Citation Nr: 21013543 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 20-13 200 DATE: March 9, 2021 ORDER Entitlement to a 20 percent disability rating for left knee degenerative arthritis from February 23, 2018, through October 14, 2018, is granted. Entitlement to a disability rating for residuals of left total knee replacement higher than 30 percent from December 1, 2019, is denied. Entitlement to a 20 percent disability rating for right knee degenerative arthritis from February 23, 2018, to February 3, 2019, is granted. Entitlement to a disability rating higher than 10 percent for right knee instability from February 23, 2018, to February 4, 2019, is denied. REMAND Entitlement to a rating for disability residual to right total knee replacement higher than 30 percent from April 1, 2020, is remanded. Entitlement to a disability rating higher than 0 percent for a residual scar on the right knee is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. From February 23, 2018, through October 14, 2018, degenerative arthritis of the Veteran’s left knee was manifested by painful motion, worsened pain with activity or prolonged inactivity, constant pain, even at rest, and functional impairment including intermittent impairment of weightbearing and difficulty with activities of daily living. 2. From December 1, 2019, the Veteran’s residual left knee disability following total replacement has been limited to intermittent soreness; weakness, limitation of motion, and other functional impairment have been no more than mild. 3. From February 23, 2018, to February 3, 2019, degenerative arthritis of the Veteran’s right knee was manifested by limitation of motion, an antalgic gait, a limp, worsened pain with activity or prolonged inactivity, constant pain, even at rest, and functional impairment including intermittent impairment of weightbearing and difficulty with activities of daily living. 4. From February 23, 2018, to February 4, 2019, instability in the Veteran’s right knee was not more than slight. CONCLUSIONS OF LAW 1. From February 23, 2018, through October 14, 2018, degenerative arthritis of the left knee met the criteria for a 20 percent disability rating. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 2. From December 1, 2019, disability residual to left total knee replacement has not met the criteria for a rating higher than 30 percent. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5256, 5260, 5261. 3. From February 23, 2018, to February 3, 2019, degenerative arthritis of the right knee met the criteria for a 20 percent rating. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 4. From February 23, 2018, to February 4, 2019, right knee instability did not meet the criteria for a rating higher than 10 percent. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1966 to November 1969. In February 2018 he submitted a claim for service connection for left and right knee disabilities. In an April 2018 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) granted service connection, effective February 23, 2018, for left knee degenerative arthritis. The RO assigned a 10 percent disability rating. For the Veteran’s right knee, the RO granted service connection for degenerative arthritis, rated at 10 percent, for instability, rated at 10 percent, and for a residual scar, rated at 0 percent. The Veteran appealed each of the ratings the RO assigned to the Board of Veterans’ Appeals (Board). Later, the Veteran indicated that his appeal of the ratings included an appeal for a TDIU. In October 2018 the Veteran underwent surgical total replacement of his left knee. He sought a temporary total (100 percent) rating and reevaluation of his left knee disability. In a December 2018 rating decision, the RO changed the description of the left knee disability to left total knee arthroplasty. The RO granted a temporary total rating from October 15, 2018, and a 30 percent rating from December 1, 2019. The Veteran continued his appeal. In February 2019 the Veteran underwent surgical total replacement of his right knee. He sought a temporary total rating and reevaluation of his right knee disability. In a November 2019 rating decision, the RO changed the description of the right knee degenerative arthritis to right total knee replacement. For the knee replacement, the RO granted a temporary total rating from February 4, 2019, and a 30 percent rating from April 1, 2020. The RO made the 10 percent rating for right knee instability effective from February 23, 2018, to February 4, 2019. In effect, the RO evaluated the musculoskeletal disability of the right knee before the knee replacement as degenerative arthritis separate ratings for limitation of motion and for instability. After the replacement, the RO rated the right knee musculoskeletal disability as disability residual to replacement, as a single rating. The RO’s actions in the November 2019 rating decision, also included continuing the 0 percent rating for a right knee scar. The Veteran continued his appeal. Increased Ratings VA assigns disability ratings by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The United States Court of Appeals for Veterans Claims (Court) has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Court also has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim for an increased rating was filed until a final decision is made. See Hart. v. Mansfield, 21 Vet. App. 505 (2007). The Court has indicated that the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. For the appealed disability ratings for musculoskeletal disabilities in each of the Veteran’s knees, there is interrelated evidence regarding the disabilities over time. The Board therefore is discussing the evidence regarding each knee in combined sections, below. 