral knee disability. After review of October 2018 x-ray imaging, the VA provider reported that, “severe bilateral medial compartment osteoarthrosis has not significantly changed.” For functional impact, the VA provider reported that, “‘modifications may be necessary during weight bearing activities (e.g., prolonged standing and walking) or where the knee joint is repetitively stressed with kneeling, squatting, or climbing; limited stair climbing and heavy lifting may be advised. Additional rest periods may be needed. Accommodations must be made for assistive devices such as a cane when needed.’” The VA provider remarked that, “(m)oderate to severe functional limitation due to reported symptomatology.” In June 2019, the Board disposed of the Veteran’s increased rating claims by denying them. In April 2020, the Court took issue with the fact that the Board did not discuss the significance of a disability benefits questionnaire presented by a private provider in June 2019, and, as a result, the Court vacated the Board’s decision and remanded the matter for further development. During the June 2019 disability benefits questionnaire, the Veteran reported knee problems (as well as flare-ups) including difficulty sitting and walking. The Veteran’s flexion was to 130 degrees bilaterally, and the Veteran’s extension was hyperextended by five degrees bilaterally. The provider indicated that the Veteran was able to perform repetitive range of motion testing without additional loss of range of motion. The provider observed pain and localized tenderness. The provider opined that that the following factors contributed to additional functional loss: less-movement than normal; weakened movement; pain on movement; atrophy of disuse; disturbance of locomotion; and interference with standing. The provider noted that the Veteran’s muscle strength was 5/5. The provider checked a portion of the disability benefits questionnaire which indicated that the Veteran manifested a favorable angle in full extension or slight flexion between zero and 10 degrees. In addition to checking that section, the provider also struck the portion out and initialed. No other portion of the disability benefits questionnaire has been struck out or initialed. The provider also noted effusion into the left knee. Joint stability testing did not reveal instability of either knee. The provider noted that the Veteran manifested a meniscal disability of the left knee. In October 2020, the Board remanded these matters for a new VA examination. The Veteran underwent another VA examination in November 2020. The Veteran reported constant pain, soreness, stiffness, swelling, and muscle spasms in both knees. The Veteran reported additional functional loss including the inability to run for an extended period of time. The Veteran’s flexion was to 120 degrees in the right knee and 110 degrees in the left knee, and the Veteran’s extension was to zero degrees in the right knee and 20 degrees in the left knee. The Veteran was able to perform repetitive range of motion testing without additional loss of range of motion. The examiner opined that the Veteran manifested additional functional loss over time and indicating the following reductions: flexion in the right knee to 110 degrees; flexion in the left knee to 100 degrees; and extension in the left knee to 30 degrees. The examiner indicated that the Veteran did not manifest additional functional loss due to flare-ups; though noting that the Veteran’s reports of flare-ups were neither medically consistent or inconsistent with the examination results. Muscle strength testing results were 3/5. The examiner noted moderate lateral instability in the left knee as well as a history of a meniscal tear with “locking,” pain, and effusion into the joint. The examiner indicated that there was no ankylosis. In a separate medical opinion, the examiner opined that, as ankylosis is defined as no movement of the joint and frozen in a fixed position, there was no evidence of ankylosis during the period on appeal. The weight of the evidence indicates that the Veteran is not entitled to an increased disability rating or a separate disability under Diagnostic Code 5256. In order to meet the criteria under Diagnostic Code 5256, the Veteran needed to manifest ankylosis to some degree, and the evidence of record does not establish that the Veteran manifested ankylosis throughout the period on appeal. The Board notes that the June 2019 disability benefits questionnaire marked a section which indicated that the Veteran manifested ankylosis. Nevertheless, that section was also struck out and initialed. The Board is convinced that the intention of the provider in striking out the section an initializing it was to indicate that the Veteran did not manifest ankylosis. The Board is further convinced by the fact that the same provider indicated that both of the Veteran’s knees manifested range of motion; albeit an abnormal range of motion. Additionally, the Board notes that the Veteran was examined multiple times throughout the period on appeal, and the Veteran was not diagnosed with ankylosis of either knee, and, in October 2020 specifically, a VA examiner