Citation Nr: 21007541 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 15-19 464 DATE: February 9, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for left knee strain prior to June 2, 2015, is denied. Entitlement to a disability rating of 20 percent, but no greater, for left knee strain for the period from June 2, 2015, to June 20, 2018, is granted. Entitlement to a disability rating in excess of 30 percent for left knee strain since June 20, 2018, is denied. Entitlement to a disability rating in excess of 10 percent for left knee instability is denied. FINDINGS OF FACT 1. Prior to June 2, 2015, the Veteran’s left knee strain was manifested, at worst, by flexion limited to 110 degrees and extension limited to 10 degrees, with no evidence of arthritis, ankylosis, dislocated and/or removed semilunar cartilage, tibia and/or fibula impairment, or genu recurvatum. 2. For the period from June 2, 2015, to June 20, 2018, the Veteran’s left knee strain was manifested, at worst, by flexion limited to 105 degrees and extension limited to 15 degrees, with no evidence of arthritis, ankylosis, dislocated and/or removed semilunar cartilage, tibia and/or fibula impairment, or genu recurvatum. 3. Since June 20, 2018, the Veteran’s left knee strain was manifested, at worst, by flexion limited to 100 degrees and extension limited to 20 degrees, with no evidence of arthritis, ankylosis, dislocated and/or removed semilunar cartilage, tibia and/or fibula impairment, or genu recurvatum. 4. Throughout the rating period on appeal, the Veteran’s left knee strain has been productive of slight instability, with no objective evidence of anterior instability, posterior instability, medial instability, and/or lateral instability. CONCLUSIONS OF LAW 1. Prior to June 2, 2015, the criteria for a disability rating in excess of 10 percent for left knee strain have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2019). 2. For the period from June 2, 2015, to June 20, 2018, the criteria for a disability rating of 20 percent, but no greater, for left knee strain have been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2019). 3. Since June 20, 2018, the criteria for a disability rating in excess of 30 percent for left knee strain have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2019). 4. Throughout the rating period on appeal, the criteria for a disability rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1983 to August 1988, and from February 1991 to April 1991. These issues come before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 Rating Decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before a Veteran’s Law Judge (VLJ) at a Travel Board hearing in June 2018. A transcript of that hearing has been associated with the claims file. In correspondence dated in November 2020, the Veteran was notified that the VLJ who conducted his June 2018 Travel Board hearing was no longer employed at the Board, and was given the opportunity to testify at another hearing. However, as the Veteran did not respond within the applicable time period, it is assumed that he did not want another hearing and the Board will proceed using the hearing testimony currently of record. On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA’s decision on their claim to seek review. Here, the Veteran has not opted-in to VA’s test program, the Rapid Appeals Modernization Program (RAMP). Although the AMA was implemented effective February 19, 2019, the Rating Decision on appeal was issued prior to that date. Accordingly, the Board will review his appeal under the existing Legacy Appeals System. Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, and 5126 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2018); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, the Veteran has not raised any issues with regard to 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 issue of entitlement to an increased disability rating for left knee strain was previously before the Board in February 2019, at which time it was remanded for additional development. Specifically, the Board’s Remand directed that the RO readjudicate the claim, with consideration of all evidence associated with the claims file since the issuance of the May 2016 Supplemental Statement of the Case. The issue was subsequently readjudicated by the RO in a March 2020 Supplemental Statement of the Case. Thus, the Board finds that there has been substantial compliance with its previous remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a remand request is required). The Veteran seeks entitlement to higher ratings for left knee strain and left knee instability. By way of history, the Veteran filed his claim of entitlement to an increased rating for “left knee condition” in October 2013, at which time his service-connected left knee strain was evaluated as 10 percent disabling under Diagnostic Code 5257. On the day of the Veteran’s June 2018 Travel Board hearing, at which time testimony was taken with respect to his claim of entitlement to an increased evaluation for left knee strain, the Veteran submitted a supplemental claim seeking a separate evaluation for left knee instability. The RO interpreted this submission as a new claim for service connection and developed it accordingly. As such, additional evidence, such as VA treatment records and an August 2018 VA Knee and Lower Leg Conditions examination, directly relevant to the Veteran’s left knee strain claim already on appeal, was added to the record. In an August 2018 Rating Decision, the RO incorrectly framed and decided these issues as new claims which were filed on June 20, 2018, and increased the Veteran’s disability rating for left knee strain to 30 percent under Diagnostic Code 5261 effective the date the claim for left knee stability was received, while denying the issue of entitlement to a separate rating for left knee strain. In a subsequent March 2020 Rating Decision, the RO granted a separate disability rating for left knee instability and assigned an evaluation of 10 percent pursuant to Diagnostic Code 5257 effective October 9, 2013, the date of his initial claim for an increased rating. As such, the Board will assess the propriety of the 10 percent rating in effect for left knee strain in effect prior to June 20, 2018; the 30 percent rating for left knee strain in effect since June 20, 2018; as well as the 10 percent rating for left knee instability in effect throughout the entire rating period on appeal. Disability ratings are determined by applying the criteria established in VA’s Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2014); 38 C.F.R. §§ 4.1, 4.20 (2019). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2019). Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3 (2019). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found; this practice is known as staged ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s left knee strain is currently rated under Diagnostic Code 5261 (leg, limitation of extension of). Under Diagnostic Code 5261, a noncompensable rating is warranted when extension is limited to 5 degrees. A 10 percent rating is warranted when extension of the leg is limited to 10 degrees. A 20 percent rating is warranted when extension is limited to 15 degrees. A 30 percent rating is warranted when extension is limited to 20 degrees. A 40 percent rating is warranted when extension is limited to 30 degrees. A 50 percent rating is warranted when extension is limited to 45 degrees. 38 C.F.R. § 4.71a (2019). Normal extension is zero degrees. 38 C.F.R. § 4.71, Plate II (2019). Additionally, under Diagnostic Code 5260, a noncompensable rating is warranted when flexion is limited to 60 degrees. A 10 percent rating is warranted when flexion of the leg is limited to 45 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a (2019). Normal flexion is 140 degrees. 38 C.F.R. § 4.71, Plate II (2019). Diagnostic Codes 5260 and 5261 are for limitation of motion. 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.”). The Veteran’s left knee instability is currently rated under Diagnostic Code 5257 (knee, other impairment of). Pursuant to Diagnostic Code 5257, a 10 percent rating is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted when there is severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a (2019). Diagnostic Code 5257 is based upon instability and subluxation, not limitation of motion, as a result, the factors set forth in 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 do not apply. DeLuca, 8 Vet. App. 202. The words “slight,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2019). It should also be noted that use of terminology such as “severe” by VA examiners and others, 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 (2019). Here, there is no evidence of left knee arthritis. As such, a rating under Diagnostic Code 5003 is not for application. Similarly, there is no evidence of ankylosis to warrant a rating under Diagnostic Code 5256, no evidence of dislocated or removed semilunar cartilage to warrant a rating under Diagnostic Codes 5258 or 5259, no evidence of tibia and/or fibula impairment to warrant a rating under Diagnostic Code 5262, and no evidence of genu recurvatum to warrant a rating under Diagnostic Code 5263. 38 C.F.R. § 4.71a (2019). An April 2011 VA orthopedics consultation note indicated that the Veteran sustained three hyperextension injuries to the left knee over the previous month, and expressed that he could not trust his left knee stability-wise due to the knee wanting to give way or hyperextend. Upon objective range of motion testing, the Veteran’s left knee flexion was to 125 degrees while his extension was to zero degrees. The Veteran was provided with a VA Knee and Lower Leg Conditions examination in December 2013, at which time he was diagnosed as having left knee strain. Subjectively, the Veteran reported that over years his left knee progressively worsened with activities such as walking long distances, sitting, and running. Additionally, the Veteran indicated that he was a phlebotomist and could not walk around to do his job duties as a result of his left knee pain. Range of motion testing revealed flexion limited to 110 degrees and left knee extension limited to 10 degrees. The Veteran was able to perform repetitive-use testing with three repetitions, and did not exhibit any additional limitation in range of motion of the knee and lower leg following repetitive-use testing. The Veteran exhibited functional loss and/or functional impairment of the left knee and lower leg manifested by less movement than normal, weakened movement, incoordination, impaired ability to execute skilled movements smoothly, pain on movement, disturbance of locomotion, and limping (favoring left over right). Additionally, the Veteran exhibited tenderness or pain to palpation for joint line or soft tissues of the left knee. Muscle strength testing revealed active movement against some resistance in the left knee. Joint stability testing revealed normal anterior instability (Lachman test), posterior instability (Posterior drawer test), and medial-lateral instability. There was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran did not have any meniscal conditions or surgical procedures for a meniscal condition, and no joint replacement or other surgical procedures. X-rays revealed slight medial compartment narrowing, as well as a 2-milimeter ossified fragment adjacent to the medial surface of the medial tibial epiphysis of uncertain etiology but with no definite overlying soft tissue swelling to suggest an acute