Citation Nr: 21011846 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 14-37 747 DATE: March 2, 2021 ORDER Over the entire appeal period, a rating in excess of 20 percent for limitation of motion in extension, under DC 5261, for a right knee disability is denied. Over the entire appeal period, a rating in excess of 20 percent for limitation of motion in extension, under DC 5261, for a left knee disability is denied. From February 6, 2013, entitlement to a 30 percent rating for right knee instability under DC 5257 is granted. From February 6, 2013, entitlement to a 30 percent rating for left knee instability under DC 5257 is granted. Entitlement to a compensable rating for bilateral knee scars is denied. FINDINGS OF FACT 1. Over the entire appeal period, the Veteran’s right knee was not limited in extension to 15 degrees or more, including with repetitive use over time, during flares, or with consideration of painful motion 2. Over the entire appeal period, the Veteran’s left knee was not limited in extension to 15 degrees or more, including with repetitive use over time, during flares, or with consideration of painful motion. 3. From February 6, 2013, the Veteran’s right knee disability was characterized by severe instability as indicated by the prescription of a knee brace, use of a cane, decreased knee strength, and multiple falls. 4. From February 6, 2013, the Veteran’s left knee disability was characterized by severe instability as indicated by the prescription of a knee brace, use of a cane, decreased knee strength, and multiple falls. 5. Over the entire appeal period, the Veteran’s bilateral knee scars were not painful or unstable, were not deep or associated with underlying tissue damage, and were less than 929 square centimeters. CONCLUSIONS OF LAW 1. Over the entire appeal period, the criteria for a rating in excess of 20 percent, for right knee limitation of extension, under DC 5261, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5261. 2. Over the entire appeal period, the criteria for a rating in excess of 20 percent, for left knee limitation of extension, under DC 5261, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5261 3. From February 6, 2013, the criteria for a 30 percent rating for right knee instability, under DC 5257, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5257. 4. From February 6, 2013, the criteria for a 30 percent rating for left knee instability, under DC 5257, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.40, 4.45, 4.71a, DC 5257. 5. Over the entire appeal period, the criteria for a compensable rating for bilateral knee scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.118, DC 7801, DC 7802, DC 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December1981 to March 1991. This matter is before the Board of Veterans’ Appeals (Board) on appeal of September 2012 and November 2019 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). These claims were previously remanded by the Board in August 2018 and January 2020 for additional development. There has been substantial compliance with the Board’s remand directives and the Veteran’s claims are returned for continued appellate review. Increased Rating 1. Entitlement to an increased rating for a right knee disability, currently rated as 20 percent disabling under Diagnostic Code 5261 2. Entitlement to an increased rating for a left knee disability, currently rated as 20 percent disabling under Diagnostic Code 5261 Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes (DCs). 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. Wood v. Derwinski, 1 Vet. App. 190 (1991); Washington v. Nicholson, 19 Vet. App. 362 (2005). Where entitlement to compensation has already been established and increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate for an increased rating claim if the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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). 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. Normal range of motion (ROM) of the knee is to zero (0) degrees (full extension ROM) to 140 degrees (full flexion ROM). 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable (0 percent) rating is warranted where flexion of the knee is limited to 60 degrees, and a 10 percent disability evaluation is warranted when flexion is limited to 45 degrees. A 20 percent disability rating is warranted when flexion is limited to 30 degrees, and a 30 percent rating is warranted when flexion of the leg is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable (0 percent) rating is warranted when extension of the knee is limited to 5 degrees, and a 10 percent disability rating is warranted when extension of the knee is limited to 10 degrees. A 20 percent disability rating is warranted when extension is limited to 15 degrees, and a 30 percent rating is warranted when extension limited to 20 degrees. A 40 percent disability rating is warranted when extension is limited to 30 degrees, and a 50 percent disability rating is warranted when extension of the leg is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Disability ratings under DC 5256 may be warranted where there is ankylosis of the knee. 38 C.F.R. § 4.71a, DC 5256. DC 5003 states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected, which in this case would be DCs 5260 (limitation of flexion of the leg) and 5261 (limitation of extension of the leg). When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71 (a), DC 5003. Under DC 5257 a disability rating may be assigned for subluxation or lateral instability of the knee. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “slight” means small in amount. “Moderate” means limited in scope or effect. “Severe” means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under DC 5257, and objective medical evidence cannot be categorically found more probative than lay evidence with respect to this DC. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Under DC 5258, dislocation of the semilunar cartilage of the knee with frequent episodes of “locking,” pain and effusion into the joint warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5258. Under DC 5259, symptomatic removal of semilunar cartilage warrants a 10 percent evaluation. 38 C.F.R. § 4.71a, DC 5259. Under DC 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating when there is malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating for malunion of the tibia and fibula with marked knee or ankle disability; and a maximum rating of 40 percent for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a, DC 5262. Under DC 5263, a 10 percent rating is warranted for genu recurvatum. 38 C.F.R. § 4.71a, DC 5263. Separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004); VAOPGCPREC 23-97 (1997), 62 Fed. Reg.63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court of Appeals for Veterans Claims (Court) held that, as a matter of law, separate ratings are not precluded for limitation of motion (DCs 5003, 5260 and 5261), meniscal disability (DCs 5258 and 5259), and instability (DC 5257). Here, service connection is established for left and right knee disabilities, identified as status post excision of tibial tubercous ossicle for both knees. In May 2012, the Veteran requested increased ratings for his left and right knee conditions. Each knee disability was then rated as 20 percent disabling under DC 5257. A September 2012 rating decision continued the 20 percent ratings and changed the applicable rating code to DC 5261. A November 2019 rating decision allowed service connection for bilateral knee scars secondary to the service-connected knee conditions. These scars are rated as noncompensable over the entire appeal period. In August 2012 a VA knee conditions examination was provided. The Veteran reported bilateral anterior knee pain which worsened with cold and rainy weather. During flare ups he was unable to walk long distances or stand for prolonged periods of time. On initial range of motion measurements, right and left knee flexion was limited to 125 degrees with objective evidence of pain at 120 degrees. The examiner described the initial right knee extension, including the point of objective evidence of pain, as “extension lag -5 degrees.” Initial range of motion for left knee extension was zero degrees with no objective evidence of painful motion. After repetitive motion testing, right knee flexion was reduced to 120 degrees, right knee extension was described as “extension lag -5 degrees.” After repetitive motion testing, left knee flexion was measured to 125 degrees and left knee extension was measured to zero degrees. There was no evidence of joint instability on testing, no evidence of patellar subluxation or dislocation, and no evidence of shin splints or other tibial or fibular impairment. There were no meniscal conditions. The Veteran did not use any assistive devices. Full knee strength was observed. Diagnostic imaging did not show arthritis. The examiner found both knees were functionally impaired due to less movement than normal and pain on movement. The August 2012 examiner found no scars which were painful or unstable or over six square inches related these surgeries. On January 7, 2013, VA primary care notes include the Veteran’s report that he fell the day before his appointment. His physician prescribed bilateral knee braces and referred the Veteran for physical therapy. In February 2013 a VA physiatrist evaluated the Veteran. The Veteran described bilateral knee pain with prolonged walking and occasional swelling. New bilateral knee x-rays confirmed mild degenerative joint disease. In June 2014, VA treatment notes and January 2015 physical therapy notes include additional reports of falls. In January 2015, the Veteran was seen in a VA orthopedic surgery clinic after having frequent falls due to right knee weakness. The VA orthopedic surgeon noted generalized knee pain and mild knee swelling. Decreased bilateral leg strength was noted. The