Citation Nr: 21014781 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 09-26 924 DATE: March 15, 2021 ORDER Entitlement to a left knee disability rating in excess of 20 percent prior to November 18, 2009 and for the periods from November 18, 2009 to November 15, 2012 and from January 1, 2013 to May 6, 2018 for patellofemoral syndrome with degenerative joint disease is denied. Entitlement to a separate evaluation for other impairment of the left knee disability of 10 percent for the periods from November 18, 2009 to November 15, 2012 and from January 1, 2013 to May 6, 2018 is granted. Entitlement to a disability rating in excess of 30 percent for the period from July 1, 2019 for total left knee arthroplasty is denied. Entitlement to a disability rating of 20 percent prior to April 18, 2016 for patellofemoral syndrome with degenerative joint disease (dislocated semilunar cartilage) of the right knee is granted. Entitlement to a disability rating in excess of 10 percent from October 1, 2016 for patellofemoral syndrome with degenerative joint disease (symptomatic removal of semilunar cartilage) of the right knee is denied. REMANDED Entitlement to a total disability rating due to individual unemployability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to November 18, 2009, and for the periods from November 18, 2009 to November 15, 2012 and from January 1, 2013 to May 6, 2018, the Veteran’s left knee symptoms manifested by no worse than semilunar dislocation, locking, and pain. 2. From November 18, 2009 to May 6, 2018, limited to the periods on appeal, the Veteran’s left knee symptoms manifested by frequent episodes of locking, pain, and giving way, indicating a slight impairment of lateral instability. 3. From July 1, 2019, the Veteran’s left knee symptoms manifested by no worse than residual weakness and pain from a knee replacement with no recurrent subluxation, lateral or patellar instability. 4. Prior to April 18, 2016, the Veteran’s right knee disorder symptoms manifested by frequent episodes of locking, pain, and giving way. 5. From October 1, 2016, the Veteran’s right knee disorder symptoms manifested in no more than pain, with no evidence of greater impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 20 percent for patellofemoral syndrome, left knee are not met prior to November 18, 2009, and for the periods from November 18, 2009 to November 15, 2012 and from January 1, 2013 to May 6, 2018. 38 U.S.C. § 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260, 5261, 5258 (2020). 2. The criteria for entitlement to a rating of 10 percent for a slight impairment of lateral instability of the left knee are met from November 18, 2009 to November 15, 2012 and from January 1, 2013 to May 6, 2018. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.71a, DC 5257 (2020). 3. The criteria for entitlement to a rating in excess of 30 percent for left total knee arthroplasty, previously rated as patellofemoral syndrome of left knee are not met from July 1, 2019. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.71a, DCs 5257, 5055 (2020), 5055, 5257 (2021). 4. The criteria for entitlement to a rating of 20 percent for semilunar dislocated cartilage with episodes of locking of the right knee prior to April 18, 2016, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.71a, DC 5258 (2020). 5. The criteria for entitlement to a rating in excess of 10 percent for patellofemoral syndrome, degenerative joint disease (symptomatic removal of semilunar cartilage), right knee from October 1, 2016, is not met. 38 U.S.C. § 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5003, 5258, 5259, 5260, 5261 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1992 to February 1995. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2008 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in June 2017 and June 2020. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. The Rating Schedule was recently updated, with the changes going into effect beginning February 7, 2021. Prior to February 7, 2021, the old code will continue to be applied. From February 7, 2021, the more favorable code of the updated or old code shall be applied. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a “staged” rating is required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2020); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45 (2020). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. A Veteran experiencing an “actually” painful joint is entitled to at least the minimum compensable rating per joint under the appropriate Diagnostic Code (DC) involved. Petitti v. McDonald, 27 Vet. App. at 424 (2015) (citing Mitchell v. Shinseki, U.S. Vet. App. No. 09-2169, Secretary’s Response (Resp.) to April 6, 2011, Order at 1). DC 5259 pertains to the residuals of semilunar cartilage removal. The highest schedular evaluation allowed for removal of semilunar cartilage of the knee is ten percent. