Citation Nr: 21014820 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 12-31 933 DATE: March 15, 2021 ORDER Service connection for right knee lateral aspect scar is granted. Entitlement to a rating greater than 20 percent for right knee degenerative joint disease, limitation of flexion, is denied. Entitlement to a rating greater than 10 percent for right knee degenerative joint disease, limitation of extension, is denied. Entitlement to a rating greater than 20 percent for left knee degenerative joint disease, limitation of flexion, is denied. Entitlement to a rating greater than 10 percent for left knee degenerative joint disease, limitation of extension, prior to September 23, 2020 is denied. Entitlement to a 40 percent rating from September 23, 2020 for left knee degenerative joint disease, limitation of extension, is granted. REMANDED Entitlement to a separate rating for right knee lateral instability is remanded. Entitlement to a separate rating for left knee lateral instability is remanded. FINDINGS OF FACT 1. During active service, the Veteran sustained a right knee lateral aspect scar. 2. The Veteran’s right knee degenerative joint disease has not more nearly approximated flexion limited to 15 degrees or less. 3. The Veteran’s right knee degenerative joint disease has not more nearly approximated extension limited to 15 degrees or more. 4. The Veteran’s left knee degenerative joint disease has not more nearly approximated flexion limited to 15 degrees or less. 5. Prior to September 23, 2020, the Veteran’s left knee degenerative joint disease did not more nearly approximate extension limited to 15 degrees or more. 6. Since September 23, 2020, the Veteran’s left knee degenerative joint disease has been limited to 30 degrees of extension but has not more nearly approximated extension limited to 45 degrees or more. CONCLUSIONS OF LAW 1. The criteria for service connection for right knee lateral aspect scar have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating in excess of 20 percent for right knee degenerative joint disease, limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5260. 3. The criteria for a rating in excess of 10 percent for right knee degenerative joint disease, limitation of extension, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5261. 4. The criteria for a rating in excess of 20 percent for left knee degenerative joint disease, limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5260. 5. The criteria for a rating in excess of 10 percent for left knee degenerative joint disease, limitation of extension, prior to September 23, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5261. 6. The criteria for a 40 percent rating for left knee degenerative joint disease, limitation of extension, from September 23, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the United States Navy from March 1979 to March 1999. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which denied disability ratings in excess of 10 percent each for service-connected left and right knee degenerative joint disease. In an August 2017 rating decision, the RO granted an increased rating of 20 percent for both left and right knee degenerative joint disease for the entire rating period on appeal. Additionally, separate 10 percent ratings for left and right knee limitation of extension were granted, effective for the entire rating period on appeal. The Board remanded these matters in March 2017, December 2017, April 2019, and August 2020 for additional development, which has been substantially completed. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection 1. Service connection for right knee lateral aspect scar is granted. The Veteran contends that his right knee scar was incurred during service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The Board concludes that the Veteran has a current disability that began during active service and continued after service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). In this case, service treatment records include the January 1979 enlistment examination, which shows no scars of the right knee. An August 1979 examination report, which was completed for entrance to officer candidate school, shows a right knee lateral aspect, 1-inch, elliptical scar. The March 1983 re-enlistment examination report notes a scar on the inferior-lateral lateral aspect of the right knee. A May 1989 reenlistment examination report shows a 3 cm linear scar on the lateral right knee. Therefore, service treatment records show that a right knee scar manifested during service. The September 2020 VA examination shows a diagnosis of a right knee lateral aspect scar; therefore, the Veteran has a current disability. In a September 2020 VA opinion, the examiner stated that the Veteran had a circular appearing scar on the right knee lateral surface. The Veteran reported that the injury occurred during a football game during service while he was stationed in Guam. He said his knee was spiked by another player accidentally. Thus, the examiner found that the scar should be service connected. In a November 2020 VA opinion, the examiner found that the Veteran’s right knee scar on the interior aspect was not caused by a post-service process. However, the examiner stated that the Veteran sustained a scar on the lateral aspect of the right knee in August 1979, a right knee lateral-inferior aspect scar in March 1983, and a lateral right knee scar in May 1989. Based on the evidence, which clearly shows no right knee scars at entrance to service, shows a right knee lateral aspect scar on examination reports completed during service, and shows a current diagnosis of right knee lateral aspect scar, service connection for right knee lateral aspect scar is warranted. The appeal is granted. