Citation Nr: 21022096 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 13-09 080 DATE: April 14, 2021 ORDER A rating higher than 10 percent for chondromalacia patella with degenerative arthritis of the right knee is denied. A rating higher than 10 percent for chondromalacia patella with degenerative arthritis of the left knee based on limitation of flexion prior to June 12, 2018 is denied. A separate rating of 10 percent for chondromalacia patella with degenerative arthritis of the left knee based on limitation of extension effective from May 16, 2017 through June 11, 2018 is granted. An effective date of August 1, 2019 for the assignment of the 60 percent rating for residuals of the total left knee replacement is granted. REMANDED Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected bilateral knee disabilities, is remanded. Entitlement to service connection for a cardiac disability, to include as secondary to service-connected hypertension, is remanded. FINDINGS OF FACT 1. The Veteran’s right knee chondromalacia patella with degenerative arthritis has been manifested by painful and limited motion, with flexion exceeding 60 degrees, and extension to 0 degrees. 2. Prior to May 16, 2017, the Veteran’s left knee chondromalacia patella with degenerative arthritis was manifested by painful and limited motion, with flexion exceeding 60 degrees, and extension to 0 degrees. 3. From May 16, 2017 through June 11, 2018 (the day before the total left knee replacement), the Veteran’s left knee chondromalacia patella with degenerative arthritis was manifested by painful and limited motion, with flexion exceeding 60 degrees, and extension limited to 10 degrees. 4. As of August 1, 2019—the date of termination of the temporary 100 percent rating for the left knee replacement—the Veteran’s left knee disability has been manifested by chronic residuals of the total knee replacement consisting of severe painful motion. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent for right knee chondromalacia patella with degenerative arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260. 2. The criteria for a rating higher than 10 percent for left knee chondromalacia patella with degenerative arthritis based on limitation of flexion prior to June 12, 2018 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260. 3. The criteria for a separate rating of 10 percent for left knee chondromalacia patella with degenerative arthritis based on limitation of extension effective from May 16, 2017 through June 11, 2018 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.40, 4.45, 4.71a, Diagnostic Code 5261. 4. The criteria for an effective date of August 1, 2019 for the rating of 60 percent for residuals of the total left knee replacement have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.40, 4.45, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran completed an honorable career in the United States Air Force, serving on active duty from December 1960 through December 1986. The Board notes that the available DD 214’s and responses from the National Personnel Records Center (NPRC) reflect service from December 1960 to December 1976, and from August 1983 to December 1986, but do not capture the period of service from December 1976 to August 1983. Nevertheless, it is clear the Veteran had a continuous period of service from December 1960 through December 1986. In this regard, the most recent DD 214 shows he had twenty-six years of active service. Moreover, his service personnel records include a formal notice of release from active duty stating he had twenty-six years plus twenty-six days of active service. They also show that he re-enlisted in December 1976, and include performance reviews dated during the period from December 1976 to August 1983. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matters in August 2017 and March 2020 for further development. Since the July 2009 rating decision, several rating decisions have been issued granting higher ratings for the Veteran’s left knee disability. In this regard, he underwent a total left knee replacement on June 12, 2018. A September 2018 rating decision accordingly granted a temporary 100 percent rating effective June 12, 2018 through July 31, 2019, which represents the one-year period following the total left knee replacement. A 30 percent rating was assigned effective August 1, 2019. A November 2019 rating decision granted a rating of 40 percent for the Veteran’s total left knee replacement effective September 9, 2019. A February 2020 rating decision granted a 60 percent rating for his total left knee replacement effective November 15, 2019. The Board notes that an April 2019 rating decision granted service connection for degenerative arthritis of the bilateral knees effective October 22, 2008. However, that grant did not alter the 10-percent ratings already in effect from October 22, 2008 for service-connected chondromalacia of the bilateral knees. As discussed above, the Veteran’s left knee disability has been assigned higher evaluations since June 12, 2018 based on the total knee replacement. The Veteran, his spouse, and his daughter testified at a hearing before the undersigned Veterans Law Judge in March 2017. A transcript of the hearing is of record. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected disabilities in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Bilateral Knee Disabilities A March 2009 private treatment record reflects x-ray findings of severe degenerative joint disease of the left knee, and minimal degenerative joint disease of the right knee. The Veteran reported bilateral knee pain that “comes and goes.” His knees were occasionally swollen. A June 2010 VA treatment record reflects that the Veteran’s left knee had a history of swelling and locking in the 1980’s. It was “not much of a problem since,” but he had significant morning stiffness in both knees. An examination of the knees was normal. There was no obvious effusion. A July 2010 VA treatment record states that the Veteran’s left knee was minimally symptomatic. The Veteran underwent a VA examination in October 2010 to assess the severity of his knee disabilities for compensation purposes. The examination report states he had episodic knee symptoms including stiffness, swelling, weakness, and instability. He denied functional limitations. He had intermittent flare-ups rated as a 7 out of 10 in severity which interfered with sleep and could last for hours. He treated his symptoms with over-the-counter medication (Aleve and Tylenol) as needed (“prn”). On examination, flexion of both knees was to 120 degrees and extension to 0 degrees after three repetitions. Testing for knee instability was negative bilaterally. Examination of the medial and collateral ligaments, and anterior and post cruciate ligaments was negative bilaterally. There were no other findings. X-ray studies showed that the right knee had mild hypertrophic marginal lipping of the joint margins, and the left knee had loss of the normal medial joint space and hypertrophic marginal lipping. The examiner diagnosed degenerative joint disease of both knees, with mild functional limitation. Private treatment records show that in June 2015, the Veteran reported right knee pain of moderate intensity that had been present for three weeks and had an acute onset. There was some swelling. On examination, the right knee had slight effusion. It was nontender and had “good” range of motion. An x-ray study showed degenerative spurring with no acute abnormality. The Veteran was prescribed a steroid pack. Records from a private orthopedic surgery facility reflect that the Veteran was seen for an initial visit in May 2017. At that time, he reported that his knees lock and catch. He had difficulty getting up and down. He could not go up and down stairs. He could not stoop or squat. He limped severely. On examination, extension of the left knee was limited to “10-15 degrees from full extension,” and flexion limited to 115 degrees. There was very little effusion. There was an obvious varus deformity. Stability testing was negative. The right knee’s extension was limited to 10 degrees, and flexion limited to 115 degrees. There was no effusion. There was a varus deformity. Stability testing was negative. An x-ray study showed near endstage arthritis in the right knee, and endstage arthritis in the left knee. The surgeon found that the Veteran’s knees were “bad enough to replace,” but he was not interested in surgery at that time. Both knees were treated with steroid injections. In June 2017, the Veteran was prescribed a brace for his left knee. A VA examination was performed in November 2017 to assess the severity of the Veteran’s bilateral knee disabilities for compensation purposes. The examination report reflects that he had knee pain with prolonged standing and walking, which was worse in the left knee. He also had difficulty getting up after prolonged sitting. On examination, range of motion of the right knee was normal, with flexion to 140 degrees and extension to 0 degrees. There was no additional loss of motion or function after three repetitions. The examiner noted that there was pain on flexion which did not cause functional loss. The examiner found that factors such as pain, weakness, fatigability, or incoordination would not significantly limit functional ability of the knee with repeated use over time. The examiner was unable to determine without resort to mere speculation whether such factors would significantly limit functional ability during flare-ups. Examination of the left knee showed flexion to 100 degrees, and extension to 0 degrees, with pain noted on flexion. There was no additional loss of motion or function after three repetitions. The examiner found that with repeated use over time, pain and fatigue would significantly limit functional ability of the left knee. In terms of range of motion, the examiner stated that flexion would be