Citation Nr: 21015961 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 10-39 693 DATE: March 18, 2021 ORDER Entitlement to service connection for a disability manifested by hematuria is denied. Entitlement to a rating in excess of 10 percent prior to March 19, 2012, for residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, is denied. Entitlement to a separate 10 percent rating effective from February 13, 2009, to February 28, 2017, for left knee arthritis manifested by limitation flexion is granted, subject to the regulations pertinent to the disbursement of monetary funds. Entitlement to an increased 20 percent rating for the period from February 28, 2017, to January 7, 2018, for residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, is granted, subject to the regulations pertinent to the disbursement of monetary funds. Entitlement to a rating in excess of 20 percent for the period from February 28, 2017, to January 7, 2018, for left knee arthritis manifested by limitation of flexion is denied. REMANDED Entitlement to a rating in excess of 30 percent for the periods from March 1, 2019, to June 5, 2019, and from September 1, 2019, to October 18, 2019, for the residuals of left total knee arthroplasty and revision is remanded. Entitlement to a rating in excess of 60 percent effective from February 1, 2020, for the residuals of left total knee arthroplasty and revision is remanded. FINDINGS OF FACT 1. A disability manifested by hematuria for VA compensation purposes is not shown. 2. The evidence demonstrates that prior to March 19, 2012, the Veteran’s service-connected residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, was manifested by no more than symptomatic semilunar cartilage removal. 3. The evidence demonstrates that for the period from February 13, 2009, to February 28, 2017, the Veteran’s service-connected residuals of a left knee injury included left knee arthritis manifested by limitation flexion due to pain. 4. The evidence demonstrates that for the period from February 28, 2017, to January 7, 2018, the Veteran’s service-connected residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, was manifested by frequent episodes of locking pain. 5. The evidence demonstrates that for the period from February 28, 2017, to January 7, 2018, the Veteran’s service-connected left knee arthritis was manifested by no more than limitation of flexion to 30 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a disability manifested by hematuria have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for entitlement to a rating in excess of 10 percent prior to March 19, 2012, for residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5259. 3. The criteria for entitlement to a separate 10 percent rating effective from February 13, 2009, to February 28, 2017, for left knee arthritis manifested by limitation flexion have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5260. 4. The criteria for entitlement to an increased 20 percent rating for the period from February 28, 2017, to January 7, 2018, for residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5258. 5. The criteria for entitlement to a rating in excess of 20 percent for the period from February 28, 2017, to January 7, 2018, for left knee arthritis manifested by limitation of flexion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from July 1990 to September 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2010 rating decision by the Louisville, Kentucky, Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2012, the Veteran testified at a personal hearing before a Veterans Law Judge who is unavailable to participate in a decision. The Veteran declined his right to another Board hearing. A copy of the transcript of the April 2012 hearing is of record. The issues then on appeal were remanded for additional development in March 2013 and February 2017. Although VA records dated in October 2020 noted the Veteran had called and requested that his appeal be withdrawn, he did not respond to a VA request that he submit a written statement withdrawing his appeal. As such, these matters remain on appeal. The Board notes that subsequent to the February 2017 Board remand, a June 2017 rating decision granted an increased 20 percent rating for the Veteran’s service-connected left knee disability. The decision assigned the increased rating under Diagnostic Codes 5003-5260 for arthritis manifested by limitation of flexion. The previous 10 percent rating had been assigned under Diagnostic Code 5259 for symptomatic semilunar cartilage removal. A January 2019 rating decision established a 100 percent rating under Diagnostic Code 5055 for left total knee arthroplasty effective from January 7, 2018, and assigned a 30 percent rating from March 1, 2019. An August 2019 rating decision established a temporary 100 percent rating from June 5, 2019, based upon surgical or other treatment necessitating convalescence and assigned a 30 percent rating effective from September 1, 2019. A November 2019 rating decision established a temporary 100 percent rating from October 18, 2019, based upon surgical or other treatment necessitating convalescence and assigned a 60 percent rating effective from February 1, 2020. Service Connection Issue 1. Entitlement to service connection for a disability manifested by hematuria. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303(a). Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The term “disability” for VA compensation purposes refers to the functional impairment of earning capacity rather than the underlying cause of the impairment and it is noted that pain alone may be a functional impairment. See Saunders v. Wilkie, 887 F.3d 1356, 1364-68 (Fed. Cir. 2018). