Citation Nr: 21013962 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-02 823 DATE: March 11, 2021 ORDER Entitlement to service connection for a bilateral hearing loss disability is granted. Entitlement to a 30 percent rating for a right knee strain (limitation of flexion) for the period from March 21, 2011 to December 17, 2015 is granted. Entitlement to a rating in excess of 20 percent for right knee instability for the period from March 21, 2011 to December 17, 2015 is denied. Entitlement to a rating in excess of 30 percent for a total right arthroplasty for the period from February 1, 2017 to October 13, 2020 is denied. Entitlement to a rating in excess of 60 percent for a total right arthroplasty for the period since October 14, 2020 is denied. Entitlement to a 30 percent rating for a left knee strain (limitation of flexion) is granted. Entitlement to a rating in excess of 20 percent for a left knee strain with lateral instability for the period prior to February 7, 2021 is denied. REMANDED Entitlement to a disability rating exceeding 20 percent for a left knee strain with lateral instability for the period since February 7, 2021 is remanded. FINDINGS OF FACT 1. The Veteran has a current bilateral hearing loss disability for VA compensation purposes that is consistent with his in-service noise exposure. 2. For the period from March 21, 2011 to December 17, 2015, the Veteran’s right knee disability was manifested by additional functional loss that resulted in weakness, limited motion, and additional pain. 3. For the period from March 21, 2011 to December 17, 2015, the Veteran’s right knee instability was manifest by moderate posterior instability. 4. For the period from May 1, 2011 through October 17, 2013, the Veteran’s left knee disability, status post total knee replacement, had not been manifested by severely limited motion (to include as due to pain), severe weakness, ankylosis in flexion between 10 and 20 degrees, extension limited to 30 degrees, or nonunion of the tibia or fibula with loose motion, requiring a brace. 5. For the period since October 14, 2020, the Veteran is in receipt of the maximum disability rating under Diagnostic Code 5055 for status-post left total knee replacement in the form of severe painful motion and weakness. 6. The Veteran’s left knee disability is manifested by additional functional loss that resulted in weakness, limited motion, and additional pain. 7. For the period prior to February 7, 2021, the Veteran’s left knee instability was manifest by moderate posterior instability. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral hearing loss disability are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for a 30 percent rating for a right knee disability (limitation of motion) for the period from March 21, 2011 to December 17, 2015 have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2020). 3. The criteria for a rating in excess of 20 percent for right knee instability for the period from March 21, 2011 to December 17, 2015 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4. 1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2020). 4. The criteria for an initial rating in excess of 30 percent for a left knee disability for the period from May 1, 2011 through October 17, 2013 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5003-5260 (2020). 5. The criteria for a rating in excess of 60 percent for status post left knee replacement for the period since October 14, 2020 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.45, 4.71a, Diagnostic Code 5055 (2020). 6. The criteria for a 30 percent rating for a left knee disability (limitation of motion) have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2020). 7. The criteria for a rating in excess of 20 percent for right knee instability for the period prior to February 7, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4. 1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1974 to October 1975. This appeal comes to the Board of Veterans’ Appeals (Board) from March 2012 and November 2014 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at an August 2016 hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the evidentiary record. The Board remanded these issues in November 2016 and September 2018 for further development. As noted above, the issues of entitlement to a disability rating exceeding 20 percent for a left knee strain with painful motion and lateral instability, entitlement to a disability rating exceeding 20 percent prior to December 17, 2015 and a rating exceeding 30 percent beginning February 1, 2017 for a right knee strain with painful limitation of motion and lateral instability were remanded by the Board in September 2018. Notably, in a November 2020 rating decision, the RO, in part, found that the decision to not grant a separate service connected evaluation for a left knee strain (limitation of flexion) was clearly and unmistakably erroneous and as a result, service connection was established at a 10 percent disability rating, effective March 21, 2011. The RO also found that the decision to not grant a separate service connected evaluation for a right knee strain (limitation of flexion) was clearly and unmistakably erroneous and as a result, service connection was established at a 10 percent disability rating, effective March 21, 2011 which would then be discontinued, effective December 17, 2015. The RO also granted an increased 60 percent rating for total right knee arthroplasty, effective October 14, 2020. As these separate evaluations and increased ratings did not constitute a full grant of the benefits sought, the issues of entitlement to a rating in excess of 10 percent for a left knee strain (limitation of flexion), entitlement to a rating in excess of 10 percent for a right knee strain (limitation of flexion) for the period prior to March 21, 2011 to December 17, 2015, entitlement to a rating in excess of 30 percent for a total right arthroplasty for the period from February 1, 2017 to October 13, 2020 and entitlement to a rating in excess of 60 percent for a total right arthroplasty for the period since October 14, 2020 remain in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include sensorineural hearing loss may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2002); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as