to 90 degrees, and extension to 0 degrees. The examiner found that pain, weakness, fatigability, or incoordination would not significantly limit functional ability of the left knee during flare-ups. On muscle strength testing, the right knee had normal (5/5) strength, and the left knee had reduced (4/5) strength. Joint stability testing of both knees was normal. The examiner indicated that the Veteran did not have a history of recurrent subluxation or lateral instability of either knee, or a meniscus (semilunar cartilage) condition of either knee. There was no ankylosis of either knee. Records from the private orthopedic surgery clinic reflect that in December 2017, trace effusion of both knees was noted. Passive range of motion testing of the right showed flexion to 115 degrees, and extension to 10 degrees. Passive range of motion testing of the left knee showed flexion to 110 degrees, and extension to 10 degrees. Stability testing was negative for both knees. In April 2018, examination showed flexion of the left knee to 120 degrees, and extension to 10 degrees. There was trace effusion. Stability testing was negative. Muscle strength and tone were satisfactory. In May 2018, passive range of motion testing of the right knee showed flexion to 115 degrees and extension to 10 degrees. The left knee had flexion to 110 degrees, and extension to 10 degrees. Stability testing was negative. The Veteran underwent total left knee replacement surgery on June 12, 2018. A 100 percent rating has been accordingly assigned from that date through July 31, 2019. See 38 C.F.R. § 4.71a, Diagnostic Code 5055. Records from the private orthopedic surgery facility dated in July 2019, September 2019 and November 2019 all show that on active range of motion testing, the right knee had flexion to 140 degrees and extension to 0 degrees; the left knee had flexion to 110 degrees and extension to 10 degrees. There was no instability of either knee on testing. A VA examination was performed in September 2019 to assess the severity of the Veteran’s bilateral knee disabilities for compensation purposes. The examination report reflects that the Veteran related having flare-ups of left knee symptoms that occurred two to three times per week since the surgery, and which were moderate to severe. They lasted two to three hours and were precipitated by driving and standing up for long periods of time. They were alleviated by stretching and resting. Regarding functional loss, the Veteran stated that he could no longer bend his knee or squat down. On examination, range of motion of the right knee was normal (0 to 140 degrees). There was no loss of function or motion after three repetitions. Pain was noted on flexion, but it did not cause functional loss. The examiner found that factors such as pain, weakness, fatigability, or incoordination would not significantly limit functional ability of the knee with repeated use over time. The left knee had flexion to 100 degrees and extension to 20 degrees. There was no additional loss of motion after three repetitions. The examiner found that factors such as pain, weakness, fatigability, or incoordination would not significantly limit functional ability of the knee with repeated use over time. The examiner indicated that the Veteran had ankylosis of the left knee in flexion between 10 degrees and 20 degrees. The examiner noted in this regard that the Veteran was working on extension and flexion through physical therapy, but continued to have considerable pain. The examiner did not indicate that flare-ups would cause additional functional loss of the knees. On muscle strength testing, the right knee had normal (5/5) strength, and the left knee had reduced (4/5) strength. Joint stability testing of both knees was normal. The examiner indicated that the Veteran did not have a history of recurrent subluxation or lateral instability of either knee, or a meniscus (semilunar cartilage) condition of either knee. Regarding functional impact, the examiner stated that the Veteran could not kneel, stand for prolonged periods, walk for a distance, or climb stairs. A VA examination was again performed in December 2019 to assess the severity of the Veteran’s bilateral knee disabilities for compensation purposes. According to the examination report, the Veteran reported a decrease in left knee pain following the June 2018 knee replacement surgery, but his symptoms persisted. More specifically, he continued to have limited range of motion with flexion, and pain on the medial knee with inflammation. He could only stand for five to ten minutes. He could walk for ten minutes. He had recently purchased a stationary bike, and used it for thirty minutes in a day. On examination, flexion of the right knee was to 130 degrees, and extension to 0 degrees. The examiner stated that the limitation in flexion was normal for the Veteran’s age. No pain was noted. The left knee had flexion to 90 degrees, and extension to 30 degrees. Pain was noted on