Veteran received a steroid injection in his right knee for pain. In February 2015, the Veteran continued receiving physical therapy and reported bilateral knee pain with edema and giving way. His physical therapist observed bilateral full range of motion, reduced right knee strength, bilateral pain on palpation of the medial joint line, and bilateral patellar grinding. In June 2015, a second VA knee conditions examination was provided. The Veteran reported his pain had increased and his ability to stand and ambulate was reduced. He described weekly flare-ups which lasted for hours. Initial range of motion measurements revealed right knee flexion to 110 degrees, right knee extension to zero degrees, left knee flexion to 120, and left knee extension to zero degrees. After three repetitions, there was no change in from the initial range of motion measurements. Although flares were reported, the examiner did not estimate additional loss of range of motion or additional functional impairment during flares. Left and right knee strength in flexion and in extension was reduced by one fifth. There was no muscle atrophy and no ankylosis. The examiner noted no history of recurrent subluxation, lateral instability or recurrent effusion for either knee. Testing did not indicate any joint instability. No meniscal conditions and no tibial or fibular impairments were reported. The Veteran used a cane due to weakness and pain in his knees. The examiner observed the left and right knee disabilities resulted in functional impairment because the Veteran was limited to standing and walking for no more than 20 to 30 minutes. No scars were described in the examination report. In July 2015, VA physical therapy notes include reports of right knee pain and a catching sensation. In December 2015, VA primary care notes show the Veteran reported his knees had worsened because of instability and recurrent falls. A right knee MRI was obtained in March 2016. Initial interpretation of the MRI indicated a probable anterior horn medial meniscus tear. In January 2016, the Veteran received physical therapy and a VA physiatrist noted chronic bilateral knee pain with worsening right knee pain. During this appointment, the Veteran reported feeling his knee was “giving off,” and intermittently locking. Full active and passive bilateral range of motion was observed. The Veteran was using a cane when he arrived for treatment. In March 2016, the Veteran was treated by a VA orthopedic surgeon for right knee pain. The surgeon found mild medial knee pain and good range of motion. After review of the MRI, the Veteran opted for conservative management of his knee conditions. In July 2016, the Veteran returned to the VA orthopedic surgery clinic. His VA orthopedic surgeon stated, “MRI again reviewed and no pathology identified on either meniscus.” The surgeon observed some atrophy of the right quadriceps as compared to the left. He recommended home exercises to strengthen the quadriceps muscles. Right knee range of motion was measured from zero to 110 degrees. No follow up care in the orthopedic clinic was needed. August 2017 and January 2018 VA primary care notes document continuing knee pain. October 2018 physical therapy notes document “diffuse tenderness to both knees and [decreased] strength in bilateral [quadriceps] muscles. In April 2019, the Veteran received a right knee steroid injection. June 2019 VA psychiatry notes include the Veteran’s reports of frequent falls due to unstable knees. In July 2019, a third VA knee conditions examination was provided. The Veteran reported his knees had worsened since the June 2015 examination. He described constant pain and stiffness in both knees. Once or twice a month, his condition flared with intense pain, swelling, and reduced range of motion. Each flare lasted two or three days. He also reported, on occasion, his knees would fail and give way. He recalled falling on five occasions. He always used a cane to prevent falls. On initial range of motion testing, the Veteran’s right knee flexion was measured from five degrees to 100 degrees and extension was measured from 100 degrees to zero degrees. Left knee flexion was measured from five degrees to 97 degrees and extension was measured from 97 degrees to zero degrees. Pain was observed in flexion and in extension. Pain resulted in functional loss. During the examination, the Veteran had difficulty dressing and undressing and moving on and off the examination table. Range of motion was not reduced after three repetitive motions. The examiner estimated, with repeated use over time, flexion in both knees would be limited to 75 degrees and extension in both knees would be limited to five degrees. During flares, he estimated both knees would be limited in flexion to 75 degrees and in extension to 10 degrees. The examiner noted knee strength was reduced by one fifth. There was no muscle atrophy and no ankylosis in either knee. The examiner observed no history of recurrent subluxation, no lateral