sensorineural hearing loss and squamous cell carcinoma is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385. Additionally, it is noted that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Veteran had in-service audiological evaluations during service in November 1974 and September 1975, at which time auditory thresholds using International Standards Organization-American National Standards Institute (ISO-ANSI) units. Factual Background and Analysis The Veteran contends that his current bilateral hearing loss disability was incurred in service. A February 1956 pre-induction examination noted a whisper test that was 15/15 for both ears. Audiometric testing on a November 1974 pre-induction examination revealed pure tone thresholds, obtained by air conduction, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 10 n/a 5 LEFT 10 10 15 n/a 15 Audiometric testing on a September 1975 separation examination revealed pure tone thresholds, obtained by air conduction, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 5 5 LEFT 5 5 15 10 10 The Veteran underwent a VA examination in June 2011. Audiometric testing on the June 2011 VA examination revealed pure tone thresholds, obtained by air conduction, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 60 65 70 LEFT 15 15 45 65 60 The examiner noted that the Veteran was a military policeman who was exposed to gunfire in service as he was a defensive driver and firearms instructor. The Veteran also reported tinnitus that began in service. The examiner noted that hearing tests at enlistment and separation indicated normal hearing thresholds bilaterally. Because the Veteran’s separation examination demonstrated normal hearing, it was less likely than not that the Veteran’s bilateral hearing loss was related to his service-related noise exposure. The examiner also opined that it was at least as likely as not that the Veteran’s tinnitus was related to his military noise exposure as the onset of the Veteran’s tinnitus occurred in service. In a September 2017 opinion, a VA examiner indicated that the prior VA examiner did not relate hearing loss to tinnitus because it was addressed in response to a separate question prompt. However, the September 2017 examiner did not specifically address the June 2011 VA examiner’s finding that the Veteran’s service-connected tinnitus is at least as likely as not associated with the Veteran’s hearing loss. Per the September 2018 Board remand instructions, a VA examiner provided an addendum opinion after a records review in May 2020. The examiner opined that it was less likely than not that the Veteran’s bilateral hearing loss was caused by or the result of any in-service event. The examiner noted that the Veteran was a military police officer which was a job with a “moderate” probability of hazardous noise exposure. The Veteran’s enlistment and separation examinations both showed normal hearing with no indications of auditory trauma. The examiner noted that there was no basis to conclude that the hearing loss was casually related to military service. The examiner also noted that research showed that patients with tinnitus have hearing problems but a small percentage have hearing that is within normal limits. The examiner noted that at the time of is original appointment, the Veteran reported the onset of tinnitus beginning during his service. There was no evidence in the record that supported this, however, given the Veteran’s MOS and his reports of noise exposure, and resolving all reasonable doubt in favor of the Veteran, the opinion was relayed that it was at least as likely as not that the Veteran’s tinnitus was related to military noise exposure. The record shows that the Veteran currently has bilateral hearing loss for VA compensation purposes. Accordingly, the first element of evidence of a current disability is accordingly met. Therefore, the question to be decided in the present appeal is whether the current bilateral hearing loss disability is associated with the Veteran’s active duty. In this regard, the Board acknowledges that service treatment records are negative for complaints of, treatment for, or findings of hearing loss. However, when considering the circumstances of the Veteran’s service, he was undoubtedly exposed to some noise in service. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for bilateral hearing loss is warranted. In support of this conclusion, the Board notes that in multiple correspondences and at his Board hearing, the Veteran has described his specific in-service noise exposure. Notably, the Veteran is already currently service connected for bilateral tinnitus based on his military in-service noise exposure. The fact that the Veteran has been diagnosed as having tinnitus as a result of his in-service noise exposure and granted compensation for tinnitus adds to the credibility of the Veteran’s contention that his bilateral hearing loss disability is related to service because “an associated hearing loss is usually present” with tinnitus. The Merck Manual, Sec. 7, Ch. 82, Approach to the Patient with Ear Problems. Further, tinnitus may occur as a symptom of nearly all ear disorders including sensorineural or noise-induced hearing loss. Id. With regard to the latter, the evidence of record reflects that the Veteran’s tinnitus is noise-induced, i.e., a result of his exposure to acoustic trauma during service. In this regard, the Board notes that “high frequency tinnitus usually accompanies [noise-induced] hearing loss.” The Merck Manual, Section 7, Ch. 85, Inner Ear. Additionally, the Board notes that the June 2011 and May 2020 VA examiners appear to have based their negative opinions in large part on the absence of documented bilateral hearing loss in the Veteran’s service treatment records as the VA examiners again found that the Veteran’s current bilateral hearing loss was less likely than not caused by or a result of military service since there was no hearing loss in service and no significant shift in hearing from enlistment to separation. The Board finds that these examinations are not accurate as the absence of documented hearing loss in service is not fatal to a service connection claim for hearing loss. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Board also notes that in the May 2020 VA examination, the examiner explained how the secondary condition of tinnitus may nevertheless be related to the Veteran’s service while hearing loss was not related to service by merely noting that while the Veteran reported the onset of tinnitus beginning during his service, there was no evidence in the record that supported this. However, the Board again notes that the Veteran is service-connected for tinnitus based on the positive nexus opinion of the June 2011 VA examiner who concluded that it was at least as likely as not that the Veteran’s tinnitus was related to his in-service noise exposure. As a result, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran had a current bilateral hearing loss disability that was caused by his service. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a bilateral hearing loss disability is granted. See 38 U.S.C. § 5107(b). Increased Ratings Laws and Regulations The Board must assess the credibility and weight of all 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. 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 all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2020). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). Where there is a question as to which of two ratings shall be applied, 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 (2020). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his knee disabilities. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.59 (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Although the first sentence of 38 C.F.R. § 4.59 refers only to arthritis, the regulation applies to joint conditions other than arthritis. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). The Veteran’s right knee strain (limitation of motion) is currently rated as 10 percent disabling under Diagnostic Codes 5260 for the period from March 21, 2011 to December 17, 2015. The Veteran’s right knee instability is currently rated as 20 percent disabling under Diagnostic Codes 5257 for the period from March 21, 2011 to December 17, 2015. The Veteran’s service-connected status post total right knee replacement disability is currently evaluated as 30 percent disabling, effective February 1, 2017 through October 13, 2020 and as 60 percent disabling since October 14, 2020 under Diagnostic Code 5055 concerning residuals following prosthetic replacement of the knee joint. See 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board notes that the Veteran has a 100 percent disability rating, effective December 17, 2015 to February 1, 2017 based on surgical or other treatment necessitating convalescence for the Veteran’s service-connected right knee total replacement. Because the 100 percent rating assigned to the Veteran’s service-connected right knee disability, due to convalescence from surgery is the maximum rating available for this disability, a higher rating claim for a right knee disability, due to convalescence from surgery for the time period between December 17, 2015 to February 1, 2017 is not on appeal. Notably, the criteria for knee instability and knee replacement under Diagnostic Codes 5257 and 5055 have changed during the period covered by this appeal, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes, 5257, 5055). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5055, which governs knee replacement (prosthesis), provides that for one year following implantation of the prosthesis, the knee joint warrants an evaluation of 100 percent. Thereafter, where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is warranted. Where there are intermediate degrees of residual weakness, pain or limitation of motion, the disability is rated by analogy to diagnostic codes 5256, 5261 or 5262. The minimum rating is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. 38 C.F.R. § 4.71a, Diagnostic Code 5055. As of February 7, 2021, under the amended criteria, Diagnostic Code 5055 notes that at the conclusion of the 100 percent evaluation period, residuals of a knee replacement surgery are to evaluated under Diagnostic Codes 5256 through 5262. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the amendments did not change the criteria under Diagnostic Codes 5256, 5258, 5259, 5260, or 5261. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. Under the criteria in effect prior to February 7, 2021, under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability, and a 20 percent disability rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under the revised criteria, Diagnostic Code 5262 now provides a 30 percent evaluation for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities; a 20 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity, a 10 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities; and a noncompensable rating is warranted for shin splints that have treatment less than 12 consecutive months, one or both lower extremities. Under the criteria in effect prior to February 7, 2021, Diagnostic Code 5257 provides a 10 percent rating 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, Diagnostic Code 5257 (2020). The terms “mild,” “moderate,” “moderately severe” and “severe” are not defined in the Rating Schedule. 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 (2020). The use of terminology such as “mild” or “moderate” 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 (2020). VA General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. A claimant who has arthritis and instability of the knee may also be rated separately under Diagnostic Code 5003 and Diagnostic Code 5257, and rating a knee disability under both of those codes does not amount to pyramiding under 38 C.F.R. § 4.14 (2020). VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). However, a separate rating must be based on additional compensable disability. Under the revised criteria, Diagnostic Code 5257 for recurrent subluxation and instability now provides a 30 percent rating for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation or a sprain incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. A 20 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For patellar instability under the revised Diagnostic Code 5257, a 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Factual Background The Veteran filed a claim for an increased