1. and 2. Left knee degenerative arthritis and disability residual to left total knee replacement The Veteran contends that his left knee disabilities warrant ratings higher than 10 percent from February 23, 2018, through October 14, 2018, and higher than 30 percent from December 1, 2019. When evaluation of a musculoskeletal disability is based on limitation of motion, that evaluation must include consideration of impairment of function due to such factors as pain on motion, weakened motion, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; see DeLuca v. Brown, 8 Vet. App. 202 (1995). In Correia v McDonald, 28 Vet. App. 158 (2016), the Court held that 38 C.F.R. § 4.59 indicates that evaluation of joints that have painful motion also should include consideration of whether there is pain on both active and passive motion, consideration of whether there is pain with and without weightbearing, and comparison of the range of motion to that of any opposite undamaged joint. The rating criteria for musculoskeletal disorders changed effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified at 38 C.F.R. §§ 4.71a, 4.73). Where the rating criteria affecting a disability have changed, VA will apply the earlier version before February 7, 2021, the effective date for the change. From February 7, 2021, VA will apply either the earlier version or the revised version, whichever is more favorable to the claimant. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The February 2021 rating criteria revisions do not change the criteria for rating degenerative arthritis, under 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under that code, degenerative arthritis is rated based on the limitation of motion of the affected joint. If the limitation of motion is noncompensable, a 10 percent rating is assigned for each major joint. The RO evaluated the Veteran’s left knee degenerative arthritis under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion. The February 2021 rating criteria revision do not change those criteria, which provide ratings of 30 percent if flexion is limited to 15 degrees, 20 percent if limited to 30 degrees, 10 percent if limited to 45 degrees, and 0 percent if limited to 60 degrees. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, limitation of extension of the knee is rated at 50 percent if extension is limited to 45 degrees, 40 percent if limited to 30 degrees, 30 percent if limited to 20 degrees, 20 percent if limited to 15 degrees, 10 percent if limited to 10 degrees, and 0 percent if limited to 5 degrees. The February 2021 rating criteria revisions do not change those criteria. The VA General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion under Diagnostic Codes 5260 and 5261, if both ranges of motion meet the criteria for a compensable rating. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). For the evaluation of total replacement of a knee with a prosthesis, the February 2021 rating criteria revisions included a decrease in the period for which a 100 percent rating is assigned following replacement. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76461 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055). A longer period at a 100 percent rating is more favorable to the Veteran. Therefore, the Board will apply the earlier version of the regulations in evaluating the Veteran’s left knee replacement from February 7, 2021, forward. Under the earlier version, after the 100 percent rating for a 1-year period following replacement, a 60 percent rating is assigned if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain, or limitation of motion, the knee is rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating for a knee following total replacement is 30 percent. Records of private medical treatment of the Veteran from as early as 2004 reflect chronic bilateral knee problems. Private orthopedic treatment records from January 2018 reflect pain and osteoarthritis in both of his knees. It was noted that he had a cortisone injection three months earlier, and that presently he used pain medication. He related that his left knee had moderate pain, and that his left knee popped out. In March 2018 the Veteran initiated treatment at a VA clinic. He had a VA orthopedic visit for evaluation of bilateral knee pain. It was noted that he was 72 years old. He indicated that he received Social Security benefits and worked part time for his son’s plumbing business. He stated that during service he had a motor vehicle accident (MVA) in 1967 and sustained significant injury of his right knee. He reported that he had surgical patellectomy. He stated that his left leg sustained a deep laceration just below the knee. He related that over time he favored his right knee, causing strain on his left knee. He reported a long history of bilateral knee pain, worsened by activity or prolonged inactivity. He stated