Citation Nr: 21005980 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 11-02 447 DATE: February 3, 2021 ORDER Entitlement to a 20 percent evaluation, but no higher, for service-connected lumbar strain with osteoarthritis, is granted. Entitlement to an evaluation higher than 10 percent for service-connected left knee osteochondritis dissecans is denied. Entitlement to an evaluation higher than 10 percent for service-connected right knee chondromalacia is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran’s lumbar strain with osteoarthritis was manifested by abnormal spinal contour, reversed lordosis, and forward flexion limited to 50 degrees. 2. The Veteran’s left knee left knee osteochondritis dissecans is manifested by painful motion without extension limited to 15 degrees or flexion limited to 30 degrees, even when considering additional functional loss. 3. The Veteran’s right knee chondromalacia is manifested by painful motion without extension limited to 15 degrees or flexion limited to 30 degrees, even when considering additional functional loss. CONCLUSIONS OF LAW 1. The criteria for entitlement to a 20 percent evaluation, but no higher, for service- connected lumbar strain with osteoarthritis have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242 (2020.) 2. The criteria for entitlement to an evaluation higher than 10 percent for service- connected left knee osteochondritis dissecans have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5099-5014 (2020). 3. The criteria for entitlement to an evaluation higher than 10 percent for service- connected right knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5099-5014 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1997 to April 15, 2001 and from April 17, 2001 to October 2007. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2009 and September 2010 rating decisions of the Department of Veteran Affairs (VA) Regional Office (RO) in Waco, Texas. In October 2013 the Veteran presented testimony at a travel Board hearing before the undersigned Veterans Law Judge. These issues were previously before the Board in May 2014, March 2015, January 2018, and February 2020, when it was remanded for further development, that development was completed, and the case has since been returned to the Board for appellate review. The issue of entitlement to TDIU, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). Duties to Notify & Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board also finds that there has been substantial compliance with the prior February 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The issues were remanded to adequately assess the functional impact of the Veteran’s flare-ups. The Veteran received new VA examination in July 2020. Accordingly, the Board will proceed with appellate review. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2020). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2020). Where 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2020). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2020). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. 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. Increased Evaluation- Spine The Veteran filed a claim for increase in March 2010. The Veteran’s spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine (General Formula), a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as “a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. 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 submitted an August 2010 private spine examination. The Veteran reported moderate low back stiffness daily and severe flare-ups twice a month. The private provider indicated no assistive devices were needed. Objective physical testing showed abnormal spine curvature with slight decrease in lordosis. Range of motion testing showed forward flexion limited to 90 degrees, with no change after the 5th range of motion test. The private provider assessed pain, painful motion, and tenderness. Additionally, the private provider indicated muscle spasm with reversed lordosis. The lumbar spine x-ray showed mild osteoarthritic changes in the apophyseal joints of L5-S1. There was no evidence of motor or sensory deficit. The private provider did not indicate how flare-ups affected range of motion. During February 2011 VA physical therapy the Veteran reported back spasms. The Veteran received a January 2012 VA examination. The Veteran continued to report decreased mobility with flare-ups. Initial range of motion testing showed flexion limited to 70 degrees with pain beginning at 70 degrees. Forward flexion was limited to 70 degrees after repetitive use testing. The examiner indicated functional impairments of less movement than normal, pain on movement, and interference with sitting, standing, and/or weight bearing. The VA examiner did not indicate an abnormal gait, guarding, or muscle spasm. The sensory exam was normal, but the examiner did not answer regarding feet/toes or L5 involvement. The examination did not indicate radiculopathy, intervertebral disc syndrome (IVDS), or use of assistive devices. The examiner did not indicate how flare-ups affected range of motion. In August 2012 private treatment the Veteran noted low back pain, including pain with excessive bending, twisting, turning, lifting, and walking. The private provider noted moderate paraspinal spams. The private provider noted no sensory or motor deficits. The Veteran continued to report