opined that the Veteran did not manifest ankylosis throughout the period on appeal. Therefore, the weight of the evidence indicates that the Veteran has not manifested ankylosis throughout the period on appeal, and the Board concludes that the Veteran does not meet the criteria for an increased disability rating or a separate disability under Diagnostic Code 5256. The weight of the evidence indicates that the Veteran is not entitled to an increased disability rating or a separate compensable disability rating under Diagnostic Code 5257 or an increased disability rating or a separate compensable disability rating under Diagnostic Code 5257 for the right knee at any time during the pendency of the appeal. The Veteran underwent numerous VA examinations throughout the period on appeal, and none of these examinations indicated that the Veteran manifested lateral instability or recurrent subluxation of the right knee. Therefore, the Veteran is not meet the criteria under Diagnostic Code 5257 during these time periods. The weight of the evidence indicates that the Veteran is entitled to an effective date of December 7, 2016 for the assignment of a disability rating of 20 percent under Diagnostic Code 5257. The Veteran underwent VA examinations in March 2009 and December 2016, and neither of these examinations indicated that the Veteran manifested lateral instability or recurrent subluxation of the left knee. In an examination conducted in December 2018, the examiner noted a history of instability but declined to test the Veteran for fear of injury. In October 2020, a VA examiner also noted a history of instability of the left knee. In November 2020, the RO granted a separate disability rating of 20 percent for moderate instability of the left knee effective November 18, 2020. It is unclear exactly when the Veteran first began to manifest instability of the left knee, but the earliest possible date would be December 7, 2016; the earlies date after the December 6, 2016 examination which indicated that the Veteran did not have instability of the left knee or a history of lateral instability of the left knee. Therefore, the Veteran should be granted an earlier effective date of December 7, 2016 for the assignment of a disability rating of 20 percent under Diagnostic Code 5257 for the left knee. The weight of the evidence indicates that the Veteran is not entitled to a disability rating in excess of 30 percent under Diagnostic Code 5257 for the left knee. In order to meet that criteria, the Veteran needed to manifest either severe recurrent subluxation or lateral instability. The Veteran was examined multiple times throughout the period on appeal, but the Veteran never manifested severe recurrent subluxation or lateral instability at any time during the period on appeal. The Board notes that the Veteran manifested a history of moderate lateral instability perhaps as early as December 6, 2016. Nevertheless, the Veteran either did not undergo testing or testing results were normal. The fact that the Veteran’s instability was so mild to avoid being detected during testing suggests that any instability that the Veteran manifested was not severe enough to be considered severe. Therefore, the weight of the evidence indicates that the Veteran is not entitled to a disability rating of 30 percent under Diagnostic Code 5257 for the left knee. The weight of the evidence indicates that the Veteran is entitled to an effective date of December 22, 2018 for the assignment of a disability rating of 40 percent for the left knee under Diagnostic Code 5261. The assignment of a disability rating of 40 percent was based on the result of a VA examination in October 2020 which indicated that the Veteran’s extension was limited to 30 degrees after taking additional functional impairment into consideration. The Veteran previously underwent a VA examination on December 21, 2018 which indicated that the Veteran’s extension was not so limited. Therefore, the Veteran should be assigned an effective date of December 22, 2018; the first day after the VA examination December 21, 2018 VA examination. As of this decision, the Veteran is being assigned the following disability ratings for the left lower extremity at or below knee level that are effective on or before December 22, 2018: a disability rating of 40 percent for limitation of extension; a disability rating of 20 percent for moderate lateral instability; and a disability rating of 10 percent of the left ankle. This results in a combined disability rating of 60 percent for the lower left extremity. 38 C.F.R. § 4.25. The combined disability rating for an extremity cannot exceed the rating for an elective amputation. 38 C.F.R. § 4.68. The disability rating for an elective amputation of the leg at the knee is 60 percent. 