rating that was received by VA in March 2011. The Veteran underwent a VA examination in May 2011. The Veteran reported that he occasionally wore knee braces for his bilateral knees. His activities, standing and walking were limited due to frequent pain and instability. He had a left knee arthroscopy with meniscal repair in 2008. Both knees had giving way, instability, pain, stiffness, weakness, incoordination, decreased speed of motion, weekly locking episodes, repeated effusions, swelling and tenderness. He was able to stand for 15-30 minutes and was able to walk ¼ mile. He intermittently but frequently used a brace. His gait was antalgic with poor propulsion. The Veteran’s right knee had crepitus, edema, tenderness, pain at rest, weakness and abnormal motion. There was grinding but no instability. The left knee had tenderness, pain at rest, weakness, abnormal motion and guarding of movement. There was crepitation, a mass behind the knee, clicking, effusion and grinding. There was no instability. A left knee meniscus abnormality was noted with effusion. On examination, flexion of the left and right knees was from 0 to 136 degrees with normal extension. There was pain with repetitive motion but no additional limitation of motion after three repetitions. The diagnosis was a post traumatic chronic bilateral knee strain with a history of a left knee meniscal repair with current x-rays showing no joint abnormalities. There were significant effects on the Veteran’s daily occupation. The Veteran underwent a VA examination in January 2014. The examiner noted that the Veteran had a right knee strain. The Veteran reported that his right knee was painful all of the time. He had locking, weakness and had difficulty changing from his sitting to standing position. His right knee also was often swollen. The Veteran reported flare-ups as he had constant limitation in his movements. On examination, right and left knee flexion was from 0 to 105 degrees with pain beginning at 100 degrees. There was 0 degrees of extension with no pain on extension. The Veteran was able to perform repetitive use testing. After 3 repetition, right knee flexion was from 0 to 95 degrees and left knee flexion was from 0 to 90 degrees. The Veteran had functional loss and additional limitation of motion after repetitive use. He had swelling in both knees and had more movement than normal, weakened movement, incoordination, excess fatigability, pain on movement, instability of station, disturbance of locomotion and interference with sitting, standing and weight bearing of the left knee. There was also pain on palpation of the left knee. Muscle strength testing revealed active movement against some resistance (4/5) for flexion and extension of the right knee while left knee flexion had active movement with gravity eliminated (2/5) and left knee extension had active movement against some gravity (3/5). There was anterior joint instability, posterior instability and medial lateral instability on the right and left of 1+ (0-5 millimeters). There was no history of recurrent subluxation or dislocation. The Veteran had shin splints but they were currently inactive. The Veteran received cortisone injections up to 8 times each year. The examiner also noted that the Veteran had weakened movements with extension and flexion of the knees. He regularly used a brace and occasionally used a cane. The Veteran’s knee disabilities impacted his work as his bilateral knee pain made stooping, kneeling and bending difficult. The Veteran underwent a VA examination in August 2017. The examiner noted that the Veteran had bilateral knee strains. The Veteran had developed arthritis in his right knee and underwent total right knee replacement surgery in December 2015. He reported flare-ups of joint pain at least 4 times since last year where he had to ice his knee and rest. He had functional loss and functional impairment. On examination, right knee flexion was from 0 to 110 degrees and extension was from 110 degrees to 0 degrees. Pain was noted on the examination that caused functional loss. There was evidence of pain with weight bearing but no tenderness to palpation. Flexion of the left knee was from 0 to 120 degrees and extension was from 120 degrees to 0 degrees. Pain was noted on the examination that caused functional loss. There was evidence of pain with weight bearing but no tenderness to palpation or crepitus. The Veteran was able to do repetitive motion testing and there was no additional limitation of motion after three repetitions. The examiner was unable to say without resorting to mere speculation whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time or during flare-ups as the Veteran was not seen during flare-ups or after a period of time. The examiner noted that the Veteran’s knees interfered with him walking long distances and he was unable to squat. Muscle strength testing was normal and there was no muscle atrophy or ankylosis. Stability testing was normal for both knees. The Veteran’s right knee replacement surgery resulted in intermittent degrees of residual pain, weakness or limitation of motion. The Veteran occasionally used a cane and regularly used a brace. The Veteran’s bilateral knee disabilities impacted his ability to work as he indicated that he was unable to walk long distances or squat secondary to his bilateral knee pain. Per the September 2018 Board remand instructions, the Veteran underwent a VA examination in October 2020. The Veteran had right knee osteoarthritis, a left knee strain and left knee instability. The Veteran reported flare-ups of his right and left knees that occurred every day, were moderate to severe, lasted minutes to hours and were alleviated with nothing. The Veteran reported that his pain caused him decreased strength and decreased range of motion in both knees which did not allow him full 100 percent of his knees which was a functional loss. On examination, right knee flexion was from 0 to 55 degrees and extension was from 55 degrees to 0 degrees. Pain was noted on the examination that caused functional loss. There was evidence of pain with weight bearing but no tenderness to palpation. There was pain with weight bearing and crepitus. Flexion of the left knee was from 0 to 50 degrees and extension was from 50 degrees to 0 degrees. Pain was noted on the