instability, and no recurrent effusion in both knees. Testing did not show joint instability. The examiner found no meniscal conditions. The examiner observed the Veteran’s knee disabilities limited his ability to move between standing to sitting, lift more than 10 pounds, walk on irregular surfaces, and climb stairs or ladders. He was unable to participate in high impact activities. Pain was noted with weight bearing, non-weightbearing, and in passive range of motion testing. This examination provided the evaluation required under Correia and Sharp. The examiner also observed two right knee scars which measured 5.0 centimeters by 0.2 centimeters and 3.5 centimeters by 1.0 centimeters and one left knee scar which measured 7.5 centimeters by 0.3 centimeters. The scars were not painful or unstable. In November 2019, the Veteran received physical therapy and reported continuing knee pain. January 2020 psychiatric progress notes include the Veteran’s reports of frequent falls due to unstable knees. In March 2020, pool therapy was planned to treat bilateral knee pain. Limitation of motion in flexion and in extension Currently, the Veteran’s limitation of extension in both knees is rated as 20 percent disabling over the entire appeal period under DC 5261. A rating in excess of 20 percent is warranted when extension is limited to 15 degrees or more. Here, there is no evidence the Veteran experienced such a limitation in either knee. Range of motion testing during the three VA knee examinations confirmed extension was not limited to 15 degrees or more. At most, the July 2019 VA examiner estimated, during flares, the Veteran’s right and left knee extension would be limited to 10 degrees. Accordingly, the preponderance of the evidence is against finding any limitation of extension of 15 degrees or higher in either knee over the appeal period. The benefit of the doubt doctrine is not applicable and a rating in excess of 20 percent under DC 5261 is not warranted. 38 C.F.R. § 4.71a, DC 5261. Over the entire appeal period, range of motion for flexion of the Veteran’s right and left knees has been reduced. The Board has considered whether an additional rating for limitation of flexion is also warranted. However, there is no evidence that flexion was reduced to 45 degrees or less, including with repetitive use over time, during flares, or due to pain on motion. A rating under DC 5260 is not indicated. 38 C.F.R. § 4.71a, DC 5260. Knee Instability VA treatment records show the Veteran was treated on February 7, 2013 after a fall which occurred on February 6, 2013. His primary care physician prescribed braces for both knees. After February 6, 2013 VA primary care, physical therapy, orthopedic clinic, and psychiatric treatment records confirm the Veteran consistently reported recurring falls and the sensation of his knees giving way. During an August 2012 VA knee examination (prior to the February 6, 2013 fall), the Veteran was not using any assistive devices and testing did not show knee weakness or instability. During June 2015 and July 2019 VA knee conditions examinations (after the February 6, 2013 fall), the Veteran used a cane and testing revealed decreased bilateral knee strength. The Board notes joint stability testing over the entire appeal period did not show joint instability. However, based on the Veteran’s credible reports of falls, his reliance on a cane to prevent falls, and medical evidence of decreased knee strength, the preponderance of the evidence is in favor of finding knee instability from February 6, 2013. The Board notes there is some evidence attributing falls to right knee weakness, however the Veteran has reported symptoms in both knees and weakness has been observed on examination in both knees. Thus, resolving reasonable doubt in favor of the Veteran, knee instability resulting in falls is attributed to both the left and right knee. As this instability resulted in multiple falls, a severe level of disability is indicated. Accordingly, from February 6, 2013, severe left and right knee instability is shown and a 30 percent rating under DC 5257 for each knee is warranted. 38 C.F.R. § 4.71a, DC 5257. The Board notes, as of February 7, 2021, changes to the rating schedule, including the criteria under DC 5257 are in effect. While these changes, if more beneficial to the Veteran, may be applied from their effective date, the application of the new criteria is not warranted here. Under the prior criteria and the new criteria, a rating in excess of 30 percent is not provided for knee instability. As 30 percent is applied under the prior criteria, there is no benefit to the Veteran available by application of the new criteria. See generally Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) Meniscal Conditions Here, VA examinations of August 2012, June 2015, and July 2019 all found the Veteran did not have any meniscal conditions. While a December 2015 VA treatment note described an MRI report showing a probable anterior horn medial meniscus tear, a VA orthopedic surgeon reviewed the MRI report in July 2016 and clarified that there was no meniscal injury. The preponderance of the evidence is against finding any meniscal condition over the entire appeal period. The benefit of the doubt rule is not indicated. An additional rating for a meniscal condition under DC 5258 or DC 5259 is not indicated. 