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. There was no change to Diagnostic Codes 5258 and 5259 in the updated Rating Schedule. DC 5260 pertains to limited flexion of the knee and provides a noncompensable rating when left flexion is limited to 60 degrees. A 10 percent rating applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees and a 30 percent rating applies when flexion is limited to 15 degrees. There was no change to Diagnostic Code 5260 in the updated Rating Schedule. Recurrent subluxation or lateral instability of the knee is rated under DC 5257, which grants a 10 percent evaluation for slight knee impairment. A 20 percent evaluation is warranted for moderate knee impairment and a 30 percent evaluation is warranted for severe knee impairment. Words such as “mild”, “slight”, “moderate”, “marked”, and “severe” are not defined in the VA 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, Order at 1). DC 5257 has changed since the February 7, 2021 revisions. The code still rates recurrent subluxation or instability. A 10 percent rating applies when there is a sprain, incomplete ligament tear, 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. A 20 percent rating applies when there is one of the following: 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 b) 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), or a walker) or bracing for ambulation. A 30 percent rating applies when 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. The updated DC 5257 also includes ratings specifically for patellar instability. A 10 percent rating applies when 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. A 20 percent rating applies when 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 30 percent rating applies when 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 walker. For clarity, the Board notes that the Agency of Original Jurisdiction has assigned multiple temporary total ratings under 38 C.F.R. § 4.30 for the bilateral knees during the appeal period. These ratings are not on appeal and will not be disturbed. 1. Entitlement to a left knee disability rating in excess of 20 percent prior to November 18, 2009 and for the periods from November 18, 2009 to November 15, 2012 and from January 1, 2013 to May 6, 2018 for patellofemoral syndrome with degenerative joint disease is denied. 2. Entitlement to a separate evaluation for other impairment of the left knee disability of 10 percent for the periods from November 18, 2009 to November 15, 2012 and from January 1, 2013 to May 6, 2018 is granted. The Veteran is rated at 20 percent disabling under DC 5258 for semilunar dislocation, pain, and locking prior to October 1, 2008, from November 1, 2008 to November 15, 2012, and from January 1, 2013 to May 6, 2018. In October 2006, January 2009, November 2009, and January 2011, the Veteran underwent four compensation and pension examinations for his bilateral knee condition. In October 2006, the Veteran was found to have 0 to 140 degrees flexion of his left knee with no physical evidence of loss of function. The Veteran reported and the examiner found that the Veteran did not have instability, stiffness, pain, or weakness. In January 2009, the Veteran was not found to have any instability, stiffness, weakness, or diminishment of range of motion. The Veteran was also noted to have no patellar abnormality. The Veteran reported a popping and grinding of his left knee. In November 2009, the Veteran again reported that his left knee was popping and that he had episodes of dislocation or subluxation weekly. The examiner opined that the Veteran did not have instability and found the Veteran had 0 to 110 degrees flexion. In January 2011, the Veteran reported left knee pain, stiffness, weakness, and instability. The examiner found that the Veteran had 0 to 90 degrees flexion and no instability but also that one to three times a month the Veteran experienced episodes of locking. In October 2015, the Veteran underwent another VA examination for compensation and pension purposes for his left knee condition. The report noted a decline in functioning with diminished ability to stand, sit, walk, kneel, squat, as well as flare-ups resulting in increased pain. Range of motion testing revealed that the Veteran had flexion of 0 to 125 degrees and extension of 125 to 0 degrees. Repetitive use testing did not result in loss of motion or functional impairment. Additionally, the examiner noted that there was no pain on palpation or tenderness, normal muscle strength and that there was no history of recurrent patellar subluxation. The examination revealed no anterior instability and no meniscal tear but documented arthritis. The examiner opined that the Veteran’s knee conditions could potentially impact his ability