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim. See Brammer v. Brown, 3 Vet. App. 223 (1992). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102. The pertinent evidence of record shows that the Veteran reported having persistent microscopic hematuria first manifest during active service. Service treatment records include a July 1990 urology clinic showing he related several episodes of hematuria. A physical examination was unremarkable. The examiner’s impression was microscopic hematuria. Records show a July 1990 radiologic study was normal. VA examination in November 1992 noted that the Veteran had one episode of hematuria with negative cytoscopy. The diagnoses included hematuria, resolved. A May 2013 VA examination included a diagnosis of chronic microscopic hematuria. It was noted the Veteran had benign prostatic hypertrophy with decreased force of urinary stream unrelated to hematuria. The examiner stated that there were no other pertinent physical findings, complications, conditions, or signs and/or symptoms related to the diagnosis and found it did not impact the Veteran’s ability to work. A February 2017 VA medical opinion found a disability manifested by hematuria was less likely incurred in or caused by an in-service injury, event or illness. As rationale, the examiner noted the Veteran had discovery of what is termed asymptomatic microscopic hematuria while on active duty in 1990. It was explained that this is a condition where red blood cells are discovered in a urine sample, but only visible by a microscope. There may be red blood cells in the urine normally, but only a small amount would be considered to be within the realm of normal. The examiner noted the Veteran had mild to moderate amounts of microscopic blood in his urine, chronically, since the 1990's and had been seen by medical specialist, none of whom had been able to identify a reason or a disease state that would explain the abnormal findings on urinalysis. His chronic kidney disease was noted to be a problem due to another reason or source. The examiner stated that the Veteran’s microscopic hematuria had been termed idiopathic, due to an unknown medical cause, and that, at this time, his microscopic hematuria was only considered an abnormal laboratory finding or anomaly. It would not be currently classified as a manifestation of a known disease or disability. Based upon the evidence of record, the Board finds a disability for VA compensation purposes manifested by hematuria is not shown. There are no identified symptoms of a disability manifest during or as a result of service. The February 2017 VA examiner’s opinion is persuasive that a disability manifested by hematuria for which service connection can be granted has not been shown during the appeal period. Moreover, the evidence of record does not suggest that any such abnormal laboratory findings of chronic microscopic hematuria cause an impairment of earning capacity. The examiner is shown to have reviewed the evidence of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, the claim for entitlement to service connection must be denied. Increased Rating Issues Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. This Rating Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. For the application of this schedule, accurate and fully descriptive medical examinations are required, with emphasis upon the limitation of activity imposed by the disabling condition. Over a period of many years, a veteran’s disability claim may require re-ratings in accordance with changes in laws, medical knowledge and his or her physical or mental condition. It is essential, both in the examination and in the evaluation of disability, that each disability be viewed in relation to its history. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). VA’s General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. In this present case, VA must consider the claim for a higher rating pursuant to the former and revised regulations only after February 7, 2021. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). The Board notes, however, that the increased rating matters as to the Veteran’s left knee addressed in this decision are for periods prior to the regulatory revisions. Therefore, only the old rating criteria are presently applicable and the revised rating criteria will be addressed subsequently, if necessary. Traumatic arthritis is rated pursuant to the criteria found in Diagnostic Code 5010, which directs that evaluations are to be made pursuant to the criteria for degenerative arthritis found in Diagnostic Code 5003. 38 C.F.R. § 4.71a. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The 20 percent and 10 percent ratings based on X-ray findings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note (1). Under Diagnostic Code 5257, a 10 percent rating is warranted for slight subluxation or lateral instability, a 20 percent rating is warranted for moderate subluxation or lateral instability, and a 30 percent rating is warranted for severe subluxation or lateral instability. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking” pain and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. Diagnostic Code 5260 provides a 30 percent rating where knee flexion is limited to 15 degrees; 20 percent where limited to 30 degrees; 10 percent where limited to 45 degrees; and 0 percent where limited to 60 degrees. Diagnostic Code 5261 provides a 50 percent rating where knee extension is limited to 45 degrees; 40 percent where limited to 30 degrees; 30 percent where limited to 20 degrees; 20 percent where limited to 15 degrees; 10 percent where limited to 10 degrees; and 0 percent where limited to 5 degrees. 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. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id. Such evidence may include facial expression, such as wincing, muscle spasm, and crepitation. See 38 C.F.R. § 4.59. 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. Consideration of a higher rating for functional loss, to include during flare ups, due to these factors accordingly is warranted for Diagnostic Codes predicated on limitation of motion. DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain itself does not constitute functional loss, and painful motion does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pain must affect the ability to perform normal working movements with normal excursion, strength, speed, coordination, or endurance in order to constitute functional loss. Id. An adequate orthopedic examination should record the range of motion for pain on active motion and passive motion and in weight-bearing and nonweight-bearing, address the necessary findings to evaluate functional loss during flare-ups, or clearly explain why the required testing cannot be completed or is not necessary. See Correia v. McDonald, 28 Vet. App. 158 (2016) An examination does not need to be conducted during an actual flare-up in order to account for additional functional impairment. Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). Instead, examiners are asked to estimate the functional impairment experienced during a flare-up, considering all competent evidence of functional loss that is available in the record. Id. Orthopedic disabilities of the knee joint are evaluated under the criteria of 38 C.F.R. § 4.71a. Under certain circumstances, a knee disability may receive separate ratings based on evidence showing limitation of motion (Diagnostic Codes 5256, 5260, and 5261) or instability (Diagnostic Codes 5257, 5262, and 5263). See VAOPGCPREC 23-97 (July 1, 1997). Additionally, VA General Counsel has held that a veteran who has arthritis resulting in limited or painful motion and instability of a knee may be rated separately under diagnostic codes 5003 and 5257, cautioning that any such separate rating must be based on additional disabling symptomatology. See VAOPGCPREC 9-98 (September 1998). VA’s General Counsel has further held that separate ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004 (September 17, 2004). Moreover, an evaluation of a knee disability under diagnostic codes 5260 or 5261 does not preclude a separate evaluation under diagnostic codes 5257, 5258, or 5259. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). Prior to the February 2021 regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. “Slight,” as relevant to a physical condition, is defined as “small of its kind or in amount.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). It is similar to “mild,” which is defined as “not severe” or temperate; with “Temperate” being defined as “keeping or held within limits” and “not extreme or excessive.” “Moderate” is defined as “tending toward the mean or average amount,” “not violent, severe, or intense,” and “limited in scope or effect.” Id. “Severe” is defined as “very painful or harmful” or “of a great degree.” Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, “severe” represented the highest or most extreme level of disability. Lay evidence as to lateral instability should be weighed on a case-by-case basis. English v. Wilkie, No. 17-2083, U.S. Vet. App. (Nov. 1, 2018). The terms slight, moderate, 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 as contemplated by the requirements of the law. 38 C.F.R. § 4.6 (2018). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. 2. Entitlement to a rating in excess of 10 percent prior to March 19, 2012, for residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst. 3. Entitlement to a separate 10 percent rating effective from February 13, 2009, to February 28, 2017, for left knee arthritis manifested by limitation flexion. 4. Entitlement to an increased 20 percent rating for the period from February 28, 2017, to January 7, 2018, for residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst. 5. Entitlement to a rating in excess of 20 percent for the period from February 28, 2017, to January 7, 2018, for left knee arthritis manifested by limitation of flexion. The Veteran contends, in essence, that increased ratings are warranted for his service-connected left knee disability. His increased rating claim was received by VA on September 14, 2009. At that time, he reported that his knee had progressively worsened and that he experienced extreme pain when squatting and when ascending or descending stairs. He noted that he limped when he walked and that he had constant pain without medication. He stated that VA treatment records documented degenerative changes in the left knee. In testimony provided in April 2012 he reported that his left knee gave out frequently. The pertinent evidence of record includes VA treatment reports noting mild degenerative changes to the left knee upon X-ray study on February 13, 2009. An April 2009 report noted the Veteran complained of progressively worsening to the left knee with worsening pain on stair climbing. He also reported having weakness and feelings as if the leg wanted to give way. He denied any locking. The examiner noted tenderness to palpation of the medial joint line, retropatellar crepitus, pain on varus/valgus stress, and mild left quadriceps atrophy. Stability was intact and range of motion was full. An August 2009 report noted active range of motion studies revealed left knee flexion to 95 degrees and extension to 8 degrees. Passive range of motion studies revealed flexion within normal limits and extension to 5 degrees. The examiner observed that the Veteran was ambulatory without assistive device/brace and was not in apparent distress. He had difficulty in sit/stand activities, tenderness on