low back pain during April 2013, May 2013, and June 2013 private treatment. There was no change in the assessment by the private treatment provider. A March 2014 VA treatment record also endorsed low back pain and included a June 2013 lumbar x-ray that showed slight anterior osteophyte formation is demonstrated involving the L4 vertebral body. The Veteran received an October 2014 VA examination. The Veteran continued to report flare-ups and stated he was usually in bed all day and could not do anything during a flare-up. Initial range of motion testing showed flexion limited to 80 degrees with pain beginning at 80 degrees. Forward flexion was limited to 80 degrees after repetitive use testing. The examiner indicated functional impairments of less movement than normal and pain on movement. There was no evidence of radiculopathy or use of assistive devices. The examiner did not address how range of motion was affected during a flare-up. The examiner noted subjective expressions exceeded objective findings and indicated the Veteran was able to dress and undress without assistance. The Veteran received an August 2016 VA examination. The Veteran reported numbness in both lower legs. The Veteran did not report flare-ups. The examiner noted the Veteran did not have previous low back surgery, physical therapy, or injections. Initial range of motion testing showed flexion limited to 50 degrees. The examiner determined pain did not contribute to a functional loss. There was no additional functional loss after repeated use testing. The examiner did not provide an opinion regarding repeated use overtime because it was not examined. There was no response provided regarding flare-ups. There was no evidence of radiculopathy or use of assistive devices. The Veteran received an August 2018 VA examination. The Veteran reported back spasm but denied specialized treatment for his back pain. The Veteran reported flare-ups with exertion such as repetitive lifting or bending. Initial range of motion testing showed flexion limited to 70 degrees. The examiner noted pain with palpitation but no pain with weight bearing. The examiner noted no additional functional loss with observed repetitive use. Regarding flare-ups and repeated use over time, the examiner was unable to provide an opinion because it was not observed. The examiner noted hypoactive bilateral knee. There was no evidence of radiculopathy or use of assistive devices. The RO requested the examiner to provide an addendum opinion regarding the Veteran’s flare-ups. In a June 2019 opinion, the examiner stated the Veteran would have to be recalled for an examination. The Veteran received a July 2020 VA examination. The Veteran reported severe flare-ups once per week. Initial range of motion testing showed all normal ranges of motion. The examiner noted forward flexion exhibited pain but did not cause functional loss. The examiner found no pain with weight bearing, no pain on palpitation, and no additional loss of function after three repetitions. The examiner indicated the examination was consistent with repetitive use over time and that pain caused functional loss with repeated use over time. The examiner noted forward flexion was limited to 70 degrees with repetitive use over time. The examiner indicated the examination was medically consistent with a flare-up and indicated pain cause functional loss with flare-up. The examiner noted forward flexion was limited to 70 degree during a flare-up. The examiner noted guarding or muscle spasms without abnormal spinal contour. The examiner noted hypoactive right knee. There was no evidence of ankylosis, radiculopathy, or use of assistive devices. The Board finds a 20 percent evaluation is warranted for the entire period on appeal because the lumbar strain with osteoarthritis was manifested by abnormal spinal contour and forward flexion limited to 50 degrees. Throughout the period on appeal, the Veteran had a private examination, VA examinations, private treatment, and VA treatment. The evidence of records showed abnormal spine curvature and forward flexion limited to 50 degrees at its worst. Although most of the examinations did not adequately address the Veteran’s flare-ups, the 2020 VA examination noted 70 degrees of flexion with consideration of flare-ups. Accordingly, the Board finds that the earlier findings of 50 to 90 degrees of flexion without consideration of flareups, would not dip below 30 degrees even, when considering additional functional loss, to include flare-ups. Thus, a 20 percent evaluation is for assignment. A higher 40 percent is not warranted. Forward flexion was limited to 50 degrees but at no point has the evidence shown forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine, including taking functional loss into account. Additionally, the evidence has not shown, and the Veteran has not asserted, 4 weeks of bed rest in a year due to IVDS. Finally, the evidence does not support any radiculopathy or neurological symptoms. Accordingly, a higher or separate evaluation is not warranted. Increased Evaluation- Knees The Veteran filed a claim for increased evaluation of his bilateral knee disabilities in May 2009. The Veteran’s knee disabilities are rated under DC 5099-5014. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be “built-up” as follows: the first 2 digits will be selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be “99” for all unlisted conditions. 