examination that caused functional loss. There was evidence of pain with weight bearing but no tenderness to palpation. There was pain with weight bearing and crepitus. The Veteran was able to do repetitive motion testing and there was no additional limitation of motion after three repetitions. The examiner indicated that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time as right knee flexion was from 0 to 50 degrees. Pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups as right knee flexion was from 0 to 45 degrees. The examiner indicated that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time as left knee flexion was from 0 to 45 degrees. Pain, weakness, fatigability or incoordination significantly limited functional ability with flare-ups as right knee flexion was from 0 to 40 degrees. Both the right and left knees had less movement than normal, weakened movement, disturbance of locomotion, interference with sitting and interference with standing. There was a reduction in muscle strength as flexion and extension in both knees exhibited active movement against some resistance (4/5). He did not have muscle atrophy or ankylosis. There was no recurrent subluxation. The Veteran did not have right knee instability but had slight left knee instability. There was no history of recurrent effusion. Joint stability testing was performed and there was no right knee instability but there was lateral instability of 1+ (0-5 millimeters) in the left knee. The Veteran never had a torn meniscus. The Veteran occasionally used a cane when he was going to do a lot of walking. The Veteran’s bilateral knee disabilities impacted his ability to work as he indicated that because of severe pain in his bilateral knees and the weakness/decreased range of motion, he could not do occupational tasks such as bending, kneeling or standing for long periods of time. Right Knee Period from March 21, 2011 to December 17, 2015 As noted above, the Veteran’s right knee strain (limitation of motion) is currently rated as 10 percent disabling under Diagnostic Codes 5260 for the period from March 21, 2011 to December 17, 2015. For the same time period, the Veteran is in receipt of a 20 percent disability rating for right knee instability under Diagnostic Code 5257. Based on the reported symptomatology of the Veteran’s limitation of motion and reported functional impairment and flare-ups at his VA examinations, the Board finds that when affording the Veteran the benefit of the doubt, that a 30 percent disability rating is warranted for the Veteran’s service-connected right knee strain (limitation of motion) for the period from March 21, 2011 to December 17, 2015. However, the Board finds that for the same period, a rating in excess of 20 percent is not warranted for instability of the right knee. Regarding limitation of flexion, the Board notes that for a 30 percent evaluation under Diagnostic Code 5260, the Veteran must demonstrate flexion limited to 15 degrees or extension must be limited to 20 degrees. Notably, on VA examination in May 2011, flexion of the right knee was from 0 to 136 degrees while on the January 2014 VA examination, flexion of the right knee was from 0 to 95 degrees after 3 repetitions. However, on his May 2011 VA examination, the Veteran reported pain, stiffness, weakness, incoordination, decreased speed of motion, weekly locking episodes, repeated effusions, swelling and tenderness. He was also only able to stand for 15-30 minutes and was able to walk for a ¼ mile while the examiner noted that the Veteran’s knees had significant effects on the daily occupation. Additionally, on the January 2014 VA examination, the Veteran reported that his right knee was painful all of the time and he had locking, weakness and had difficulty changing from his sitting to standing position. The Veteran also reported flare-ups as he had constant limitation in his movements and the examination revealed a reduction in muscle strength while the examiner again noted that his ability to work was impacted. Additionally, the Board notes that while the January 2014 VA examination demonstrated only flexion of the right knee from 0 to 95 degrees, the Veteran’s knee condition was impaired to such a degree that he underwent total right knee replacement surgery the very next year. Based on the reported symptomatology of the Veteran’s reported functional impairment at his May 2011 and January 2014 VA examinations, the Board finds that when affording the Veteran the benefit of the doubt that a higher 30 percent rating is warranted for the Veteran’s right knee disability for limitation of motion for the period from November 9, 2007 to March 7, 2010. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. However, while the Board finds that the Veteran’s right knee disability warrants a higher 30 percent disability rating, the evidence does not demonstrate that a rating is warranted for an evaluations in excess of 30 percent for the right knee disability for the period from March 21, 2011 to December 17, 2015. The Board notes that the maximum rating for limited flexion of the knee does not exceed 30 percent. Hence, Diagnostic Code 5260 is inapplicable. As noted above, to warrant a rating in excess of 30 percent for the right knee, the Veteran would have to be found to have extension limited to 30 degrees. The evidence reflects that the Veteran had full extension of the right knee without objective evidence of painful motion. There is no indication that the Veteran ever had extension of the right knee limited to 30 degrees or more, even with consideration of the DeLuca factors, to warrant a disability rating in excess of 30 percent under Diagnostic Code 5261 for the period from March 21, 2011 to December 17, 2015. The Board has also considered other diagnostic codes to determine if higher evaluations are warranted for a right knee disability for the period from March 21, 2011 to December 17, 2015. However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, a meniscus disability, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 do not apply. Accordingly, the Board finds that a 30 percent rating, but no higher, for the right knee disability (limitation of motion) for the period from March 21, 2011 to December 17, 2015 is warranted. Regarding instability of the right knee, the Veteran