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. Part IV. If two evaluations are potentially applicable, the higher evaluation 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In this case, the Veteran seeks increased ratings for degenerative joint disease of both knees, which is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260, for traumatic arthritis rated as limitation of flexion, and under Diagnostic Code 5010-5261, for traumatic arthritis rated as limitation of extension. The Veteran’s knees are both rated 20 percent disabling based on limitation of flexion and 10 percent disabling for limitation of extension. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Codes 5003, 5010, and 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to February 7, 2021, Diagnostic Code 5010 provided that the rating for arthritis due to trauma was determined under the criteria pertaining to degenerative arthritis, Diagnostic Code 5003, which rated based on limited motion. 38 C.F.R. § 4.71a. Since February 7, 2021, Diagnostic Code 5010 provides that post-traumatic arthritis shall be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Since the old and new Diagnostic Code 5010 indicate that the joint is rated based on limitation of motion, for the purposes of this case, the amendment to Diagnostic Code 5010 does not affect the Veteran’s claim. Regarding the diagnostic codes pertaining to the knees, separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), instability and recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The February 2021 amendments did not affect Diagnostic Codes 5260, limitation of flexion, or 5261, limitation of extension. 38 C.F.R. § 4.71a. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege that he has tibia or fibula impairment, genu recurvatum, or ankylosis of either knee. As such, those diagnostic codes are not for application. The evidence shows that during a January 2011 VA examination, the Veteran reported bilateral knee weakness, stiffness, giving way, locking, and pain. He had flare-ups as often as twice per day, lasting for one hour, at a severity of 8. During flare-ups he had increased pain with prolonged standing, walking, and climbing stairs. He had difficulty squatting and kneeling. The examiner found no evidence of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement. Both knees exhibited crepitus. Both knees measured from 0 degrees of extension to 140 degrees of flexion, with no additional limitations after repetitive motion. Stability testing was normal, bilaterally, and there was no evidence of subluxation with either knee. VA treatment records dated in May 2012 indicate that the Veteran had positive McMurray signs, bilaterally. A July 2012 letter from treating provider, M.O., indicates that the Veteran’s bilateral knee pain had been worsening. The Veteran’s main complaints were knee buckling and pain. September 2012 treatment records show the Veteran reported chronic bilateral knee pain with recent history of his knees locking and giving way. A September 2016 VA examination report shows the Veteran indicated continued knee buckling and constant pain. He noted that he had been diagnosed with a meniscus tear in both knees. Flare-ups were described as sharp, tingling pain in both knees and lower legs. He wore knee pads to help with the pain. He stated that his pain rated a 9 on the pain scale most of the time. On examination, the Veteran’s right knee range of motion (ROM) testing showed extension to 0 degrees and flexion to 70 degrees, with pain noted on flexion and extension and causing in functional loss. The Veteran had pain with weightbearing and localized tenderness at the medial, posterior area. The right knee also had crepitus. The examiner indicated that disturbance of locomotion and interference with standing contributed to the right knee disability. The left knee ROM testing showed extension to 0 degrees and flexion to 90 degrees, with pain noted on exam; however, pain did not cause functional loss. The Veteran had pain with weightbearing and localized tenderness at the medial area. The left knee also had crepitus. The examiner found no additional loss of ROM after repetitive use testing in either knee. The examiner did not observe subluxation or lateral instability of either knee. Joint stability testing was normal, bilaterally. The examiner stated that the knee disabilities could cause difficulty with prolonged walking, kneeling, and squatting. As noted in the