that cortisone injections in his knees temporarily reduced pain. The clinician observed that the Veteran had a mildly antalgic gait, with limping on the right. The Veteran’s left knee had tenderness to palpation. That knee lacked 5 degrees of full extension. The active range of motion was from 5 degrees to 120 degrees. The left knee had a varus deformity. The left knee was stable to varus and valgus stress testing. Left knee x-rays showed tricompartmental degenerative joint disease, with bone-on-bone contact of the medial compartment and osteophytes on tibial spine and the patella. On VA examination in April 2018, the Veteran reported injury of both knees in an MVA in 1967. He reported having knee surgeries in 1967 and 1968. He stated that presently he had daily bilateral knee pain. He related flare-ups during which he had more severe pain and he could not bear weight. He reported that he occasionally used a cane. He stated that he was a self-employed plumber. He reported that his bilateral knee problems interfered with his work. He explained that he had severe knee pain with crawling, kneeling, or squatting. He related that knee pain made him unable to do many tasks, such as digging holes, entering crawl spaces, or climbing ladders. The examiner reviewed the claims file, including the March 2018 x-rays. The examiner listed a diagnosis of degenerative arthritis in both knees. On examination, the Veteran’s left knee was limited to 90 degrees of flexion. The knee had extension to 0 degrees. There was pain with flexion and with weightbearing. After three repetitions of motion the ranges of motion were the same. The knee had 5/5 muscle strength in flexion and extension. The examiner indicated that the knee did not have a history of recurrent subluxation or lateral instability. Testing did not show instability. In May 2018 the Veteran had a VA orthopedic visit for reevaluation of both of his knees. The Veteran reported ongoing and worsening bilateral knee pain, presently worse in the left knee. He indicated that the bilateral knee pain negatively affected his overall quality of like and ability to perform activities of daily living. The clinician reviewed the March 2018 x-rays of both knees. The clinician observed that presently the Veteran had a mildly antalgic gait, with limping on the right. The Veteran’s left knee had tenderness to palpation. That knee lacked 5 degrees of full extension. The active range of motion was from 5 degrees to 120 degrees. The left knee had a varus deformity. The left knee was stable to varus and valgus stress testing. In VA treatment visits in May, June, and July 2018, the Veteran indicated that in May 2018 one or both of his knees gave way and he fell. In August 2018 he reported ongoing bilateral knee pain. He had knee braces. A physical therapist recommended continued use of knee braces. With replacement of the Veteran’s left knee in October 2018, the surgeon described the history leading to the replacement. The surgeon described the osteoarthritis in that knee as end stage, with x-rays showing bone-on-bone arthritis in all three compartments. The surgeon noted progressive worsening of pain and dysfunction. The physician noted constant pain with activity and at rest. The physician related that, despite medications and injections, the left knee had significant functional deficits and produced difficulties even with activities of daily living. The left knee replacement surgery was followed by physical therapy. The Veteran underwent total right knee replacement surgery in February 2019. On VA examination of the Veteran’s knees in August 2019, the replaced left knee had motion from 0 to 140 degrees, with no pain on motion. There was pain in the knee area with weightbearing. In December 2019 the Veteran had a VA examination of his knees. He reported that he recovered well from his left knee replacement in October 2018. He related that two weeks after the surgery he was able to walk a mile. He stated that presently his left knee got sore, but that the knee was in much better condition than before the replacement. He reported that presently his left knee functioned well. He related that he regularly used a cane when walking. On examination, the Veteran’s left knee had flexion to 125 degrees and extension to 0 degrees. There was no pain with motion. There was no pain with weightbearing. After three repetitions the ranges of motion remained the same. The left knee had 5/5 muscle strength in flexion and extension. The examiner indicated that the left knee did not have a history of recurrent subluxation or a history of lateral instability. The examiner stated that knee stability testing was not indicated. On VA examination in July 2020, the Veteran reported that his left knee replacement in October 2018 was followed by a good recovery. He did not relate any present impairment or functional loss involving his left knee. On examination, the Veteran’s left knee had motion from 0 to 130 degrees. There was no pain on active or passive motion. There was no pain with or without weightbearing. After three repetitions, the ranges of motion remained the same. Stability of the knee was not tested, to avoid aggravation of pain. The examiner found that the left knee had no residual disability following replacement. In August 2020 the Veteran, through his