flexion and extension. There was no additional loss of motion of the left knee after three repetitions. The examiner found that factors such as pain, weakness, fatigability, or incoordination would not significantly limit functional ability of the knee with repeated use over time. The examiner found that there was no ankylosis of the left knee. On muscle strength testing, both knees had normal (5/5) strength. Joint stability testing of both knees was normal. The examiner indicated that the Veteran did not have a history of recurrent subluxation or lateral instability of either knee, or a meniscus (semilunar cartilage) condition of either knee. The examiner characterized the residuals of the June 2018 left knee replacement as chronic residuals consisting of severe painful motion or weakness. A. Right Knee For the right knee, the Board finds that the criteria for a rating higher than 10 percent have not been met. The Veteran’s right knee disability is rated under Diagnostic Code (DC) 5003-5010. Diagnostic Code 5003 pertains to degenerative arthritis. 38 C.F.R. § 4.71a. Under DC 5003, 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. See id. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. Id. In the absence of limitation of motion, a 20 percent rating is assigned for arthritis when there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. If there are no incapacitating exacerbations, a 10 percent rating is assigned for such involvement. Id. Ratings based on X-ray findings of arthritis will not be combined with ratings based on limitation of motion. Id., Note (1). Diagnostic Code 5260 pertains to limitation of flexion of the leg. Under DC 5260, a 0 percent rating is assigned for flexion of the leg limited to 60 degrees; a 10 percent rating is assigned for flexion limited to 45 degrees; a 20 percent rating is assigned for flexion limited to 30 degrees; and a 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.1a. Under DC 5261, a 0 percent rating is assigned for extension of the leg limited to 5 degrees; a 10 percent rating is assigned for extension limited to 10 degrees; a 20 percent rating is assigned for extension limited to 15 degrees; a 30 percent rating is assigned for extension limited to 20 degrees; a 40 percent rating is assigned for extension limited to 30 degrees; and a 50 percent rating is assigned for extension limited to 45 degrees. Id. Normal range of motion of the knee is defined as flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71a, Plate II. Separate ratings may be assigned under DC’s 5260 and 5261 for limitation of flexion and limitation of extension of the same joint. VAOPGCPREC 9-2004 (Sept. 17, 2004). In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. In this regard, pain “must actually affect some aspect of ‘the normal working movements of the body’ [under] 38 C.F.R. § 4.40 in order to constitute functional loss” warranting a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. Accordingly, under sections 4.40 and 4.45, it must be determined whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable diagnostic code(s) pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Here, the criteria for a rating higher than 10 percent for arthritis of the right knee with limitation of motion have not been met. The VA examination reports, VA treatment records, and private treatment records spanning more than ten years consistently show that flexion of the right knee has exceeded 60 degrees, including after repetitive use testing. Thus, the criteria for a rating higher than 10 percent under DC 5260 are not met. With regard to limitation of extension, examinations spanning a period of more than ten years generally show extension of the right knee to 0 degrees. The only exception are the records from the private orthopedic surgery facility dated from May 2017 through May 2018 showing extension of the right knee to 10 degrees. The Board finds that a staged rating for that period is not warranted. During that period, the November 2017 VA examination was performed, in which the examiner found that extension of the right knee was to 0 degrees, including after three repetitions. Moreover, the same private facility recorded extension of the right knee to 0 degrees from July 2019 forward. There is a gap in time between the May 2018 record and the July 2019 record with regard to range of motion findings for the right knee, presumably because the focus was on the left knee following the June 2018 total knee replacement surgery. The September 2019 and December 2019 VA examination reports similarly record extension of the right knee to 0 degrees. There is no indication of a general worsening of the right knee during the roughly one-year period from May 2017 to May 2018, or any explanation or discussion in the private records accounting for the findings during that period. Thus, they do not appear to be an accurate representation of extension of the right knee, since they are not consistent with