the medial-interior aspect of the knee, crepitus, and gait deviation. VA examination in December 2009 included diagnoses of left knee anterior cruciate ligament (ACL) reconstruction, mild degenerative joint disease, and tendonitis. The examiner noted left knee tenderness and crepitus without instability. Active range of motion studies revealed flexion to 145 degrees and normal extension without objective evidence of pain on motion. Lachman’s testing revealed mild laxity to the left knee with a good end point. VA treatment records dated in September 2010 noted a physical therapy consult for left knee strengthening and pain relief. It was noted the Veteran complained of left knee pain and giving way. The examiner noted mild effusion to the left knee and tenderness to palpation of the medial joint line. Range of motion to flexion and extension was full. The examiner’s assessment included decreased left extremity flexion, decreased patellar tracking due to limited flexibility, left knee weakness, mild left knee effusion, and moderately audible crepitus to the left patella. An April 2012 report noted he was provided a medial unloader knee brace. A May 2013 VA examination included a diagnosis of tear, left ACL and medial/lateral menisci, status post ACL surgical repair. It was noted the Veteran reported current symptoms of limited range of motion, pain, tenderness, and poor stability. He reported wearing his brace continuously. He denied any flare-ups. Range of motion studies revealed left knee flexion to 90 degrees with objective evidence of pain at 35 degrees. Extension ended at 5 degrees. There was no additional limitation of motion following repetitive-use testing. Joint stability testing revealed 2+ anterior instability (Lachman test) to the left knee. The examiner found that the left knee disorder would have a mild impact on sedentary employment and a severe impact on his ability to perform physical employment. VA examination in July 2014 included a diagnosis of tear, left ACL and medial/lateral menisci, status post ACL surgical repair. It was noted the Veteran complained of left knee pain that was worse with walking up stairs or running, intermittent swelling after prolonged activity, and occasional locking and giving way. He denied flare-ups. Range of motion studies revealed left knee flexion to 90 degrees with objective evidence of pain at 45 degrees. Extension ended at 5 degrees with objective evidence of pain at that point. There was no additional limitation of motion following repetitive-use testing. Joint stability testing revealed 1+ anterior instability to the left knee. The examiner found that the left knee disorder would have a mild impact on sedentary employment and a moderate to severe impact on his ability to perform physical employment due to instability, pain, and limited movement. VA treatment records dated in October 2014 noted the Veteran reported an injury to the left knee the previous day and feeling an instant pop, swelling, and inability to bear weight. An examination revealed medial and lateral joint line tenderness without swelling or deformity. There was no instability, however, the examiner noted Lachman’s testing felt more give on the left versus the right. There was decreased range of motion due to pain. An October 2014 magnetic resonance imaging (MRI) study revealed an ACL repair that appeared intact, multifocal osteochondral defects suspected involving the lateral trochlea and lateral femoral condyle, suspected vertical tear through the posterior horn of the lateral meniscus, moderate chondromalacia in the patellofemoral compartment, moderate to severe chondromalacia within the medical compartment, suspected multiloculated ganglion cyst deep to the quadriceps tendon, Baker’s cyst formation, and an enlarged medial plica. A November 2014 report noted range of left knee motion from 10 to 106 degrees. A January 2015 report noted range of left knee motion from 0 to 106 degrees. VA examination on February 28, 2017, included diagnoses of degenerative arthritis to the left knee and residual of left knee injury, status post ACL repair with Baker’s cyst. The Veteran reported left knee pain that had progressed over time with limited mobility and ability to exercise. He complained of pain during weight bearing with exacerbations of pain on prolonged standing, walking, stooping, and climbing. It was noted he was currently employed at a VA Medical Center in a clerical position. He used a brace anytime he was required to bear weight. Range of motion studies revealed left knee flexion to 30 degrees and extension to 0 degrees. There was pain on weight bearing and objective evidence of crepitus. There was no additional limitation of motion following repetitive-use testing. The examination was noted to be consistent with the Veteran’s statements describing functional loss following repetitive use and during flare-ups. The examiner noted a history of slight left knee instability. Joint stability testing to the left knee was normal. It was noted that the Veteran had a meniscus (semilunar cartilage) condition on the left with a meniscal tear, frequent episodes of joint locking, and frequent episodes of joint pain. Based upon the evidence of record, the Board finds that prior to March 19, 2012, the Veteran’s service-connected residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, was manifested by no more than symptomatic semilunar cartilage removal. Although the Veteran is shown to have experienced slight left knee instability, there is no evidence of a moderate disability for a higher alternative rating under Diagnostic Code 5257. In the absence of additional disabling symptomatology separate ratings may not be assigned under Diagnostic Codes 5257 and 5259. The assigned 10 percent rating under