38 C.F.R. § 4.27 (2020). The Veteran’s knees are evaluated as 10 percent disabling under Diagnostic Code 5014, osteomalacia. Osteomalacia is to be rated based on limitation of motion of the affected part, as degenerative arthritis under 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5261, a 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. In April 2009 private treatment, the Veteran complained of bilateral knee pain. The private provider observed bilateral swelling and tenderness. The private provider indicated good flexion and extension. The Veteran returned in May 2009 and reported bilateral knee pain. A June 2009 private treatment x-ray showed no acute processes. The June 2009 right knee x-ray showed mild capsular distention. The June 2009 private treatment noted the x-rays were normal except of evidence of arthritis. During August 2009 private treatment the provider indicated crepitus upon passive range of motion. All joint stability tests were negative. The provider observed bilateral joint line tenderness. The Veteran reported popping and locking, and the private provider recommended an MRI. The Veteran received an August 2009 VA examination. The Veteran reported flare-ups, aching, and pain. The Veteran indicated he wears a knee brace daily and experiences left knee locking. The Veteran reported bilateral knee joint symptoms of giving way, pain, and stiffness. The was no evidence of bilateral knee instability, dislocation, subluxation or effusion. The Veteran reported bilateral moderate flare-ups weekly and lasting for hours, precipitated by standing. The examiner observed normal gait, bilateral grinding, tenderness, and crepitus. The examiner found no evidence of instability or meniscus abnormality. Range of motion testing showed left knee flexion from 0 to 130 and right knee flexion from 0 to 130. The examiner noted the Veteran always uses a brace. During October 2009 VA treatment the Veteran reported a meniscal tear. The Veteran received a November 2009 VA orthopedic follow-up. The Veteran stated his private treatment provider indicated a meniscal tear via MRI. The VA treatment provider noted the Veteran did not provide the MRI results and ordered a new MRI. January 2010 VA treatment showed MRI results of right degenerative changes meniscus and left degenerative changes meniscus and left knee osteochondritis desiccans. The private provider noted minimal findings were discussed with the Veteran. In March 2010 VA treatment, the Veteran underwent left knee arthroscopic surgery for left knee pain and possible torn meniscus. The post-operative diagnosis was scarring in notch with normal articular cartilage and menisci. The Board notes that from March 2010 to May 2010 the Veteran received a 100 percent evaluation for his left knee due to surgery and recovery. In September 2010 private treatment, the Veteran reported bilateral knee pain. September 2010 left knee x-ray showed osteoarthritis, no effusion, and no subluxation. Right knee x-ray showed osteoarthritis, no effusion, and no subluxation. The private provider indicated crepitus with flexion an extension, no tenderness, and range of motion from 0 to 130 degrees. The private provider noted there was no evidence of instability and instability test were negative. The private provider recommended physical therapy. During October 2010 VA treatment, the treatment provider noted the right knee MRI showed early degenerative changes in menisci but no tears. The VA treatment provider recommended physical therapy and reduction of body mass index. In January 2011 VA treatment, the Veteran reported bilateral knee pain. The VA treatment provider recommend bilateral knee braces during activity, aquatic therapy, icing, and elevation. In February 2011, the Veteran received an aquatic therapy treatment plan. The treatment provider noted bilateral lower extremities range of motion within normal limits but strength testing fair. The Veteran continued with aquatic therapy February 2011, March 2011, and April 2011 The Veteran received a January 2012 VA examination. The Veteran reported locking, popping, and pain in both knees. The Veteran indicated his left knee gives way the most causing him to fall. The Veteran reported right knee swelling and stiffness in both knees in the morning. Initial range of motion testing showed right knee flexion ended at 110 degrees with normal extension and left knee flexion ended at 90 degrees with normal extension. There was bilateral objective evidence of pain on examination. There was no additional loss after repetitive use testing. The examiner indicated bilateral symptoms of less movement than normal, pain on movement, and pain on palpitation. Joint stability and strength test were normal. The examiner noted bilateral frequent episodes of locking and pain. The examiner noted regular use of a brace and occasional use of a cane. During April 2013 and May 2013 private treatment the Veteran reported bilateral knee pain. The private provider noted bilateral knees abnormal. In June 2013 private treatment the provider noted bilateral knee effusions with x-rays done one day prior. The Veteran received a right knee injection. During March 2014 VA treatment the Veteran received a physical therapy assessment. The VA treatment provider indicated bilateral lower extremities with limited range and range of motion within functional limits. Right knee flexion was limited to 75 degrees and left knee flexion was limited to 80 degrees. The VA treatment provider