process. The Veteran regularly wore a knee brace. However, there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. A February 2014 VA addendum opinion stated that although pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups or when the joint was used repeatedly over a period of time, any additional limitation of range of motion in the left knee could not be estimated by the examiner. A VA treatment note dated on June 2, 2015, indicated that the Veteran’s left knee extension was limited to 15 degrees. The Veteran was provided with another VA Knee and Lower Leg Conditions examination in August 2015, at which time he was again diagnosed as having left knee strain. The examiner noted that the Veteran’s pain was consistent with redundant patellar tendon pain and instability and that he was treated with plasma injections. Range of motion testing revealed left knee flexion limited to 105 degrees and left knee extension limited to 10 degrees. Pain noted on examination contributed to functional loss, although the range of motion itself did not contribute to functional loss. There was evidence of pain with weight bearing as well as objective evidence of localized tenderness over the patellar tendon. There was no evidence of crepitus. The Veteran was able to perform repetitive-use testing with three repetitions, and did not exhibit any additional functional loss or limitation in range of motion of the knee and lower leg following repetitive-use testing. The examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Muscle strength testing revealed a reduction in left knee muscle strength, manifested by active movement against some resistance during forward flexion and extension; however, there was no evidence of muscle atrophy or ankylosis. Joint stability testing revealed no history of recurrent subluxation, lateral instability, or recurrent effusion. Anterior instability (Lachman test), posterior instability (posterior drawer test), medial instability, and lateral instability were all within normal limits. There was no evidence of patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. Similarly, there was no evidence of meniscus (semilunar cartilage) condition. X-rays revealed no evidence of degenerative or traumatic arthritis. The Veteran walked with a pronounced antalgic gait favoring the left knee, constantly used an offloading knee brace, and regularly used a cane. However, there was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran testified at a Travel Board hearing in June 2018, at which time he testified that he could only walk for a block or two due to his left knee pain, and that he also experienced buckling and instability of the left knee. The Veteran was provided with another VA Knee and Lower Leg Conditions examination in August 2018, at which time he was again diagnosed as having left knee strain, and left knee tendonitis/tendonosis. Subjectively, the Veteran reported constant left knee pain in the anterior and medial aspect of the left knee, as well as weakness and frequent buckling and giving out associated with sharp pain. The Veteran further described flare-ups of severe pain with swelling and warmness occurring approximately 2 to 3 times per week. Range of motion testing revealed left knee flexion limited to 100 degrees and left knee extension limited to 20 degrees. This limited range of motion itself contributed to a functional loss in that the Veteran could not fully extend his knee, which effected his walking and standing. There was objective evidence of localized tenderness over the patellar tendon, as well as evidence of pain with weightbearing and crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions, although there was no additional loss of function or range of motion after three repetitions. The examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Muscle strength testing revealed a reduction in left knee muscle strength, manifested by active movement against some resistance during forward flexion and extension; however, there was no evidence of muscle atrophy or ankylosis. Joint stability testing revealed no history of recurrent subluxation, lateral instability, or recurrent effusion. Anterior instability (Lachman test), posterior instability (posterior drawer test), medial instability, and lateral instability were all within normal limits. There was no evidence of recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, any other tibial or fibular impairment, or a meniscus (semilunar cartilage) condition. The Veteran reported regular use of a knee brace and occasional use of a cane when at home and not wearing the knee brace. X-rays revealed no joint effusion and no acute findings. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The Veteran also reported that he worked from home as an information technology technician and that less than one week of work time was lost in the last 12 months. The Veteran was provided with another VA Knee and Lower Leg Conditions examination in December 2019, at which time he was diagnosed as having left knee strain and left knee tendonitis/tendonosis. Subjectively, the Veteran reported constant use of a left knee brace while walking for stability, and that his knee pain was now constant (causing him to wake once per night). The Veteran further reported that he was able to work installing computer hardware without restrictions, but did modify work by using a portable collapsible chair instead of kneeling and ascended ladders leading with the same leg. Range of motion testing revealed left knee flexion limited to 120 degrees and left knee extension limited to 10 degrees. However, the range of motion itself did not contribute to functional loss, and while pain was noted on examination it did not result in/cause functional loss. There was evidence of pain