again has a current 20 percent disability evaluation for instability of the right knee under Diagnostic Code 5257 for the period from March 21, 2011 to December 17, 2015. Considering the pertinent facts in light of applicable rating criteria, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran’s instability of the right knee. As noted above, to warrant a 30 percent disability rating under Diagnostic Code 5257, severe recurrent subluxation or lateral instability must be demonstrated. In this instance, severe recurrent subluxation or lateral instability has not been shown. The May 2011 VA examination noted that the Veteran had grinding but no instability. Additionally, the June 2014 VA examiner noted that while the Veteran had anterior joint instability, posterior instability and medial lateral instability on the right and left of 1+ (0-5 millimeters), there was no history of recurrent subluxation or dislocation. The Board finds that the Veteran is competent and credible in his reporting of his right knee instability. The Board, nevertheless, ultimately places more weight on the consistent results of his VA examinations, which revealed no objective evidence of severe instability in his right or left knee. Winsett v. West, 11 Vet. App. 420 (1998), aff’d 217 F.3d 854 (Fed. Cir. 1999); Guerrieri v. Brown, 4 Vet. App. 467 (1993). As the record only demonstrates at most moderate instability for the right knee, an evaluation in excess of 20 percent is not warranted. The Board again notes that the criteria for knee instability under Diagnostic Code 5257 have changed during the period covered by this appeal, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). However, as the Veteran’s 20 percent rating for right knee instability under Diagnostic Code 5257 is for the period from March 21, 2011 to December 17, 2015 the revised criteria is not applicable. Accordingly, as the preponderance of the evidence is against the claims for a rating in excess of 20 percent for service-connected instability of the right knee for the period from March 21, 2011 to December 17, 2015, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Period from February 1, 2017 to October 13, 2020 The Veteran’s service-connected status post total right knee replacement disability is currently evaluated as 30 percent disabling for the period from February 1, 2017 to October 13, 2020 under Diagnostic Code 5055. Following a review of the evidence and the Veteran’s contentions, the Board finds that symptomatology and findings associated with the Veteran’s right knee disability do not warrant a disability rating in excess of 30 percent for the period from February 1, 2017 to October 13, 2020. The Board notes that the maximum rating for limited flexion of the knee does not exceed 30 percent. Hence, Diagnostic Code 5260 is inapplicable. As noted above, to warrant an increased rating for a right knee disability in excess of 30 percent, the Veteran would have to be found to have extension limited to 30 degrees. However, for this time period there is no indication that the Veteran ever had extension of the right knee limited to 30 degrees or more, even with consideration of the DeLuca factors, to warrant a disability rating in excess of 30 percent under Diagnostic Code 5261 as the August 2017 VA examination noted extension from 0 degrees. While it was noted on the August 2017 VA examination that the Veteran reported flare-ups of joint pain at least 4 times since last year where he had to ice his knee and rest, the examiner also specifically found that there was no additional limitation of motion following repetitive testing. While the VA examiner did not provide range of motion estimates in degrees regarding flare-ups or after repetitive use over time, such is understandable as the examiner explained that an estimate could not be provided and would be speculative as the examination was not performed during a flare-up or after repetitive use over time. The Board finds these explanations adequate for why the examiners could not offer range of motion estimates. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). The Board notes that there is no reason to suspect that passive range of motion would be any less than that of active motion absent some indication of such by the examiner or report of such by the Veteran, neither of which is present in this case. The Board also notes that during the Veteran’s reported flare-ups there is no indication that the Veteran contacted his healthcare provider. Thus, the Veteran’s flare-ups were relatively infrequent and fairly short in duration based on the reported frequency and duration of such episodes on VA examination in August 2017. In addition to testing, the Veteran had been asked to describe functional loss and impairment in various situations and he had not identified that he has loss of motion to the degree required for a higher rating in excess of 30 percent. The Board again acknowledges that the Veteran had pain, weakened movement and less movement than normal. This is well documented in the lay and medical evidence. Furthermore, the Board again accepts that he has functional impairment, pain and limited motion as demonstrated by the August 2017 VA examination. See DeLuca, supra. The Board further finds that the Veteran’s own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of impairment required for an evaluation in excess of 30 percent. The Board has also considered other diagnostic codes to determine if higher evaluations are warranted for a right knee disability. However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, current meniscus disability, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 do not apply. The Board acknowledges the Veteran’s reports of right knee instability during the appeal period. However, the August 2017 VA examination demonstrated normal stability testing. Additionally, the Board finds that this symptom is contemplated in the rating assigned under Diagnostic Code 5055, as this evaluation include weakness and are intended to compensate for all residuals of a knee replacement. Thus, to assign a separate rating under 38 C.F.R. § 4.71a, Diagnostic Code 5257, would constitute improper pyramiding. 