38 C.F.R. § 4.71a, Diagnostic Codes 5162-5164. Therefore, the Board shall not consider assigning any additional disability ratings of the left knee at or above December 22, 2018. The weight of the evidence indicates that the Veteran is not entitled to a separate disability rating pursuant under Diagnostic Codes 5258-5259 for the right knee. In order to meet the criteria for these Diagnostic Codes, the Veteran needed to manifest a cartilage condition of the right knee. The Veteran was examined multiple times throughout the period on appeal, but the Veteran did not manifest such a condition of the right knee. Therefore, a separate disability rating for a cartilage condition of the right knee under Diagnostic Codes 5258-5259 have not been met. The weight of the evidence indicates that the Veteran is entitled to separate compensable disability rating of 10 percent for the left knee under Diagnostic Code 5259 from the beginning of the period on appeal until December 21, 2018. The Veteran underwent meniscal surgery in order to remove semilunar prior to the commencement of the period on appeal. Therefore, the Veteran is entitled to a separate disability rating of 10 percent under Diagnostic Code 5259 for the left knee. Nevertheless, the Veteran has already been assigned a maximum disability rating of 60 percent effective December 22, 2018. Therefore, the disability rating shall end effective the day prior. The weight of the evidence indicates that the Veteran’s separate cartilage disability of the right knee should not be increased to a disability rating of 20 percent effective December 22, 2018. In order to meet these criteria, the Veteran needed to manifest “locking,” pain, and effusion into the joint. The Veteran did manifest pain throughout the period on appeal, but this has been separately compensated under the Veteran’s separate disability rating for loss of range of motion and limitation of extension. Additionally, the Veteran’s did not manifest “locking” or effusion of the left knee prior to December 22, 2018. The Board notes that the Veteran did manifest “locking” and effusion into the joint during an October 2020 VA examination, but, as discussed above, an increased disability rating is precluded based on the amputation rule. The Veteran is not entitled to an increased disability rating or a separate compensable disability rating pursuant to Diagnostic Codes 5260-5261 for the right knee prior to June 11, 2019 and for the left knee prior to December 22, 2018. In order to meet the criteria for an increased disability rating or a separate compensable disability rating, the Veteran needed to manifested: a flexion limited to 30 degrees or less; an extension limited to 15 degrees or more; or a flexion limited to 45 degrees or more and an extension limited to 10 degrees or more. The Veteran’s range of motion was measured multiple times throughout the period on appeal, and the Veteran never met these criteria. The weight of the evidence indicates that the Veteran is not entitled to a separate compensable disability rating for under Diagnostic Code 5263. Under Diagnostic Code 5263, a disability rating of 10 percent is assigned when the Veteran is diagnosed with genu recurvatum. The record is silent for a diagnosis of genu recurvatum. The Board does note that a June 2019 disability benefits questionnaire indicates that the Veteran manifest a hyperextension of five degrees. Nevertheless, the same provider declined to actually diagnose the Veteran with genu recurvatum. Therefore, the Board finds that the Veteran is not entitled to a separate compensable disability rating for genu recurvatum. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. Even if range of motion was slightly limited by pain however, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 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. Id. Even after taking additional functional impairment into consideration, the Veteran is not entitled to an increased disability rating pursuant to Diagnostic Codes 5260-5261, & 5263 for the right knee prior to June 11, 2019 and for the left knee prior to December 22, 2018. The Veteran was consistently able to perform repetitive range of motion testing without additional loss of range of motion during this time period. Additionally, VA examiners consistently opined that the Veteran’s opined that the Veteran’s knee disabilities did not manifest additional functional impairment during this time period. Therefore, the Veteran is not entitled to an increased disability rating pursuant to Diagnostic Codes 5260-5261 for the right knee prior to June 11, 2019 and for the left knee prior to December 22, 2018 even after taking additional functional impairment into consideration. Here, The weight of the evidence indicates that the Veteran is entitled to separate compensable disability rating for a cartilage condition of the left knee, an earlier effective date for the assignment of an instability condition the left knee, and an earlier effective date for the assignment of limitation of extension of the left knee. Therefore, the evidence in this case is evenly balanced enough so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, a disability rating for a cartilage condition as well as earlier effective dates for disability ratings for instability and limitation of extension of the left knee are granted. 