with weight bearing as well as objective evidence of localized tenderness or pain on palpation of the joint line. There was no objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions, with no additional functional loss or range of motion after three repetitions. The examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time as well as his statements describing functional loss during flare-ups. Although pain significantly limited functional ability with repeated use over a period of time and during flare-ups, this did not result in additional limited range of motion. Muscle strength testing revealed normal strength in the left knee, with no evidence of muscle atrophy or ankylosis. Joint stability testing revealed no history of recurrent subluxation, lateral instability, or recurrent effusion. Anterior instability (Lachman test), posterior instability (posterior drawer test), medial instability, and lateral instability were all within normal limits. The Veteran did not exhibit recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, any other tibial and/or fibular impairment, or a meniscus (semilunar cartilage) condition. The Veteran did exhibit an abnormal gait while wearing knee orthosis, as well as a lack of complete knee extension causing shortened step length on the left side. The Veteran regularly used a left knee brace when active to prevent twisting and buckling. There was no functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Although there was evidence of pain on passive range of motion testing as well as evidence of pain when the joint is used in non-weight bearing, the opposing joint was undamaged (in a March 2020 addendum opinion, the VA examiner clarified that the Veteran exhibit full range of motion in the opposing right knee joint). In an attached medical opinion, the VA examiner who conducted the December 2019 VA Knee and Lower Leg Conditions examination explained: The veteran's service connection for a left knee strain was originally described in STRs a patellofemoral pain. Therefore the veteran's 2011 diagnosis of tendonitis (patellofemoral) is at least as likely as referring to the same chronic disability as strain. Additional support for this opinion is the veteran's exam in STRs is also very similar to exam for DBQ. Abnormalities seen in today's DBQ, pain, tenderness, and limited motion symptoms of knee strain/tendonitis. Although the veteran reports left knee instability and a 2019 CBOC evaluation notes instability for which a knee brace was recommended, knee instability was not added as an additional diagnosis. The symptom of knee buckling/instability is a residual of the veteran's diagnosis of strain/tendonitis. Exam for DBQ was negative for knee instability and there is no medical evidence the veteran has been diagnosed or treated for the separate condition of left knee instability." Many people with PFP [tendonitis] report instability or their knee "giving out", which stems from pain causing reflex inhibition of the quadriceps." [Up to Date] Evaluating the Veteran’s left knee disability under Diagnostic Code 5261, prior to June 2, 2015, his left knee extension was limited to 10 degrees or less. As such, a disability rating in excess of 10 percent for limited left knee extension is not warranted at any time prior to June 2, 2015. However, it was the June 2, 2015, VA treatment note that first documented left knee extension limited to 15 degrees. As such, the Board finds that the Veteran is entitled to a 20 percent disability rating under Diagnostic Code 5261, but no higher, effective June 2, 2015. It was not until the August 2018 VA Knee and Lower Leg Conditions examination that the Veteran’s left knee extension was limited to 20 degrees. As such, the Board will not disturb the current June 20, 2018, effective date for the grant of a 30 percent disability for limited left knee extension under Diagnostic Code 5261. However, the Board notes that at no time has that Veteran’s left knee extension been limited to more than 20 degrees. Therefore, a disability rating in excess of 30 percent is not warranted at any time during the rating period on appeal. Similarly, the evidence does not show left knee flexion limited to 45 degrees or less at any time during the rating period on appeal to warrant a compensable rating under Diagnostic Code 5260; rather, at worst, the Veteran’s left knee flexion has been limited to 100 degrees. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. The Board observes, however, that the current 10, 20, and 30 percent staged ratings for the left knee disability under Diagnostic Code 5261 contemplate the effects of any complaints of pain, fatigue, swelling, weakness, or lack of endurance. Significantly, the VA examiners performed repetitive testing and considered the point at which the Veteran demonstrated pain on motion. Even considering those factors, the Veteran did not exhibit flexion limited to less than 100 degrees or extension limited to less than 20 degrees at any time during the rating period on appeal. Accordingly, consideration of other factors of functional limitation does not support the grant of a rating in excess of the 10, 20, and 30 percent staged ratings already assigned. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. Regarding left knee instability, the Veteran has complained of his left knee wanting to give way or hyperextend since April 2011. The December 2013 VA Knee and Lower Leg Conditions examination indicated that he regularly wore a knee brace while walking for stability. However, all VA examination reports found that there was no history of recurrent subluxation, lateral instability, or recurrent effusion, while joint stability testing consistently indicated that anterior instability (Lachman test), posterior instability (posterior drawer test), medial instability, and lateral instability were all within normal limits. The December 2019 VA examiner acknowledged that the symptom of knee buckling/instability is a residual of the Veteran’s diagnosed strain/tendonitis, and indicated that many people with tendonitis reported instability or their knee “giving out”, which stemmed from pain causing reflex inhibition of the quadriceps. As such, the Board finds that the Veteran’s current separate 10 percent disability rating for “slight” left knee instability is warranted. However, given the negative instability testing results throughout the rating period on appeal, the Board concludes that the Veteran’s left knee instability has not been “moderate” or “severe” in nature. As such, a separate disability evaluation in excess of 10 percent is not warranted at any time during the rating period on appeal. To summarize, the Board finds that the preponderance of the evidence demonstrates that the Veteran is entitled to a 10 percent rating (but no greater) for limited left knee extension prior to June 2, 2015; entitled to a 20 percent rating (but no greater) for limited left knee extension from June 2, 2015, to June 20, 2018; and entitled to a 30 percent rating (but no greater) for limited left knee extension since June 20, 2018, under Diagnostic Code 5261. Additionally, the Veteran is entitled to a 10 percent rating (but no greater) for left knee instability throughout the rating period on appeal. Although the record suggests that the Veteran experiences a sensation of left knee instability as a result of reflex inhibition of the quadriceps due to pain associated with his service-connected left knee disability, joint stability testing conducted in December 2013, August 2015, August 2018, and December 2019 were negative for instability. We acknowledge that the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries has been revised effective February 7, 2021, but find that higher or separate ratings are not warranted on any available basis. 85 Fed. Reg. 76453 (Nov. 30, 2020). Therefore, disability ratings for limited extension and instability in excess of those delineated above are not warranted for the period on appeal. In reaching these conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against assignment of higher ratings, that doctrine is not applicable. See 38 U.S.C. § 5107(b). With respect to both claims, the Court has held that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008), aff’d sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires the Board to determine whether the “evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.” Id. This requires the Board to compare a veteran’s specific symptoms and their severity with those contemplated by the rating schedule. King v. Shulkin, 29 Vet. App. 174, 178-79 (2017). If the Board determines that a veteran’s symptoms or their severity is not contemplated by the rating schedule, then the second element requires the Board to “determine whether the claimant’s exceptional disability picture exhibits other related factors,” such as marked interference with employment or frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Finally, if the first two elements are met, the final element mandates that the Board refer the claim to the Director of Compensation Service for a determination about whether an extraschedular rating is warranted. Id.; see also 38 C.F.R. § 3.321(b). Here, all the symptomatology and functional impairment described above (to include abnormal gait) result from the limitation of motion the left knee, to include as due to pain, tenderness, and instability. All the symptoms described by the appellant are contemplated in the schedular rating assigned under the various Diagnostic Codes relevant to knee impairment, or indirectly as orthopedic factors, including pain, that limit motion and function. See 38 C.F.R. § § 4.40, 4.45, 4.59, 4.71a; DeLuca, 8 Vet. App. at 206-07. The schedular rating criteria specifically include instability as well as limitations of motion of the knee in any direction, including in flexion and extension, including limitations of motion and function due to pain. Such symptoms and impairment are part of or similar to symptoms listed under the schedular rating criteria. See 38 C.F.R. § 4.20 (schedular rating criteria provides for rating by analogy based on similar functions, anatomical location, and symptomatology); Mauerhan v. Principi, 16 Vet. App. 436 (2002) (the schedular rating criteria also include analogous symptoms that are “like or similar to” listed schedular rating criteria). Absent any exceptional factors associated with a knee disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). (Continued on the next page)   Finally, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims held that a total disability rating based on individual unemployability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, although VA examiners indicated that the Veteran’s right knee symptomatology had some impact on his ability to perform certain occupational tasks, a TDIU was not raised by the record or asserted. To the contrary, the Veteran has expressed that he works from home as an information technology technician and that less than one week of work time was lost in a 12-month span. He subsequently indicated that he was able to work installing computer hardware without restrictions, but did modify his work habits, while the December 2019 VA examiner opined that the Veteran’s disability did not impact his ability to perform any type of occupational task. Accordingly, the TDIU claim is not before the Board as a component of his claims for increased evaluations. Id. N. RIPPEL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Anthony M. Flamini 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.