38 C.F.R. § 4.14. See also Tedesco v. Wilkie, 31 Vet. App. 360, 367, n. 5 (2019) (where the Secretary argued that separate ratings under Diagnostic Code 5257 were prohibited in cases involving Diagnostic Code 5055 due to improper pyramiding, the Court declined to reach the question of whether the Board committed legal error when it found that a separate rating for instability under Diagnostic Code 5257 could be granted in addition to a rating for knee replacement under Diagnostic Code 5055 because to allow such a rating would constitute improper pyramiding). Accordingly, the Board finds that a rating in excess of 30 percent for a right knee disability for the period from February 1, 2017 to October 13, 2020 is not warranted. Period from October 14, 2020 The Board finds that a rating in excess of 60 percent is not warranted for the Veteran’s residuals status post right knee replacement disability for the period since October 14, 2020. As noted above, a 60 percent rating is the highest rating available under Diagnostic Code 5055, absent the year following implantation of prosthesis under both the old and revised rating criteria. Additionally, the Board finds that the Veteran’s pain upon range of motion and weakness are accounted for under Diagnostic Code 5055 and that separately applying Diagnostic Codes 5260 or 5261 would result in pyramiding. See 38 C.F.R. § 4.14; see also Esteban, 6 Vet. App. at 261-62 (1994). The Board has also considered other diagnostic codes to determine if higher evaluations are warranted for a right knee disability. However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, a current meniscus disability, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 do not apply. The Board acknowledges the Veteran’s reports of right knee instability and giving way during the appeal period. However, the Board finds that this symptom is contemplated in the rating assigned under Diagnostic Code 5055, as this evaluation include weakness and are intended to compensate for all residuals of a knee replacement. Thus, to assign a separate rating under 38 C.F.R. § 4.71a, Diagnostic Code 5257, would constitute improper pyramiding. 38 C.F.R. § 4.14. See also Tedesco v. Wilkie, 31 Vet. App. 360, 367, n. 5 (2019) (where the Secretary argued that separate ratings under Diagnostic Code 5257 were prohibited in cases involving Diagnostic Code 5055 due to improper pyramiding, the Court declined to reach the question of whether the Board committed legal error when it found that a separate rating for instability under Diagnostic Code 5257 could be granted in addition to a rating for knee replacement under Diagnostic Code 5055 because to allow such a rating would constitute improper pyramiding). Additionally, the most recent VA examination in October 2020 found that the Veteran did not have instability of his right knee. Neither the Veteran nor her representative has identified any other rating criteria that would provide a higher rating or an additional rating. The potential applications of various provisions of Title 38 of the Code of Federal Regulations (2014) have been considered whether or not they were raised by the veteran as required by the holding of the Court in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Accordingly, a 60 percent rating is clearly the maximum rating assignable for the Veteran’s right knee replacement with limited range of motion and an initial rating in excess of 60 percent for the period since October 14, 2020 is not available. As the preponderance of the evidence is against the claim a rating in excess of 60 percent for the right knee for the period since October 14, 2020, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left Knee Limitation of Motion As noted above, the Veteran’s left knee strain (limitation of motion) is currently rated as 10 percent disabling under Diagnostic Codes 5260. Based on the reported symptomatology of the Veteran’s limitation of motion and reported functional impairment and flare-ups at his VA examinations, the Board finds that when affording the Veteran the benefit of the doubt, that a 30 percent disability rating is warranted for the Veteran’s service-connected left knee strain (limitation of motion). Regarding limitation of flexion, the Board notes that for a 30 percent evaluation under Diagnostic Code 5260, the Veteran must demonstrate flexion limited to 15 degrees or extension must be limited to 20 degrees. Notably, on VA examination in May 2011, flexion of the left knee was from 0 to 136 degrees, on VA examination in January 2014 VA examination, flexion of the left knee was from 0 to 90 degrees after 3 repetitions, on VA examination in August 2017 flexion of the left knee was from 0 to 120 degrees and on VA examination in October 2020 flexion of the left knee was from 0 to 50 degrees. However, on his May 2011 VA examination, the Veteran reported pain, stiffness, weakness, incoordination, decreased speed of motion, weekly locking episodes, repeated effusions, swelling and tenderness while the examiner noted that the Veteran’s knees had significant effects on the daily occupation. Additionally, on the January 2014 VA examination, the Veteran reported that his left knee was painful all of the time and he had locking, weakness and had difficulty changing from his sitting to standing position. The Veteran also reported flare-ups as he had constant limitation in his movements and the examination revealed a reduction in muscle strength while the examiner again noted that his ability to work was impacted. Most recently, the October 2020 VA examiner found that the Veteran had less movement than normal, weakened movement, disturbance of locomotion, interference with sitting and interference with standing while there was also a reduction in muscle strength as flexion and extension exhibited active movement against some resistance (4/5). Based on the reported symptomatology of the Veteran’s reported functional impairment at his VA examinations, the Board finds that when affording the Veteran the benefit of the doubt that a higher 30 percent rating is warranted for the Veteran’s left knee disability for limitation of motion. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. 