indicated negative testing for instability. The Veteran received an October 2014 VA examination. The examiner indicated the Veteran did not report flare-ups. Initial range of motion testing showed right knee flexion limited to 90 degrees without objective evidence of pain and normal extension. Left knee flexion limited to 80 degrees without objective evidence of pain and normal extension. There was no changed after repetitive use testing. The examiner noted functional loss to include less movement than normal bilaterally. Joint strength and stability testing were normal. The examiner noted meniscal condition with frequent episodes of joint pain. The examiner noted regular use of knee braces but stated there was no sign of instability, crepitus, or subluxation. The Veteran received an August 2016 VA examination. Initial range of motion testing showed right knee flexion limited to 113 degrees and extension 130 to 0 degree. The examiner noted flexion exhibited pain. Left knee flexion was limited to 130 degrees an extension from 130 to 0 degrees. There was no additional functional loss with repetitive use. The examiner did not indicate impairment of repeated use over time noting it was not examined. There was no answer provided regarding flare-ups. There was no evidence of diminished strength, ankylosis, or joint instability. The examiner noted left knee pain as a surgery residual. The examiner noted that braces and a cane were used regularly. In May 2017 VA treatment the Veteran received a new left knee brace. The VA treatment provider indicated it was for support and alignment, reducing swelling, decreasing pain, providing symmetry, increasing range of motion, facilitating healing of injury, and preventing deformity. The Veteran received a June 2017 VA examination. The Veteran reported bilateral knee pain and knee buckling. Initial range of motion testing showed right knee flexion limited to 110 degrees and extension 110 to 0 degree. The examiner noted flexion exhibited pain. Left knee flexion was limited to 130 degrees an extension from 130 to 0 degrees. The examiner noted flexion exhibited pain. The examiner indicated left knee pain on palpitation. There was no additional functional loss with repetitive use. The examiner did not indicate impairment of repeated use over time noting it was not examined. There was no answer provided regarding flare-ups. Muscle strength testing was normal, there was no evidence of ankylosis, joint instability, or recurrent effusion. Xray’s showed minimal degenerative changes in the left knee and normal right knee. No assistive devices were indicated, and the examiner emphasized there was no objective evidence of joint instability. During November 2017 VA treatment the Veteran reported no flare-ups with joints getting really warm, painful or swollen. The Veteran endorsed joints being achier and sorer with good and bad days. The Veteran endorsed his knees becoming swollen sometimes. The Veteran denied any falls or knees giving out on him. The Veteran received a July 2018 VA examination. The Veteran reported flare-ups with extended standing. Initial range of motion testing showed right knee flexion limited to 110 degrees and extension 110 to 0 degree. The examiner noted flexion exhibited pain and pain along the joint line. Left knee flexion was limited to 125 degrees an extension from 125 to 0 degrees. The examiner noted flexion exhibited pain and pain along the joint line. There was no additional functional loss with repetitive use. The examiner stated there was no additional functional impairment with repeated use over time. The examiner did not provide an opinion regarding flare-ups because they were not observed. Muscle strength testing was normal, there was no evidence of ankylosis, or joint instability. The examiner noted a history of recurrent effusion per the Veteran’s report but stated it was not documented over the last two years. The examiner noted frequent episodes of joint pain. There was no indicated of use of assistive devices. A June 2019 VA medical opinion was provided that stated the Veteran needed to report for re-examination to assess flare-ups. A September 2019 VA examination addendum indicated flare-ups were not observed and the Veteran did not report loss of functional ability or describe additional loss in range of motion with flare-ups. The Veteran received a July 2020 VA examination. The Veteran reported right knee flare-ups once or twice per week and left knee flare-ups three or four per month. The Veteran indicated the flare-ups were moderate in severity. Initial range of motion testing showed right knee flexion limited to 120 degrees and extension 120 to 0 degree. The examiner noted pain on flexion and extension and objective evidence of crepitus. Left knee range of motion testing showed flexion limited to 120 degrees and extension 120 to 0 degree. The examiner noted left knee pain on palpitation. The examiner noted no additional function loss with repetitive use. The examiner assessed with repeated use over time, right knee flexion was limited to 110 degrees and extension limited to 10 degrees. The examiner assessed left knee flexion limited to 115 degrees and extension to 10 degrees with repeated use over time. The examiner assessed with flare-ups, right knee flexion was limited to 110 degrees and extension limited to 10 degrees. The examiner assessed left knee flexion limited to 115 degrees and extension to 10 degrees with flare-ups. Muscle