Board’s March 2017 remand, the examiner did not adequately address whether pain would significantly limit functional ability with repeated use over time or address the functional impact of the Veteran’s reported flare-ups in terms of loss of motion. As such, the Veteran had another examination in April 2017. The examiner diagnosed bilateral meniscal tear as well as degenerative arthritis. The examiner stated that the diagnosis is a progression of the previous diagnosis. The Veteran reported increased pain, frequent falls from his knees giving way unexpectedly, inability to sit or stand for long periods, and inability to squat, climb, or run due to bilateral knee pain. He could not stand for more than 5 to 7 minutes without feeling discomfort in the knees. His right knee flare-ups manifested as sharp and continuous pain with intermittent swelling. He wore a knee brace daily. For the left knee, flare-ups were described as continuous pain with intermittent buckling and swelling. ROM testing showed right knee extension to 10 degrees and flexion to 30 degrees with pain, and with increased pain when attempting to fully extend the knee. The pain caused functional loss and pain was observed on weightbearing. The examiner noted palpable tenderness medially and laterally of the right knee. The right knee had crepitus. ROM testing of the left knee showed extension to 10 degrees and flexion to 20 degrees, with pain, and with a history of locking resulting in frequent falls. The pain caused functional loss and pain was observed on weightbearing. The examiner noted palpable tenderness medially and laterally of the left knee. The left knee had crepitus. No additional loss of motion was observed after repetitive use. The examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner stated that bilateral knee pain, fatigue, and lack of endurance contributed to functional loss after repeated use over time and during flare ups. The examiner noted that the examination was being conducted during a flare up. Also contributing to functional impairment of the right knee were less movement than normal, swelling, disturbance of locomotion, interference with sitting and standing, and inability to fully extend the right knee without significant pain. Contributing to left knee functional impairment were less movement than normal, swelling, disturbance of locomotion, and interference with sitting and standing. The examiner found no history of recurrent subluxation or lateral instability of either knee. Joint stability testing was normal for both knees. The examiner noted that the Veteran had a meniscus tear, bilaterally, which resulted in frequent episodes of joint pain, locking, and intermittent swelling. The Veteran constantly used knee braces. He regularly used a cane for stability and to prevent falls when his knees locked up and gave way. The Veteran had objective evidence of pain on motion in both active and passive range of motion and in weight-bearing and non weight-bearing ROM testing. The examiner did not measure both active and passive range of motion, in weight-bearing and non weight-bearing portrayed in terms of the degree of additional ROM loss due to pain in these situations. In a separate opinion, the examiner stated that he was able to find a May 2014 record referring to an MRI of the knees showing bilateral torn menisci of the knees; however, the examiner was not able to find the MRI report. He also noted that the Veteran’s pain is the limiting factor for his ability to carry out activities of daily living. However, he also noted instability of gait due to the Veteran’s knees giving way or locking up, resulting in frequent falls. The Veteran indicated that he had periods of locking of the knees with the knees giving way on average 2 to 3 times per week, often resulting in falls. He wore knee braces and used a cane for stability and to assist in ambulation by helping to maintain stability and reduce the chances of falling while ambulating. An April 2018 examination report indicates that the Veteran’s diagnoses included degenerative joint disease and meniscal tear, indicating a progression of the previous diagnosis. The Veteran had more pain, swelling, and locking up. He reported that during flare-ups he could not jog, drive for long periods, or put any significant pressure on his knees. He had more pain and swelling during flare ups. Despite the Veteran’s reports, the examiner stated that the Veteran did not have functional impairment due to flare ups, making the assessment in this regard inadequate. However, ROM testing showed both knees had extension to 0 degrees and flexion to 115 degrees. The examiner stated that there was pain on motion but that it did not cause functional loss. There was no pain on weight bearing, no objective evidence of localized tenderness or pain, or evidence of crepitus. The examiner did not observe additional limitation of motion after repetitive use or repetitive use over time. The examiner noted that the examination of the right knee was being conducted during a flare up but that no symptoms during flare up significantly limited functional ability. The