representative, challenged the adequacy of the July 2020 VA examination and examination report. The examiner is a licensed physician. The Board finds that the examiner was competent to perform the examination and express opinions regarding the findings. The Veteran contends that the examiner did not review the Veteran’s treatment records. The examination findings regarding the replaced left knee are consistent with the findings in the assembled treatment records. The Board therefore accepts that, with respect to the left knee, the examination and examination report are adequate. From February 23, 2018, through October 14, 2018, degenerative arthritis of the Veteran’s left knee was productive of painful motion, worsened pain with activity or prolonged inactivity, and constant pain, even at rest. His knee disability intermittently interfered with his capacity for weightbearing. The disability produced functional impairment, including difficulty with activities of daily living. The overall functional impairment of that knee was reasonably consistent with a 20 percent rating immediately prior to total knee replacement. Considering the remaining function in the knee, including capacity for weightbearing and walking at most times, the impairment was not so great as to warrant a rating higher than 20 percent. The Board grants a 20 percent rating for that period. Given the evidence of a stable left knee, application of DC 5257 is not necessary. After the October 2018 replacement of the Veteran’s left knee, the RO assigned, under Diagnostic Code 5055, a 100 percent rating through November 30, 2019, and a 30 percent rating from December 1, 2019. From December 2019, the Veteran’s statements and the medical findings indicate that his replaced left knee has produced soreness at times, but has nearly full function in motion, weightbearing, walking, and other activity. The left knee disability picture has not included degrees of residual weakness, pain, or limitation of motion that warrant a rating higher than the 30 percent minimum rating. The Board denies a rating higher than 30 percent. 3. and 4. Right knee degenerative arthritis, with pain and instability The Veteran has appealed the initial and later ratings assigned for musculoskeletal disabilities of his right knee. He is seeking ratings higher than 10 percent for degenerative arthritis and 10 percent for instability from February 23, 2018, to February 22, 2019. The Veteran also is seeking a rating higher than 30 percent from April 1, 2020, for disability residual to total right knee replacement. The Board is remanding that issue for additional evidence and action, as explained in the remand section, below. Prior to replacement of the Veteran’s right knee, evaluation of his right knee disability included a separate rating for instability. Under the applicable rating criteria, at C.F.R. § 4.71a, Diagnostic Code 5257, other impairment of the knee, including recurrent subluxation or lateral instability, warrants ratings of 30 percent if severe, 20 percent if moderate, and 10 percent if slight. The knee was replaced in February 2019. After replacement the knee was evaluated under one rating, under Diagnostic Code 5055, without a separate rating for instability. A rating for instability therefore was no longer at issue by the time revisions of Diagnostic Code 5257 became effective in February 7, 2021. In VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997), the VA General Counsel held that a veteran who has arthritis and instability of the knee might be rated separately under Diagnostic Codes 5003 and 5257, provided that any separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 in order to obtain a separate rating for arthritis. In VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998), the VA General Counsel clarified that when a veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on x-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. Records of private medical treatment of the Veteran from as early as 2004 reflect chronic bilateral knee problems. Private orthopedic treatment records from January 2018 reflect his bilateral knee pain and osteoarthritis. It was noted that he had a cortisone injection three months earlier and presently used pain medication. He related that his right knee had moderate pain. In a VA orthopedic consultation in March 2018, the Veteran reported a long history of bilateral knee pain, worsened by activity or prolonged inactivity. It was noted that he was 72 years old. He indicated that he received Social Security benefits and worked part time for his son’s plumbing business. He stated that during service he had an MVA in 1967 and sustained significant injury of his right knee. He reported that he had surgical patellectomy. He stated that his left leg sustained a deep laceration just below the knee. He related that over time he favored his right knee, which resulted in strain on his left knee. He reported that cortisone injections in his knees temporarily reduced his knee pain. The clinician observed that the Veteran had a mildly antalgic gait, with limping on the right. The Veteran’s right knee lacked 10 degrees of extension. Active flexion of the right knee was to 120 degrees. The right knee had tenderness to palpation. The right knee had a varus deformity. The right knee was stable to varus and