strength testing was normal, there was no evidence of ankylosis, or joint instability. The examiner noted a history of recurrent effusion and stated the Veteran described regular swelling of bilateral knees after any significant activity, and described history of getting fluid removed from left knee. The examiner did not note meniscal conditions or frequent episodes of joint effusion. The examiner found no objective evidence of pain in non-weight bearing or on passive range of motion testing. The Board finds the Veteran’s bilateral knee disability is not manifested by extension limited to 15 degrees or flexion limited to 30 degrees, even when considering additional functional loss. At its worst, flexion was limited to 75 or 80 degrees. The 2020 VA examination was the only one that adequately considered flare-ups, and it reduced the range of flexion by 5 or 10 degrees. Applying that to the most severe flexion findings would result in flexion to 65 degrees. Furthermore, the July 2020 VA examination showed limitation of extension to 10 degrees during a flare-up. Moreover, although the evidence shows painful motion, there was good muscle strength and reflexes throughout the time period. Repetitive use also did not reduce flexion or extension to the level required for a 20 percent evaluation. Accordingly, a higher evaluation is not warranted for the bilateral knee disabilities under DCs 5260 and 5261. All potentially applicable diagnostic codes have been considered. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991) (holding that the Board must consider all potentially applicable regulatory provisions). The evidence does not demonstrate right or left knee ankylosis, tibia or fibula impairment, or genu recurvatum. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Additionally, the evidence does not show removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Thus, higher or separate evaluations are not warranted under these diagnostic codes. The Board finds that a higher or separate evaluation is not warranted for dislocated semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5258. In March 2010 VA treatment, the Veteran underwent left knee arthroscopic surgery for left knee pain and possible torn meniscus. The post-operative diagnosis was scarring in notch with normal articular cartilage and menisci. Additionally, some of the VA examinations indicated recurrent popping and locking related to meniscal condition based on prior surgery – it does not appear that these examiners were aware of the findings of the surgery. The Board affords significant probative weight to the findings of the specialist who operated over the VA C & P examiners who only saw the Veteran once. The Veteran has reported a history of effusion but for the entire period on appeal, but only a June 2013 private treatment record showed bilateral effusion on Xray. The Board finds preponderance of the evidence weighs against the finding of an increased or separate evaluation for a meniscal condition. Lastly, separate or increased evaluations are not warranted for instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. During the October 2013 Board hearing the Veteran reported his knees would give out and cause falls. During the August 2009 VA examination the Veteran reported giving way and during a June 2017 VA examination the Veteran reported buckling and instability. All objective medical evidence, including VA treatment, private treatment, and VA examinations, has found no evidence of knee joint instability. Additionally, the Board does not find the Veteran’s statements credible because they are inconsistent. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff’d, 78 F.3d 604 (Fed. Cir. 1996). During November 2017 VA treatment, the Veteran denied knee instability, giving way, or falls. Notably, the VA treatment was five months after the June 2017 VA examination. Accordingly, a separate increased evaluation is not warranted as the most probative evidence of record demonstrates no instability. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim of evaluations higher than 10 percent for bilateral knee disabilities. In denying such an evaluation, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND TDIU Remand is required for additional development regarding the Veteran’s employment status. During the July 2020 VA back examination, the Veteran reported he was off work for half off the year due to his back pain. The Veteran’s TDIU application was submitted in September 2015. On the application the Veteran indicated he last worked full-time in March 2015. The Veteran should be sent a new application to determine employment status as it is pertinent to the TDIU claim. Accordingly, remand is required. The matters are REMANDED for the following action: Provide the Veteran a letter explaining the factors pertinent to establishing entitlement to a TDIU. The letter must be enclosed with a VA From 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. The letter should inform the Veteran that it is vital to his appeal for entitlement to a TDIU that he provide the information requested on the VA Form 21-8940, to include, but not limited to, a detailed explanation of his employers, the nature of the work performed, the dates of employment, and his reasons for leaving his employment during the appeal period. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bruton, Associate 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.