38 C.F.R. § 4.71a, DC 5258, DC 5259. Additional Left and Right Knee Ratings Finally, the Board finds additional ratings for a left knee disability are not indicated. A rating under DC 5256 is not indicated because there is no evidence of ankylosis. There is no evidence of impairment of the tibia and fibula to warrant a rating under DC 5262. There is no evidence of genu recurvatum to warrant a rating under DC 5263. 38 C.F.R. § 4.71a, DC 5258, DC 5259. 3. Entitlement to a compensable rating for bilateral knee scars During the pendency of the Veteran’s claim for increased ratings of his service-connected bilateral knee conditions, a November 2019 rating decision allowed service connection for scars associated with bilateral knee surgeries. A noncompensable rating was provided. As of August 13, 2018, changes to the rating schedule pertaining to the skin, including scars, are in effect; the Board will apply the new criteria for the period beginning August 13, 2018, if the new criteria are more beneficial to the Veteran than the prior version of the regulation. See Kuzma, supra. Prior to August 13, 2018, DC 7801 considered scars that are deep and non-linear, and since August 13, 2018, DC 7801 considers scars associated with underlying soft tissue damage. Under both iterations of DC 7801, qualifying scars warrant a 10 percent rating if the area or areas exceed 6 square inches (39 sq. cm). A 20 percent rating requires an area or areas exceeding 12 square inches (77 sq. cm); a 30 percent evaluation is assigned for an area or areas exceeding 72 square inches (465 sq. cm); and a 40 percent evaluation is warranted for an area or areas exceeding 144 square inches (929 sq. cm). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801, Note 1 (2018). Since August 13, 2018, a separate evaluation may be assigned for each affected zone of the body (each extremity, anterior trunk, and posterior trunk) if there are multiple scars, or a single scar, affecting multiple zones of the body. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this DC. 38 C.F.R. § 7801, Notes1-2 (2019). Prior to August 13, 2018, DC 7802 considered scars that are superficial and non-linear, and since August 13, 2018, DC 7802 considers scars not associated with underlying soft tissue damage. Under both iterations, only a 10 percent disability evaluation is available. It is assigned when a qualifying scar involves an area or areas at least 144 sq. inches (929 sq. cm.) or greater. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802 (2018). Since August 13, 2018, a separate evaluation may be assigned for each affected zone of the body (each extremity, anterior trunk, and posterior trunk) if there are multiple scars, or a single scar, affecting multiple zones of the body. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under this DC. 38 C.F.R. § 4.118, DC 7802, Notes 1-2 (2019). (Continued on the next page)   Under DC 7804, a 10 percent evaluation is assigned for 1 or 2 unstable or painful scars; a 20 percent evaluation is assigned for 3 or 4 unstable or painful scars; and, a 30 percent evaluation is assigned for 5 or more unstable or painful scars. 38 C.F.R. § 4.118, DC 7804. Note 1 indicates that an unstable scar is one where, for any reason, there is frequent loss of covering over the scar. Additionally, if one or more scars are both unstable and painful, an extra 10 percent will be added to the evaluation that is based on the total number of unstable or painful scars. See id., Note 2. This particular diagnostic code did not receive any changes in the August 2018 update to the skin rating criteria. The August 2012 VA knee conditions examiner found no painful or unstable scars were associated with the Veteran’s knee disabilities. The June 2015 VA examiner did not provide any evaluation of scars. The July 2019 examiner described a right knee scar measuring 5.0 centimeters by 0.2 centimeters (1.0 square centimeters), a second right knee scar measuring 3.5 centimeters by 1.0 centimeters (3.5 square centimeters), and one left knee scar measuring 7.5 centimeters by 0.3 centimeters (2.25 square centimeters). He stated the scars were not painful or unstable. Over the appeal period, there is no evidence of painful or unstable scars. There is no evidence of scars which are deep or associated with underlying tissue damage. The area of the individual scars and the combined total area of all scars does not exceed 929 square centimeters. A compensable rating for bilateral knee scars is not warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; 38 C.F.R. § 4.71a, DC 7801, 7802, 7804. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.