202. However, while the Board finds that the Veteran’s left knee disability warrants a higher 30 percent disability rating, the evidence does not demonstrate that a rating is warranted for an evaluation in excess of 30 percent. The Board notes that the maximum rating for limited flexion of the knee does not exceed 30 percent. Hence, Diagnostic Code 5260 is inapplicable. As noted above, to warrant a rating in excess of 30 percent for the left knee, the Veteran would have to be found to have extension limited to 30 degrees. The evidence reflects that the Veteran had full extension of the left knee without objective evidence of painful motion. There is no indication that the Veteran ever had extension of the left knee limited to 30 degrees or more, even with consideration of the DeLuca factors, to warrant a disability rating in excess of 30 percent under Diagnostic Code 5261. The Board has also considered other diagnostic codes to determine if higher evaluations are warranted for a left knee disability. However, evaluation of the relevant evidence of record reflects that the record contains no evidence of ankylosis, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, Diagnostic Codes 5256, 5262, and 5263 do not apply. The Board also finds that a separate or higher initial rating is not warranted under Diagnostic Codes 5258 or 5259. Notably, the May 2011 VA examiner indicated that the Veteran had a left knee arthroscopy with meniscal repair in 2008. However, as the Veteran is now being awarded a 30 rating in the left knee based, in part, on pain and limitation of motion, separate disability ratings under either Diagnostic Codes 5258 and 5259 would violate 38 C.F.R. § 4.14 and the rule against pyramiding as those codes already contemplate such manifestation. Thus, for this reason, separate ratings under these codes would violate 4.14. Accordingly, the Board finds that a 30 percent rating, but no higher, for the left knee disability (limitation of motion) is warranted. Instability As noted above, the Veteran has current 20 percent disability evaluation for instability of the left knee under Diagnostic Code 5257 for the period prior to February 7, 2021. Considering the pertinent facts in light of applicable rating criteria, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran’s instability of the left knee. As noted above, to warrant a 30 percent disability rating under Diagnostic Code 5257, severe recurrent subluxation or lateral instability must be demonstrated. In this instance, severe recurrent subluxation or lateral instability has not been shown. The May 2011 VA examination noted that the Veteran had grinding but no instability while the June 2014 VA examiner noted that while the Veteran had anterior joint instability, posterior instability and medial lateral instability on the right and left of 1+ (0-5 millimeters), there was no history of recurrent subluxation or dislocation. Notably, the August 2017 VA examiner found that the Veteran had no instability while the most recent VA examination in October 2020 demonstrated slight left knee instability without recurrent subluxation. The Board finds that the Veteran was competent and credible in his reporting of his left knee instability. The Board, nevertheless, ultimately places more weight on the consistent results of his VA examinations, which revealed no objective evidence of severe instability in his left knee. Winsett v. West, 11 Vet. App. 420 (1998), aff’d 217 F.3d 854 (Fed. Cir. 1999); Guerrieri v. Brown, 4 Vet. App. 467 (1993). As the record only demonstrates at most moderate instability for the left knee, an evaluation in excess of 20 percent is not warranted. Accordingly, as the preponderance of the evidence is against the claims for a rating in excess of 20 percent for service-connected instability of the left knee, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claim remaining on appeal. The Veteran’s left knee disability is currently rated as 20 percent disabling under Diagnostic Codes 5257. As noted above, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended and the criteria for knee instability under Diagnostic Code 5257 have changed during the period covered by this appeal, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). As a result, for the period since February 7, 2021, a rating in excess of 20 percent is possibly available under the revised criteria. As reflected above, a 30 percent rating is warranted under the revised criteria of Diagnostic Code 5257 for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation or a sprain incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation or for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Notably, while the most recent October 2020 VA examiner indicated that the Veteran had not undergone surgical repair of his left knee, the May 2011 VA examiner specifically noted that the Veteran had undergone left knee surgery. As a result, the record does not contain sufficient evidence to rate the Veteran’s disability under the new rating criteria to determine whether there is unrepaired or failed repair of complete ligament tear whether a medical provider has prescribed both and assistive device and bracing for ambulation .Accordingly, a new examination for the period since February 7, 2021 is warranted. The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disability on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. After the development requested above has been completed to the extent possible, the Veteran should also be scheduled for VA examination before an appropriate physician to determine the current level of severity of his service-connected instability of the left knee disability. The Veteran’s claims file and a copy of this remand must be provided to the examiner for review in conjunction with this examination, and the examination reports should reflect review of these items. All necessary tests and studies should be performed, and the examiner should describe in detail all symptomatology associated with the Veteran’s left knee instability disability. The examiner should specifically address the revised criteria for knee instability under Diagnostic Code 5257, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). The examiner should also provide an opinion concerning the impact of the Veteran’s service-connected left knee instability on his ability to work. 3. Thereafter, readjudicate the issue on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James A. DeFrank, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.