Diagnostic Code 5259 was most appropriate for the semilunar cartilage disability prior to February 28, 2017. The Board finds, however, that the evidence demonstrates that the left knee for the period from February 13, 2009, to February 28, 2017, included left knee arthritis manifested by limitation flexion due to pain. There is no evidence of a demonstrated limitation of flexion to 30 degrees for a rating higher than 10 percent under Diagnostic Code 5260 nor a sustained limitation of extension of 10 degrees warranting an additional separate compensable rating under Diagnostic Code 5261. Therefore, a separate 10 percent rating, but no higher, for left knee arthritis manifested by limitation of flexion for the period from February 13, 2009, to February 28, 2017, is warranted. The Board finds that the evidence demonstrates that for the period from February 28, 2017, to January 7, 2018, the Veteran’s service-connected residual left knee injury, status post anterior cruciate ligament repair with Baker's cyst, was manifested by frequent episodes of locking pain. As such, an increased 20 percent rating under Diagnostic Code 5258 is most appropriate for the semilunar cartilage disability for the period from February 28, 2017, to January 7, 2018. The Board also finds that the evidence demonstrates that for the period from February 28, 2017, to January 7, 2018, the Veteran’s service-connected left knee arthritis was manifested by no more than limitation of flexion to 30 degrees. As such, the assigned 20 percent rating under Diagnostic Code 5260 is most appropriate for the left knee arthritis with limitation of flexion disability for the period from February 28, 2017, to January 7, 2018. The Board notes that an adequate discussion of functional loss includes consideration of manifest functional loss during flare-ups. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because VA regulations under 38 C.F.R. § 3.344(a) and 38 C.F.R. § 4.1 address the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given to the Veteran’s reports indicating flare-ups of increased pain and functional loss. The reported flare-ups, however, are not shown to additionally limit function in a quantifiable way and are not of such length or duration that a staged rating would not violate the rule regarding stabilization of ratings. In sum, the Board finds the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. Here, the reports of exacerbation or flare-ups are not quantifiable nor of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell and the provision of 38 C.F.R. § 4.1 and 38 C.F.R. § 3.344(a) regarding stabilization of ratings. The Board acknowledges that the Veteran is competent to report observable symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he is not competent to identify a specific level of disability. Competent evidence concerning the nature and extent of the Veteran’s service-connected disability, however, has been provided by VA medical professionals who have examined him. VA findings in this case directly address the criteria under which the disability is evaluated, including whether a specific symptom caused a level of impairment required for a higher disability rating. The Board accords these medical findings greater weight than any subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The preponderance of the evidence in this case is against any higher or additional separate ratings. REASONS FOR REMAND 1. Entitlement to a rating in excess of 30 percent for the periods from March 1, 2019, to June 5, 2019, and from September 1, 2019, to October 18, 2019, for the residuals of left total knee arthroplasty and revision is remanded. 2. Entitlement to a rating in excess of 60 percent effective from February 1, 2020, for the residuals of left total knee arthroplasty and revision is remanded. The Board notes that VA treatment records indicate the Veteran experienced postsurgical residuals following his left total knee arthroplasty including an infection in May 2019 that required aspiration. It is also noted that an August 2019 VA examination report noted that joint stability testing were indicated but could not be performed and that the Veteran was non-weight-bearing with no left knee mobility. The examiner also noted that he was scheduled for left knee surgery in September 2019 and could not return to work until after he recovered. Records show the Veteran underwent a left total knee arthroplasty revision in October 2019. A January 2020 report noted he had a recent infection in December 2019. As the available evidence is unclear as to whether the Veteran had severe postoperative residuals, such as an incompletely healed surgical wound, during the periods from March 1, 2019, to June 5, 2019, and from September 1, 2019, to October 18, 2019, an additional development is required. The Board also notes that the revised VA criteria for evaluating musculoskeletal disorders effective February 7, 2021, include significant changes to disabilities evaluated under Diagnostic Code 5055. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected residuals of left total knee arthroplasty and revision. The examiner should address whether he had severe postoperative residuals, such as an incompletely healed surgical wound, during the periods from March 1, 2019, to June 5, 2019, and from September 1, 2019, to October 18, 2019. The examiner should provide a full description of the current disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues remaining on appeal, with consideration of the applicable criteria of 38 C.F.R. § 4.30 and the revised criteria for 38 C.F.R. § 4.71a, Diagnostic Code 5055 (effective February 7, 2021). If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Douglas 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.