to perform occupational tasks. In September 2016, the Veteran had a sixth VA examination. The Veteran reported experiencing flare-ups approximately two times per week which rendered him unable to walk. The Veteran was able to perform repetitive-use testing with at least three repetitions. Range of motion testing revealed no limitations and no painful motion. Additionally, there was no pain on palpation, normal muscle strength, and no history of recurrent patellar subluxation. The examination revealed no instability. The examiner concluded that the Veteran’s knee condition did functionally impact his ability to walk moderated distances, squat, and lift. On May 7, 2018, the Veteran had a total left knee replacement. Following his replacement, in June 2018, the Veteran had a seventh VA examination. The Veteran reported that his knees had become very unstable and his knee pain worsened with movement. The Veteran reported that it impacted his daily living activities; making him unable to walk up flights of stairs or go shopping. The Veteran also reported having flare-ups that lasted from 20-30 minutes several times per day. The range of motion for flexion and extension was 0 to 110 degrees. There was localized tenderness or pain on palpation of the left knee that the examiner attributed to surgery. There was no additional loss of function or further loss of range of motion after three repetitions of the left knee. The Veteran had no meniscal tearing, no joint instability found, and 4 out of 5 muscle strength. The examiner opined that the Veteran had pain and decrease in range of motion (ROM) with sitting, standing, walking, jogging, twisting, bending, carrying weight, and climbing ladders and stairs. The Board reviewed the Veteran’s private medical records in addition to the VA examinations. The records contain the Veteran’s subjective complaints pertaining to knee popping, ambulating with a cane, and reports of his knee giving out. In May 2007, the Veteran reported infrequent left knee buckling. In June 2009, the Veteran was prescribed an updated knee brace due to the pain, popping, and stiffness in his left knee. In November 2017, the Veteran reported left knee locking and disclosed that he recently fell. Further, private medical records in April and May 2018 include reports of left knee instability from the Veteran. The Veteran is in receipt of a 20 percent evaluation for the left knee under 38 C.F.R. § 4.71a which provides for a compensable rating, i.e. a 20 percent rating, under Diagnostic Code 5258 based on semilunar dislocation, pain, and locking. The regulation does not provide any mechanism for a rating higher than 20 percent. Therefore, an increased rating is not warranted based on the diagnostic codes pertaining to semilunar dislocation. Notably, there is not an updated diagnostic code for DC 5258. After May 7, 2018, this code changed to 5055-5311 because of the total knee replacement and was then discontinued. The Board has considered whether separate or higher ratings for instability or subluxation of the knee may be appropriate. The old Diagnostic Code 5257, pertaining to recurrent subluxation or lateral instability, provides for a 10 percent rating for slight lateral instability or recurrent subluxation, a 20 percent rating for moderate lateral instability or recurrent subluxation, and a maximum 30 percent rating for severe lateral instability or recurrent subluxation. 38 C.F.R. § 4.71a. The Board finds that the Veteran does not warrant a separate rating under DC 5257 prior to November 18, 2009, as neither the Veteran’s lay statements nor the medical records indicate that the Veteran experienced recurrent subluxation, lateral instability, or recurrent effusion. The Veteran reports infrequent episodes of knee locking which is already awarded a 20 percent rating under Diagnostic Code 5258 and cannot also be awarded under Diagnostic Code 5257 due to the prohibition against pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261. The Board finds the Veteran warrants a separate rating under DC 5257 as of November 18, 2009. At the November 2009 VA examination, as well as in November 2017, and May 2018, the Veteran reported instability and that his knee gives way, which causes him to fall. The Board notes that joint instability and recurrent subluxation were not found by the examiner at any of the Veteran’s VA examinations. However, when making a decision, the Board must consider all the evidence of record, to include lay statements. 