valgus stress testing. The clinician observed a scar consistent with a previous open patellectomy. Right knee x-rays showed bone-on-bone contact of the medial compartment, osteophytes of the tibial spines, and previous patellectomy with heterotopic ossification of the distal quadriceps tendon. On VA examination in April 2018, the Veteran reported injury of both knees in an MVA in 1967. He stated that presently he had daily bilateral knee pain. He related flare-ups of more severe pain. He indicated that during flare-ups he could not bear weight. He reported that he occasionally used a cane. He stated that his bilateral knee problems interfered with his work as a self-employed plumber. He explained that crawling, kneeling, or squatting produced severe knee pain. He stated that knee pain made him unable to do many tasks, such as digging holes, entering crawl spaces, or climbing ladders. On examination, the Veteran’s right knee had normal motion, from 0 to 140 degrees of flexion and extension. That knee had pain at rest, had pain on motion with flexion and extension, and had pain with weightbearing. After three repetitions of motion the ranges of motion were the same. The knee had 5/5 muscle strength in flexion and extension. The examiner indicated that the knee did not have a history of recurrent subluxation or lateral instability. Testing showed 0 to 5 millimeters of anterior instability and 0 to 5 millimeters of lateral instability. In VA treatment in May 2018, the Veteran reported ongoing and worsening bilateral knee pain, presently worse in the left knee. He indicated that the bilateral knee pain negatively affected his overall quality of like and ability to perform activities of daily living. The clinician reviewed the March 2018 x-rays of both knees. The clinician observed that presently the Veteran had a mildly antalgic gait, with limping on the right. The Veteran’s right knee lacked 10 degrees of extension. Active flexion of the right knee was to 120 degrees. The right knee had tenderness to palpation. The right knee had a varus deformity. The right knee was stable to varus and valgus stress testing. The clinician again observed a scar consistent with a previous open patellectomy. In VA treatment visits in May, June, and July 2018, the Veteran indicated that in May 2018 one or both of his knees gave way and he fell. In August 2018 he reported ongoing bilateral knee pain. He had knee braces. A physical therapist recommended continued use of knee braces. The Veteran underwent total replacement of his left knee in October 2018. Left knee replacement was followed by physical therapy. The Veteran underwent right total knee replacement surgery in February 2019. The surgeon who replaced that knee described the condition of that knee before replacement. The surgeon stated that the knee had end stage osteoarthritis, shown by x-ray to be bone-on-bone in the medial and lateral compartments. He related that the knee had progressively worsening pain and dysfunction. He reported that the pain was constant, with activity and at rest. He stated that, despite extensive treatment, the pain produced significant function deficits, including difficulties even with activities of daily living. From February 23, 2018, to February 3, 2019, degenerative arthritis of the Veteran’s right knee did not limit flexion to 60 degrees. That arthritis sometimes limited extension to 10 degrees, but did not limit extension to 15 degrees. In addition to limitation of motion, his right knee had painful motion, worsened pain with activity or prolonged inactivity, and constant pain, even at rest. His disability in that knee caused an antalgic gait and limping, and intermittently interfered with his capacity for weightbearing. The disability produced functional impairment including difficulty with activities of daily living. The overall functional impairment of that knee was reasonably consistent with a 20 percent rating immediately prior to total replacement. Considering the remaining function in that knee, including capacity for weightbearing and walking at most times, the impairment was not so great as to warrant a rating higher than 20 percent. The Board grants a 20 percent rating for that period prior to total knee replacement. From February 23, 2018, to February 4, 2019, examination reports and treatment records did not indicate that the instability in the Veteran’s right knee was more than slight. The instability found in the April 2018 examination was in the smallest range provided on the examination form. No clinician described the instability as more than slight. In addition, the Veteran has not indicated that the instability in that knee was more than slight. The Board denies a rating higher than 10 percent for his right knee instability during that period. REASONS FOR REMAND 1. Rating for disability residual to total right knee replacement The Board is remanding this issue for more recent treatment records and for a new VA examination. The Veteran underwent total right knee replacement in February 2019. The RO rated his total right knee replacement at 100 percent from February 4, 2019, and at 30 percent from April 1, 2020. The Veteran’s ongoing appeal of the ratings assigned for his right knee disabilities includes an appeal for a rating for disability residual to total left knee replacement higher than 30 percent from April 1, 2020. As noted above, with respect to the Veteran’s left knee replacement, for the evaluation of total knee replacement, the February 2021 rating criteria revisions included a decrease in the period for which a 100 percent rating is assigned following replacement. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76461 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055). The longer period is more favorable to the Veteran. Therefore, the Board will apply the earlier version of the regulations in evaluating the Veteran’s right knee replacement from February 7, 2021, forward. The earlier version of course applies for the period before February 7, 2021. Under the earlier version of the rating criteria, after the 100 percent rating for a 1 year period following replacement, a 60 percent rating is assigned if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain, or limitation of motion, the knee is rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating for a knee following total replacement is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Veteran had a VA examination of his knees in August 2019. The Veteran reported onset in July 2019 of severe pain and swelling in his replaced right knee. He stated that he could not bear weight on that leg and could not bend that knee. In the August 2019 examination, motion of the right knee was from 5 to 140 degrees. That knee had pain at rest, on motion, and with weightbearing. In private treatment in August 2019, the Veteran had pain and swelling in his right knee and leg pain and swelling. A clinician indicated that these symptoms possibly were due to infection. In September 2019 the Veteran had VA treatment for right knee and leg pain. On VA examination in December 2019, the Veteran reported that his right knee replacement initially was followed by good recovery. He related onset in June 2019 of severe soreness and swelling in his right knee and lower leg. He stated that since then the swelling intermittently improved and worsened. He reported that presently the knee had intermittent swelling, especially after activity. He indicated that each episode of swelling later resolved. He related that his right knee function was no better than it was before the replacement surgery. He stated that he regularly used a cane when walking. He reported he could not walk long distances without his right knee swelling. He stated that right knee pain occurred daily. He related that the pain limited his endurance for standing and awakened him from sleep. On examination, motion of the Veteran’s right knee was limited to 105 degrees of flexion and 20 degrees of extension. There was pain with flexion and with extension. There was pain with weightbearing. There was tenderness to palpation. The examiner observed swelling of the right knee, compared to the left knee. The examiner also observed swelling, described as a mass, in the right calf. After three repetitions, the ranges of motion remained the same. The right knee had 5/5 muscle strength in flexion and extension. The examiner indicated that the right knee did not have a history of recurrent subluxation or a history of lateral instability. The examiner stated that knee stability testing was not indicated. The examiner noted that the Veteran worked as plumber from 1986 to 2018, and that he left that work due to a fall and back injury. The examiner stated that presently the Veteran’s right knee problems and his heart condition made him unable to do physical work. The examiner concluded that the Veteran had not recovered from his right knee replacement. In private treatment in May 2020, the Veteran was noted to have ongoing pain and swelling in his right calf and knee. In May 2020 he underwent surgery to address right knee periprosthetic joint infection with septic arthritis. The surgery included resection arthroplasty and placement of an antibiotic spacer. In VA treatment on July 9, 2020, the Veteran was still recovering from the resection arthroplasty six weeks earlier. He reported ongoing right knee pain. A clinician stated that the Veteran required further post-operative visits. On VA examination on July 22, 2020, the Veteran reported that his right knee replacement in February 2019 was followed by a fair recovery until later in 2019, when severe infection developed. He stated that the infection required aggressive intervention with surgery and antibiotics. He reported present pain in the right knee, aggravated by weightbearing. He stated that his right knee problem caused difficulty with walking or prolonged standing. He related that he regularly used a cane when walking. On examination, flexion of the right knee was limited to 110 degrees. Extension was limited to 10 degrees. There was pain on flexion. There was no pain on passive motion. There was mild tenderness to palpation of the anterior aspect of the knee. There was no pain with weightbearing or without weightbearing. After three repetitions, the ranges of motion remained the same. Stability of the knee was not tested, to avoid aggravation of pain. The examiner indicated that the replaced knee had intermediate degrees of residual weakness, pain, or limitation of motion. Medical records reflect that, a few months after the Veteran’s right total knee replacement, he had onset of knee pain