8. A disability rating of 10 percent for scarring effective December 5, 2016 is granted. At issue is whether the Veteran is entitled to compensable disability rating for scarring. The weight of the evidence indicates that the Veteran is entitled to a disability rating of 10 percent. In an August 2017 rating decision, the Veteran was assigned a scar of the left knee effective December 5, 2016. The Veteran appealed. During the pendency of the appeal, the Veteran was assigned a noncompensable disability rating for scarring of the right knee. Disability ratings for scars are assigned pursuant to Diagnostic Codes 7800-7802 & 7804-7805. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7802, 7804-7805. Diagnostic Code 7800 (scars of the head, face, and neck) is not raised by the record, because the Veteran has not been granted service connection for scars of the head, face, or neck. Diagnostic Code 7805 (other disabling effects) is not raised by the record, because the Veteran’s scars have not manifested any additional disabling effects. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7802, 7804-7805. Under Diagnostic Code 7801, a disability rating of 10 percent is assigned for scars associated with underlying tissue damage with an area of six square inches (39 sq. cm) but less than 12 square inches (77 sq. cm), and a disability rating of 20 percent is assigned for scars associated with underlying tissue damage with an area with 12 square inches (77 sq. cm) but less than 72 square inches (465 sq. cm). A disability rating of 30 percent is assigned for scars associated with underlying tissue damage with an area with an area of at least 72 square inches (465 sq. cm) but less than 144 square inches (929 sq. cm), and a disability rating of 40 percent is assigned for scars associated with underlying tissue damage with an area of at least 144 square inches (929 sq. cm). 38 C.F.R. § 4.118, Diagnostic Code 7801. Under Diagnostic Code 7802, a disability rating of 10 percent is assigned for scars not associated with underlying tissue damage with an area of 144 square inches (929 sq. cm) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802. Under Diagnostic Code 7804, a disability rating of 10 percent is assigned for one or two painful or unstable scars. Diagnostic Code 7804 does provide for disability rating in excess of 10 percent, but these criteria requires that the Veteran manifest three or more painful or unstable scars; and the Veteran has only been assigned service connection for two scars. The Veteran testified at a personal hearing before the Board in August 2015, but this hearing occurred prior to the period on appeal. See Transcript. The Veteran’s treatment records indicate that the Veteran manifested scarring throughout the period on appeal. The Veteran underwent a VA examination in December 2016. The examiner noted that the Veteran had scar of the left knee that was .6 sq. cm. The examiner further indicated that the Veteran did not have any scars that were painful, unstable, having a total area equal to or greater than 39 sq. cm. The Veteran underwent another VA examination in December 2018. The examiner noted that the Veteran had scar of the left knee that was.6 sq. cm. The examiner further indicated that the Veteran did not have any scars that were painful, unstable, having a total area equal to or greater than 39 sq. cm. The Veteran submitted a disability benefits questionnaire completed by a private provider in July 2019. The examiner noted that the Veteran had three scars on the left knee with the following areas: 5 sq. cm; 3 sq. cm; 3 sq. cm; totalling 11 sq. cm. The Veteran underwent a VA examination in November 2020. The examiner indicated that the Veteran did not have any painful or unstable scars. The examiner indicated that the Veteran had a scar of the right knee that had an area of 19.5 sq. cm and a scar on the left knee that had an area of 3.75 sq. cm; for a total area of 23.25 sq. cm. The weight of the evidence indicates that the Veteran is entitled to a disability rating of 10 percent. The Veteran’s scar on the left knee was measured multiple times throughout the period on appeal. It has been various measured as .6 sq. cm; .5 sq. cm; and 3.75 sq. cm. These various measurements demonstrate to the Board that the Veteran’s scar of the left knee. Therefore, the Veteran is entitled to a disability rating of 10 percent. The weight of the evidence indicates that the Veteran is not entitled to a disability rating in excess of 10 percent. In order to meet the criteria for a disability rating in excess of 10 percent, the Veteran needed to manifest scarring that had an area of at least 12 square inches (77 sq. cm). The Veteran’s scars were measured multiple times throughout the period on appeal, and the area of the Veteran’s scars never approximated the area necessary for a disability rating in excess of 10 percent. Here, the weight of the probative evidence of record indicates that the Veteran is entitled to a disability rating of 10 percent for scarring. Therefore, the evidence in this case is evenly balanced enough so as to allow application of the benefit-of-the-   doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such a disability rating of 10 percent for scarring is granted. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Seaton 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.