38 U.S.C. § § 5107 (b), 7104(a); 38 C.F.R. § 3.303 (a). The Veteran is competent and credible to describe his symptoms regarding his knees and therefore his statements are provided probative weight. See Barr v. Nicholson, 21 Vet. App. 303. Therefore, the Board finds that the Veteran’s reports of instability and his knee giving way indicates instability of the left knee that is at most, slight, thus a separate rating of 10 percent is warranted under DC 5257 as of November 18, 2009 and ending May 7, 2018, as that is the date of the total knee replacement. The Board notes that the Veteran may not be assigned separate ratings under both DCs 5003 (via 5010) and 5258. The Veteran’s knee disability has been manifested by joint “locking,” painful motion, effusion, and arthritis. Both DCs overlap in ratings based on pain and “locking” as forms of limitation of motion; therefore, assigning separate ratings under both DC 5003 (via 5010) and DC 5258 would violate the prohibition against pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). The Board finds that an increased rating is not warranted for the left knee based on limitation of motion. Throughout the appeal period, the Veteran’s left knee has manifested noncompensable limitation of motion that most nearly approximates flexion limited to 85 degrees or better and extension limited to 0 degrees. Range of motion with limitation of flexion and extension 0 to 85 degrees or better is noncompensable under Diagnostic Codes 5260 and 5261. An increased rating under these codes is therefore not possible. The Board finds that there is no other schedular basis for granting a higher or other separate rating. Diagnostic Codes 5256 and 5262 provide for ratings higher than 10 percent with a showing of ankylosis and impairment of tibia or fibula. The medical and lay evidence does not establish any pathology associated with these knee conditions. The Board therefore finds that additional separate or higher ratings are not warranted and the claim for an increased evaluation is granted to the extent discussed above. 3. Entitlement to a disability rating in excess of 30 percent for the period from July 1, 2019 for total left knee arthroplasty is denied. Diagnostic Code 5055 provides criteria for rating knee disabilities that require knee replacement surgery. Under those criteria, a 100 percent disability rating is assigned for one year following the surgery. Thereafter, the disability warrants a minimum 30 percent rating, but may be assigned a higher rating if the Veteran has intermediate degrees of residual weakness, pain or limitation of motion, by analogy to DCs 5256 (ankylosis of the knee), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). See 38 C.F.R. § 4.71a, DC 5055. While DC 5055 has been amended, the portions applicable to this Veteran’s total left knee arthroplasty claim remain the same. The Veteran’s left knee strain with associated with muscle groups XI and XII is evaluated as 30 percent disabling under DCs 5311 and 5055. 38 C.F.R. § 4.73, DC 5311 contemplates disabilities to muscles including the posterior and lateral crural muscles and muscles of the calf, including the triceps surae (gastrocnemius and soleus), tibialis posterior, peroneus longus, peroneus brevis, flexor hallucis longus, flexor digitorum longus, popliteus, and plantaris. The functions of these muscles are propulsion, plantar flexion of the foot, stabilization of the arch, flexion of the toes, and flexion of the knee. 38 C.F.R. § 4.73, DC 5311. Under DC 5311, which outlines the rating criteria for impairments of the calf muscle, a moderately severe muscle disability warrants a 20 percent rating, and a severe muscle disability warrants a 30 percent rating. There was no change made to DC 5311 in the updated Rating Schedule. The Veteran has already been awarded the highest schedular rating under 38 C.F.R. § 4.73, DC 5311. There is no other more applicable diagnostic code for which a higher disability rating than 30 percent may be warranted. There has been no change to DC 5311 in the updated Rating Schedule. Under the ratings by analogy for DCs 5256, 5261, and 5262, the Veteran is entitled to a 40 percent rating if he has (a) ankylosis in flexion between 10 and 20 degrees (DC 5256), (b) extension of the leg limited to between 30 and 44 degrees (DC 5261), or (c) symptoms analogous to nonunion of the tibia and fibula with loose motion and requiring a brace. See 38 C.F.R. § 4.71a, DCs 5055, 5256, 5261. He is entitled to a 50 percent rating if he has (a) ankylosis in flexion between 20 and 45 degrees (DC 5256), or (b) extension limited to 45 or more degrees (DC 5261). Id. He is entitled to a 60 percent rating if he has extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more (DC 5256). Id. A 60 percent rating is also warranted unde DC 5055 where the post-replacement evidence shows chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. There has been no change to DC 5256 or 5261 in the updated Rating Schedule. The word “severe” referencing painful motion or weakness is not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all evidence, to the end that decisions will be equitable and just. See 38 C.F.R.