examination of the left knee was not being conducted during a flare up. Joint instability was not found. The Veteran had another VA examination in November 2019; however, as noted in the August 2020 Board remand, the examination report lacks significant information and explanations rendering the examination report inadequate for rating purposes. The September 2020 examination report shows diagnoses of bilateral degenerative joint disease, bilateral knee instability, and bilateral meniscal tears. The Veteran’s constant bilateral knee pain was aggravated by constant walking, stair climbing, and prolonged standing, but did not constitute a standard flare up. His pain was worse with walking, climbing stairs, and prolonged standing and sitting. In a separate opinion, the examiner stated that the Veteran did not describe his knees giving way or locking as a flare; rather, he complained of the injury that occurs when his knees give way and he falls. He reported that his knees give way daily. His knees lock once a month. The examiner stated that the knee instability is likely caused by the longterm meniscal tears and not due to degenerative joint disease. On examination, the right knee ROM was from 10 degrees of extension to 70 degrees of flexion, with pain on movement. The limitation of motion did not cause functional loss. The Veteran had right knee pain with weight bearing and crepitus. The left knee showed ROM from 30 degrees of extension to 65 degrees of flexion, with pain. The limitation of motion did not cause functional loss. The Veteran had left knee crepitus as well as pain with weight bearing. The Veteran did not have additional limitation of motion after repetitive use, bilaterally, and no additional limitation of motion after repetitive use over time or during flare up. In a separate opinion, the examiner stated that the Veteran was tested in active and passive motion and that while he had greater range of motion than documented, it was with significant pain. Thus, the range provided was to the limits of pain. Regarding flare ups, the examiner stated that the Veteran had exacerbations, like when his knee gave way or locked; however, he did not have flares. Thus, the examiner found no additional loss of ROM or pain during flare-up or repetitive use. The Veteran’s constant pain was aggravated by walking, climbing stairs, and prolonged standing but this did not constitute a standard flare up. Joint stability testing showed medial and lateral instability of 1+ (0-5 mm), bilaterally. The Veteran regularly used knee braces for instability. The examiner opined that the joint instability was likely due to the long-term meniscal tears and not due to the degenerative joint disease of the knees. 2. Entitlement to a rating greater than 20 percent for right knee degenerative joint disease, limitation of flexion, is denied. 3. Entitlement to a rating greater than 10 percent for right knee degenerative joint disease, limitation of extension, is denied. The Veteran seeks a rating greater than 20 percent for his right knee degenerative joint disease manifesting as limitation of flexion and a rating greater than 10 percent for his right knee degenerative joint disease manifesting as limitation of extension, rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260 and 5010-5261. ROM testing of the right knee was performed during VA examinations in January 2011, September 2016, April 2017, April 2018, and September 2020, and was at worst to 30 degrees of flexion and 10 degrees of extension. See VA examination, April 2017. During the examinations, the Veteran was asked about pain, flare-ups, and functional limitations, and relevant testing was performed, to include testing for pain and to reveal additional functional limitations in certain circumstances, such as after repetitive use. During the January 2011 examination, the Veteran reported having flare ups twice per day, lasting one hour, and rated an 8 on the pain scale. He had increased pain with prolonged standing, walking, and climbing stairs, and he had difficulty squatting and kneeling. In September 2016, his flare ups consisted of sharp, tingling pain in the knees and lower legs. In April 2017, flare ups manifested as sharp and continuous pain with intermittent swelling. During the April 2018 examination, the Veteran reported that during flare-ups he had pain and swelling, and he could not jog, drive for long periods, or put any significant pressure on his knees. The right knee examination was conducted during a flare-up and showed ROM from 0 degrees extension to 115 degrees of flexion. The September 2020 examiner documented the Veteran’s report that he had exacerbations, as opposed to flare-ups, due to his reported knee instability. Per the Board’s remand directives, the examiner estimated that ROM of the right knee during flare up and after repetitive use would be to 10 degrees of extension and 70 degrees of flexion. The Board has considered the Veteran’s reports of right knee flare ups, to include the documented limitations of motion due to pain, weakness, fatigability, and repetitive use, but cannot find that his functional