and swelling, considered as possibly due to infection in the area of the replaced joint. In May 2020 he had surgery to address the problem. His claims file contains medical records dated as late as August 2020. In July 2020 a clinician stated that further treatment visits were needed for follow-up from the May 2020 surgery. Further information is needed regarding the manifestations and severity of the Veteran’s right knee disability after the May 2020 surgery. The Board is remanding the issue for any more recent treatment records and for a new examination of the knee. 2. Right knee residual scar The Board is remanding this issue for a new VA examination. VA has established service connection, effective February 23, 2018, for disability following injury of and surgery on the Veteran’s right knee during service. The RO assigned an initial disability rating of 0 percent for a residual scar on the knee. The Veteran appealed for a higher rating. Later, in February 2019, the Veteran underwent right total knee replacement surgery. His appeal for a higher rating for scarring at that knee has continued. On VA examination in April 2018, the examiner observed a scar on the anterior aspect of the Veteran’s right knee. The scar measured 17 centimeters long by 1 centimeter wide. The scar was stable and was not painful. The Veteran underwent total right knee replacement surgery in February 2019. Medical records reflect that the Veteran initially experienced good healing following the replacement surgery. However, from June or July 2019, he began to experience pain and swelling in his right knee, as well as in his right lower leg. On VA examination in December 2019, the examiner observed a scar measuring 20.5 centimeters long by 0.2 centimeters wide on the anterior aspect of the Veteran’s right knee. 4.1 The examiner indicated that the scar was stable and was not painful. In 2020 pain and swelling in the Veteran’s right knee continued. In May 2020 he had another right knee surgery to address the problem. His claims file contains medical records dated as late as August 2020. The assembled records do not address the nature and characteristics of scarring on the Veteran’s right knee after the May 2020 surgery. The Board is remanding the scar rating issue for a new examination to obtain current findings. 3. TDIU The Board is remanding this issue for review after actions on intertwined issues. The Veteran contends that his service-connected disabilities make him unemployable. The Board’s present decisions on appealed issues may affect the TDIU issue. Actions on the rating issues the Board is remanding also may affect the TDIU claim. The Board is remanding the TDIU for review after completion on actions on those issues. The matters are REMANDED for the following action: 1. Obtain records of VA outpatient and inpatient treatment of the Veteran from August 2020 forward. 2. Effectuate the Board’s present decisions, above, on ratings for the Veteran’s left knee degenerative arthritis and right knee degenerative arthritis. 3. For the VA examination requested below, schedule the examination when, in the opinion of the Veteran, and in the opinion of an appropriate official at a VA medical facility near the Veteran, it is reasonably safe, in light of local conditions with regard to the COVID pandemic, to perform in-person examinations. 4. Schedule the Veteran for a VA examination to determine the current manifestations and severity of: (a) musculoskeletal disability residual to his right total knee replacement, (b) scarring residual to all right knee surgeries. Ask the examiner to provide detailed findings. On musculoskeletal disability, findings should include, but not be limited to, the ranges of motion of the knee, and the existence and severity of any pain, pain on motion, and weakness. Ask the examiner to report on the existence and severity of any excess fatigability, diminished endurance, incoordination, or flare-ups of more severe symptoms. Ask the examiner to indicate whether any pain on motion occurs on both active and passive motion, and with and without weightbearing. As to scarring, inform the examiner that the Veteran had right knee surgeries for service-connected disorders in the 1960s, in February 2019, and in May 2020. Current findings regarding scarring should include the existence of any underlying tissue damage, instability, or pain, and the measurements of the scar(s). 5. Then review the expanded claims file and review the claim for higher ratings for musculoskeletal disability residual to right total knee replacement and for right knee scar(s). Application of the new regulations, made effective in February 2021, should be made. 6. Then review the expanded claims file and review the claim for a total disability rating based on individual unemployability (TDIU). 7. Then, if any of the remanded claims is not granted to the Veteran’s satisfaction, issue a supplemental statement of the case and afford the Veteran and his representative an opportunity to respond. Then return the case to the Board for appellate review, if otherwise in order. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kunz 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. ouble Click To Sign K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kunz 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.