§ 4.6. Here, the preponderance of the evidence shows the Veteran does not meet the criteria for a 40 percent rating under DCs 5256, 5261, or 5262, nor the criteria for a 60 percent rating under DCs 5256 or 5055. In September 2019, the Veteran had a VA examination for his left knee. The examiner found the Veteran’s range of motion to be 0 to 110 degrees for flexion and extension with a decreased range of motion 0 to 105 degrees during flare-ups. The Veteran’s muscle strength was rated 4 out of 5 and was found to have normal joint stability. The examiner found that the Veteran had intermediate degrees of residual weakness, pain or limitation of motion. The examiner also found objective evidence of pain on passive range of motion testing and non-weight bearing testing of the left knee. The examiner opined that pain and decrease in ROM with sitting, standing, walking, jogging, twisting, bending, carrying weight, and climbing ladders and stairs. In August 2020 and September 2020, the Veteran had two VA examinations at which he reported intermittent throbbing left knee pain along with intermittent popping and numbness. The Veteran contended that prolonged standing and walking made the pain worse. The Veteran’s left knee range of motion for flexion and extension was measured at 0 to 110. With pain, weakness and fatigability, the Veteran’s left knee flexion and extension diminished to 0 to 100 degree flexion. During a flare-up, the examiner determined the Veteran’s flexion and extension diminished to 0 to 90 degrees. The Veteran was found to have atrophied muscle on the left side, 38 cm compared to 42.5 cm on his right side. The Veteran would not warrant a rating in excess of 30 percent under Diagnostic Code 5261, applying to limitation of extension. To warrant an increased 40 percent rating, the Veteran would have to demonstrate extension limited to 30 degrees. The VA examinations and medical records show that the Veteran’s extension has not met that standard. Accordingly, the Veteran is not entitled to a higher rating based on limitation of extension. Further, Diagnostic Code 5262 applying to malunion of the tibia or fibula does not apply, because there is no evidence, and the Veteran does not argue, that his left knee disability manifests as malunion or nonunion of the tibia or fibula. To warrant an increased rating of 40 percent under Diagnostic Code 5262, the Veteran’s left knee replacement would have to manifest as nonunion of the tibia or fibula with loose motion requiring bracing. As there is no evidence of any nonunion, or even malunion, of the tibia or fibula, an increased rating greater than 30 percent is not warranted under DC 5262. Similarly, the updated Diagnostic Code 5262 does not apply, because there is no evidence, and the Veteran does not argue, that his left knee disability manifests as malunion or nonunion of the tibia or fibula. To warrant an increased rating of 40 percent under Diagnostic Code 5262, the Veteran’s left knee replacement would have to manifest as nonunion of the tibia or fibula with loose motion requiring bracing. The updated DC 5262 states that the Veteran’s claim should be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. The Board has considered whether the Veteran’s left knee disability could be better rated under another Diagnostic Code applying to the knees. Considering the evidence of record, the Board finds that the Veteran does not have recurrent subluxation or lateral instability in his left knee and therefore a separate rating is not warranted under the old Diagnostic Code 5257 for his left knee. The Board also finds that the Veteran does not warrant a separate rating under the updated DC 5257, as the Veteran’s diagnosed left knee patellofemoral syndrome does not manifest as recurrent instability and the Veteran reported only occasional use of his brace for ambulation following his surgery. Similarly, there was no evidence of an unrepaired or failed repair of complete ligament tear at the Veteran’s August 2020 VA examination. Therefore, the Veteran is not better rated under the new Diagnostic Code 5257 for his left knee. Further, the Veteran does not have limitation of flexion that would warrant even a compensable rating under Diagnostic Code 5260, as at worst he was limited to 85 degrees with pain. There has been no change to DC 5260 in the updated Rating Schedule. Additionally, as there is no evidence of any nonunion, or even malunion, of the tibia or fibula, an increased rating greater than 30 percent is not warranted under new or old DC 5262. Therefore, the residual symptoms he has following his left knee replacement are best rated under Diagnostic Code 5055. Finally, it cannot be said that the Veteran’s left knee replacement manifests as severe painful motion or weakness in the affected extremity to warrant a 60 percent rating under Diagnostic Code 5055. According to MERRIAM