impairment of the right knee has resulted in limitation of flexion less than 30 degrees or limitation of extension greater than 10 degrees at any time during the pendency of the claim. Significantly, the Veteran’s ROM has more consistently measured to 70 degrees of flexion or greater and his extension has measured 10 degrees or less. Giving the Veteran the benefit of the doubt, his right knee disability has been rated based on the worst measurements obtained during the pendency of the claim - 30 degrees of flexion and 10 degrees of extension – warranting the currently assigned ratings. The evidence does not show that the Veteran’s right knee disability has manifested as functional impairment equivalent to 15 degrees of flexion or 15 degrees of extension at any time during the pendency of the claim, even with consideration of functional impairment due to flare ups and repetitive use. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Consequently, a rating greater than 20 percent for right knee degenerative joint disease manifesting as limitation of flexion and a rating greater than 10 percent for right knee degenerative joint disease manifesting as limitation of extension is not warranted at any time during the pendency of the appeal. The appeals are denied. 4. Entitlement to a rating greater than 20 percent for left knee degenerative joint disease, limitation of flexion, is denied. 5. Entitlement to a rating greater than 10 percent for left knee degenerative joint disease, limitation of extension, prior to September 23, 2020 is denied. 6. Entitlement to a 40 percent rating from September 23, 2020 for left knee degenerative joint disease, limitation of extension, is granted. The Veteran seeks a rating greater than 20 percent for his left knee degenerative joint disease manifesting as limitation of flexion and a rating greater than 10 percent for his left knee degenerative joint disease manifesting as limitation of extension, rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260 and 5010-5261. As discussed below, a 40 percent rating for left knee limitation of extension from September 23, 2020 is warranted. ROM testing was performed during VA examinations in January 2011, September 2016, April 2017, April 2018, and September 2020, and at its worst measured to 20 degrees of flexion. See VA examination, April 2017. Prior to September 23, 2020, the Veteran’s left knee extension was, at its worst, 10 degrees. In September 2020, the VA examination showed the Veteran’s left knee extension was limited to 30 degrees. During the examinations, the Veteran was asked about left knee pain, flare-ups, and functional limitations, and relevant testing was performed, to include testing for pain and to reveal any additional functional limitations in certain circumstances, such as after repetitive use. During the January 2011 examination, the Veteran reported having left knee flare ups twice per day, lasting one hour, and rated an 8 on the pain scale. He had increased pain with prolonged standing, walking, and climbing stairs, and he had difficulty squatting and kneeling. In September 2016, he reported that his flare ups consisted of sharp, tingling pain in the knees and lower legs. In April 2017, flare ups of the left knee were described as continuous pain with intermittent buckling and swelling. During the April 2018 examination, the Veteran reported that during flare-ups he had pain and swelling, and he could not jog, drive for long periods, or put any significant pressure on his knees. The September 2020 examiner documented the Veteran’s report that he had exacerbations, as opposed to flare-ups, due to his reported knee instability. Per the Board’s remand directives, the examiner estimated that ROM during flare up and after repetitive use would be to 30 degrees of extension and 65 degrees of flexion. The Board has considered the Veteran’s reports of left knee flare ups, to include the documented limitations of motion due to pain, weakness, fatigability, and repetitive use, but cannot find that his functional impairment of the left knee has resulted in limitation of flexion to less than 20 degrees at any time during the pendency of the claim or limitation of extension greater than 10 degrees prior to September 23, 2020. Significantly, the Veteran’s left knee flexion has consistently measured to 65 degrees or greater throughout the entire pendency of the claim. Prior to September 23, 2020, his extension consistently measured 10 degrees or less. Giving the Veteran the benefit of the doubt, his left knee disability has been rated on the worst measurement obtained during the pendency of the claim for limitation of flexion at 20 degrees, warranting the currently assigned 20 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5250. Similarly, giving the Veteran the benefit of the doubt, prior to September 23, 2020, his left knee disability has been rated based on the worst measurement obtained for limitation of extension at 10 degrees, warranting the currently assigned 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5261. The evidence does not show that the Veteran’s left knee disability manifested as functional impairment equivalent to 15 degrees of flexion at any time during the pendency of the claim or to 15 degrees of extension prior to September 23, 2020, even with consideration of functional impairment due to flare ups and repetitive use. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Consequently, a rating greater than 20 percent for left knee degenerative joint disease manifesting as limitation of flexion is denied as is a rating greater than 10 percent for left knee degenerative joint disease manifesting as limitation of extension prior to September 23, 2020. To this extent, the appeals are denied. Since September 23, 2020, a 40 percent rating is warranted for the left knee degenerative joint disease based on limitation of extension to 30 degrees. A higher rating is not warranted even with consideration of functional impairment due to pain, weakness, fatigability, and repetitive use. 38 C.F.R. § 4.71a, Diagnostic Code 5010-5261. The September 2020 VA examiner specifically found that the Veteran had no additional limitation of motion during flare up or after repetitive use. As such, the Board finds that the evidence does not show that the Veteran’s left knee degenerative joint disease manifested as functional impairment equivalent to 45 degrees of extension since September 23, 2020, even with consideration of functional impairment due to flare ups and repetitive use. 38 C.F.R. § 4.71a, Diagnostic Code 5010-5261. Consequently, a 40 percent rating for left knee degenerative joint disease manifesting as limitation of extension is warranted from September 23, 2020, and to this extent, the appeal is granted. The Board is sympathetic to the Veteran’s lay statements to the extent that he claims his disabilities are worse than currently evaluated, and those statements have been considered in the Board’s denials of increased ratings above. The Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which the disabilities are evaluated. The medical and lay evidence has been assessed by the Board in determining the overall disability ratings. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. REASONS FOR REMAND 1. Entitlement to a separate rating for right knee lateral instability is remanded. 2. Entitlement to a separate rating for left knee lateral instability is remanded. During the pendency of his claim, the Veteran has consistently reported that his knees have been unstable, resulting in his knees locking, buckling, and giving way. VA treatment records dated in May 2012 indicate that the Veteran had positive McMurray signs, bilaterally. The April 2017 VA examination report shows diagnoses of bilateral degenerative arthritis and bilateral knee meniscus tears. The examiner stated that the established diagnosis is changed and is a progression of the previous diagnosis. See also VA examination report, April 2018. In September 2020, objective testing revealed bilateral knee instability. The examiner stated that bilateral knee instability and meniscal tears have been diagnosed and that the instability is likely caused by the long-term meniscal tears and not likely due to his bilateral degenerative joint disease of the knees. He did not indicate whether the meniscal tears are due to service or the Veteran’s degenerative joint disease. Based on a review of the medical evidence, it is unclear whether the Veteran’s meniscal tears are due to service or due to or have been aggravated by the service-connected bilateral knee degenerative joint disease. On remand, an opinion should be obtained addressing the nature and etiology of the bilateral knee meniscus tears. The matters are REMANDED for the following action: 1. Ask the Veteran to identify any outstanding treatment records relevant to his claims for separate ratings for bilateral knee instability. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. Ask the September 2020 examiner or another qualified clinician to provide an addendum opinion addressing the nature and etiology of the Veteran’s bilateral knee meniscus tears. The examiner must be provided access to the electronic claims file and a copy of this remand. After reviewing the evidence, the examiner should provide the following opinions: a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral meniscus tears are due to service? b) If the foregoing is negative, is it at least as likely as not that the Veteran’s bilateral meniscus tears are due to or a progression of his bilateral knee degenerative joint disease? c) In the foregoing is negative, is at least as likely as not that the Veteran’s bilateral knee degenerative joint disease has aggravated the bilateral meniscus tears? In providing the opinions, the examiner must consider the findings in the April 2017 and 2018 examination reports indicating that the Veteran’s diagnoses, bilateral degenerative joint disease and bilateral meniscal tears, are a progression of the previous diagnoses. The examiner must provide a rationale in support of all opinions provided. Robert N. Scarduzio Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. G. Alderman, 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.