WEBSTER’S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), “Severe” means very painful or harmful or of a great degree. The Veteran reported pain with walking and using braces and canes on and off throughout the period on appeal. As noted above, the Veteran’s motion was limited to 85 degrees of flexion with pain, and normal extension with pain. The limitation in the Veteran’s flexion and extension would not warrant a compensable rating higher than 10 percent if rated under the appropriate codes with consideration of the pain on motion. Such limitations cannot be called “severe,” considering they would warrant a rating far lower (a lesser degree) than the one the Veteran has if he were evaluated strictly on limited motion. It also cannot be said that the Veteran’s residuals include extreme weakness, as muscle strength testing was noted to be only a slight reduction in muscle strength, a five out of five at the August and September 2020 examinations. Additionally, all ligamentous stability testing was normal, and at no point was there evidence of ankylosis or malunion or nonunion of the tibia and fibula. For these reasons, the Board finds that a higher rating for a left knee replacement is not warranted under Diagnostic Code 5055. Accordingly, a rating in excess of 30 percent is not warranted under any appropriate diagnostic code, at any time during the appeal period, for total left knee replacement. See Hart, 21 Vet. App. 505 (2007). 4. Entitlement to a disability rating of 20 percent for the periods prior to April 18, 2016 for patellofemoral syndrome with degenerative joint disease (dislocated semilunar cartilage) of the right knee is granted. 5. Entitlement to a disability rating in excess of 10 percent from October 1, 2016 for patellofemoral syndrome with degenerative joint disease (symptomatic removal of semilunar cartilage) of the right knee is denied. The Veteran is rated at 10 percent for patellofemoral syndrome with degenerative joint disease under DC 5003-5260 prior to April 18, 2016 and from October 1, 2016. These matters come before the Board on appeal from a November 2008 rating decision. In October 2006, January 2009, November 2009, and January 2011, the Veteran underwent four compensation and pension examinations for his bilateral knee condition. In October 2006, the Veteran was found to have 0 to 140 degrees flexion with no physical evidence of loss of function of his right knee. The examiner noted that the Veteran did not have any knee locking or episodes of subluxation, stiffness, pain, or weakness. In January 2009, the Veteran reported right knee popping. Additionally, the examiner found range of motion to be 0 to 120 degrees and did not find any grinding or clicking or instability. In November 2009, the Veteran reported right knee popping and weekly episodes of dislocation or subluxation. The examiner did not find grinding, instability, and found the Veteran to have 0 to 112 degrees flexion. In January 2011, the Veteran reported that he experienced locking episodes one to three times per month and that his right knee had pain, stiffness, weakness, instability. The examiner determined the Veteran’s range of motion to be 0 to 90 degrees and found no instability or grinding. In October 2015 he underwent a VA examination. The report noted a decline in functioning with diminished ability to stand, sit, walk, kneel, squat, as well as flare-ups resulting in increased pain. Range of motion testing revealed no limitations and no painful motion. Repetitive use testing did not result in loss of motion or functional impairment. Additionally, the examiner found no pain on palpation or tenderness, normal muscle strength and no history of recurrent patellar subluxation. The examination revealed no anterior instability and no meniscal tear as well as documented arthritis. The examiner concluded that the Veteran’s right knee condition could potentially impact his ability to perform occupational tasks. In September 2016, the Veteran had another VA examination. This examination notes that the Veteran was diagnosed on August 11, 2016 with a right knee meniscal tear. The Veteran reported experiencing flare-ups approximately two times per week when he must rest and is unable to walk. The Veteran was unable to perform repetitive-use testing with at least three repetitions due to the pain. Range of motion testing revealed no limitations and moderate painful motion. Additionally, there was pain on palpation, normal muscle strength and no history of recurrent patellar subluxation. The examination revealed no instability. The examiner concluded that the Veteran’s right knee condition does functionally impact his ability to walk moderated distances, squat, and lift. In September 2019, the Veteran had a seventh VA examination. At the examination, the Veteran was diagnosed with knee degenerative joint disease. The Veteran’s range of motion for flexion and extension was 0 to 115 degrees. Pain was noted to cause functional loss. The examiner found objective evidence of localized tenderness or pain on palpation of the anterior/medial knee, with the severity being categorized as moderate. There was no additional loss of function or range of motion after repetitions. During flare-ups, the Veteran’s range of motion was estimated to decrease to 0 to 110. The Veteran’s muscle strength was rated 4/5 with no history of recurrent subluxation or lateral instability. In August 2020, the Veteran had an eighth VA examination. The Veteran’s right knee flexion and extension was measured at 0 to 120 degrees. There was evidence of pain during flexion and extension as well as during weight bearing. The Veteran does not show functional loss or range of motion after three repetitions. The examiner determined that the Veteran’s range of motion diminished with pain to 0 to 110 for flexion and extension. During a flare-up, the flexion and extension diminished to 0 to 100. The Veteran’s muscle strength was rated 5/5 with no history of recurrent subluxation or lateral instability. The Board reviewed the Veteran’s private medical records in addition to the VA examinations. The records contain the Veteran’s subjective complaints pertaining to knee popping, ambulating with a cane, and reports of his knee giving out. In May 2007, the Veteran reported experiencing knee locking. In June 2009, the Veteran reported that his right knee gave out. In June 2015, the Veteran stated that he experienced pain and stiffness, that his right knee “pops all the time,” and that he is unstable some of the time. In February 2016, the Veteran reported right knee locking, popping, and instability. In April 2016, the Veteran had many complaints of his right knee giving way and causing him to fall. In April 2018, the Veteran indicated that he had been falling because he had to place increased weight on the right knee due to left knee instability. The Board notes that DC 5258 allows for a higher (and maximum) rating of 20 percent based on dislocation of semilunar cartilage with frequent episodes of pain, effusion, and locking. As such, the use of DC 5258 is more favorable for the time period prior to April 18, 2016. Therefore, the evidence of record establishes that the Veteran is entitled to a 20 percent rating under DC 5258 prior to April 18, 2016. 6. The Board notes that the Veteran may not be assigned separate ratings under both DCs 5003 (via 5010) and 5258. The Veteran’s knee disability has been manifested by joint “locking,” painful motion, effusion, and arthritis. Both DCs overlap in ratings based on pain and “locking” as forms of limitation of motion; therefore, assigning separate ratings under both DC 5003 (via 5010) and DC 5258 would violate the prohibition against pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). Since the Board is granting a higher rating of 20 percent under DC 5258, the 10 percent rating under DC 5010 will be discontinued prior to April 18, 2016. This change does not amount to a reduction, as the rating of the Veteran’s knee disability increases from a 10 percent rating prior to April 18, 2016. The Board finds that the Veteran warrants a 10 percent rating under DC 5259 from October 1, 2016, as the Veteran had a right knee meniscectomy in April 2016 and therefore, the record establishes a removal of semilunar cartilage to warrant an evaluation under DC 5259. See 38 C.F.R. § 4.71a. Notably, the Veteran’s lay statements and medical records do include any notes or reports of locking of the Veteran’s right knee from October 1, 2016, under DC 5258. Since the Board is granting the 10 percent rating under DC 5259, the 10 percent rating under DC 5010 will be discontinued. This change does not amount to a reduction, as the rating of the Veteran’s knee disability will remain at 10 percent. Notably, there was no change made to DC 5259 in the updated Rating Schedule. See Read v. Shinseki, 651 F.3d 1296 (Fed. Cir. 2011); Murray v. Shinseki, 24 Vet. App. 420 (2011). The Board finds that an increased rating is not warranted under the old DC 5257 from October 1, 2016, as neither the Veteran’s lay statements nor the medical records indicate that the Veteran experienced recurrent subluxation, lateral instability, or recurrent effusion following his right knee meniscectomy in April 2016. There has been no evidence presented that demonstrates to the Board that the right knee instability has increased in severity to warrant an increased rating. The Board finds that an increased rating is not warranted under the updated DC 5257 from February 7, 2021, as the Veteran’s diagnosed right knee condition does not manifest as recurrent instability and the Veteran reported only occasionally using his brace for ambulation. Similarly, there was no evidence of an unrepaired or failed repair of complete ligament tear at the Veteran’s August 2020 VA examination. Therefore, the Veteran is not better rated under the updated Diagnostic Code 5257 for his right knee. The Board finds that an increased rating is not warranted for the right knee based on limitation of motion. Throughout the appeal period, the Veteran’s right knee has manifested noncompensable limitation of motion that most nearly approximates flexion limited to 90 degrees or better and extension limited to 0 degrees. Range of motion with limitation of flexion and extension 0 to 90 degrees or better is noncompensable under Diagnostic Codes 5260 and 5261. An increased rating under these codes is therefore not possible. There were no changes made to DC 5260 or DC 5261 in the updated Rating Schedule. The Board finds that there is no other schedular basis for granting a higher or other separate rating. Diagnostic Codes 5256 and the old DC 5262 provide for ratings higher than 10 percent with a showing of ankylosis and impairment of tibia or fibula. The medical and lay evidence does not establish any pathology associated with these knee conditions. Similarly, the new Diagnostic Code 5262 applying to malunion of the tibia or fibula does not apply, because there is no evidence, and the Veteran does not argue, that his right knee disability manifests as malunion or nonunion of the tibia or fibula. To warrant an increased rating of 40 percent under Diagnostic Code 5262, the Veteran’s right knee disorder would have to manifest as nonunion of the tibia or fibula with loose motion requiring bracing. The updated DC 5262 states that this should be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. To warrant an increased rating of 30 percent under the new Diagnostic Code 5262, the Veteran’s right knee disorder would need to manifest as medial tibial stress syndrome (MTSS), or 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. The medical and lay evidence does not establish that the Veteran’s right knee disorder manifests as a malunion or nonunion of the tibia or fibula. Additionally, the Veteran’s symptoms do not manifest as MTSS or shin splints. The Board therefore finds that additional separate or higher ratings are not warranted and the claim for an increased evaluation is granted to the extent discussed above. REASONS FOR REMAND 7. Entitlement to a total disability rating due to individual unemployability based on individual unemployability (TDIU) is remanded. An October 2018 notification explained the evidence and legal requirements necessary to support the claim of TDIU and provided the Veteran a VA Form 21-8940 and a VA Form 21-4192 Request for Employment Information in Connection with Claim for Disability Benefit. The Veteran did not complete and return the enclosed forms. The evidence of record indicates that the Veteran has been variously employed throughout the appeal period; however, the Veteran has not provided a TDIU application with updated and complete information regarding his employment history and educational background. Based on various reports during VA treatments and the Veteran’s Social Security Administration (SSA) records, the Veteran has engaged in full-time and potentially part-time employment. Given the incomplete information, the Veteran should clarify his employment history as well as his annual income from his employment, so that a determination may be made as to whether any employment is marginal. As the Board does not have complete and accurate information regarding the Veteran’s employment history a remand is necessary for further development. The matter is REMANDED for the following action: 1. Provide a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, to the Veteran for completion. 2. Request the Veteran to provide his employment history from military service to present, to include all periods of self-employment. The list should include the dates of employment (month, year), position title, a description of duties and skills learned, hours worked (daily/weekly), income earned (hourly and yearly). 3. Request the Veteran provide a complete list of schools attended since high school, to include college, trade schools, certificate programs or any other educational programs designed to teach a skill set. The list should include the dates attended (month, year), course(s) taken, degree or certificate earned (if any). 4. Upon completion of the above directives, complete any other necessary development after review of any additionally received records, to include additional VA examinations if warranted. 5. Finally, readjudicate the appeal. If TDIU remains denied, issue a supplemental statement of the case and return the case to the Board. Emily Tamlyn Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board V. Schmidt 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.