other findings dated during that one-year period, prior to that period, and subsequent to that period, all of which show normal extension with no pain . Accordingly, for the reasons just discussed, the Board finds that the preponderance of the evidence weighs against a separate rating of 10 percent or higher under DC 5261 for limitation of extension of the right knee, notwithstanding the aforementioned records reflecting findings of extension limited to 10 degrees for the period from May 2017 through May 2018. The evidence does not show that flare-ups or repeated use over time of the right knee would result in further limitation of flexion or extension satisfying the criteria for a 20 percent rating or higher under DC 5260, or a 10 percent rating or higher under DC 5261. See DeLuca, 8 Vet. App. at 206-07. Because the Veteran’s right knee arthritis is assigned a 10 percent rating based on limitation of motion under DC 5260, a separate 10 percent rating for right knee arthritis may not be assigned as a matter of law. See 38 C.F.R. § 4.71a, DC 5003, Note (1). The Board has considered the fact that in June 2015, the Veteran reported an increase in right knee pain that had an acute onset. This record in itself does not support assignment of a higher or staged rating. As explained above, the criteria for a higher rating have not been met under the applicable diagnostic codes, regardless of whether there has been some fluctuation in the Veteran’s symptoms. The Board notes that the Veteran has also been diagnosed with chondromalacia patella of the right knee, for which a 10-percent rating had been assigned until service connection for arthritis was granted in the April 2019 rating decision. As the chondromalacia does not result in manifestations or functional limitations distinct from the arthritis with limited motion, a separate rating may not be assigned, as that would result in compensating twice for the same disability under different diagnoses, in contravention of the rule against pyramiding. See 38 C.F.R. § 4.14. The Board finds that no other diagnostic code pertaining to the knee is applicable to the Veteran’s right knee disability. According to the October 2010 VA examination report, the Veteran’s knee symptoms, as listed by the examiner, included episodic instability. Stability testing was normal, however. Objective evidence of instability is not necessarily required to satisfy the criteria for a rating under DC 5257, which pertains to “other impairment” of the knee, with recurrent subluxation or lateral instability. English v. Wilkie, 30 Vet. App. 347, 353 (2018). In this case, apart from the one-time listing of a subjective report of instability in the October 2010 VA examination report, the VA treatment records, VA examination reports, and private treatment records spanning a period of over ten years do not show complaints of instability. Moreover, they consistently show that stability testing of both knees was normal. Accordingly, the Board finds that instability of the right knee is not established. The record also shows that the Veteran has not had a history of recurrent subluxation of the right knee. Accordingly, DC 5257 does not apply. Under DC 5258, a 20-percent rating is assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a. The evidence shows that that the Veteran has not had a dislocated semilunar cartilage (meniscus) of the right knee, which is the basis for the assignment of a rating under DC 5258; therefore, the Board finds that the criteria for a separate rating under DC 5258 are not satisfied. His knee pain with limited motion is already compensated by the 10-percent rating assigned under DC 5260. The occasional effusion, which generally has been characterized as “slight,” “very little,” or “trace,” is not shown to cause disability or functional impairment distinct from that contemplated by the 10-percent rating based on limited motion under DC 5260. The record shows that the Veteran has not had ankylosis of the right knee, removal of semilunar cartilage, impairment of the tibia and fibula with nonunion or malunion, or genu recurvatum. Thus, DC’s 5256, 5259, 5262, and 5263, which pertain to these conditions, respectively, do not apply. See 38 C.F.R. § 4.71a. The Board notes that revisions to the rating schedule applicable to the musculoskeletal system went into effect on February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020). The Board may consider these changes without remand to the AOJ for consideration in the first instance. See 38 C.F.R. § 20.904(d)(2). The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. VAOPGCPREC 7-2003 (Nov. 19, 2003); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overruling Karnas v. Derwinski, 1 Vet. App. 308 (1991) to the extent it conflicts with the precedents of the United States Supreme Court and the Federal Circuit). Thus, the changes to the rating schedule that went into effect on February 7, 2021 do not apply prior to that date. See id.; 85 Fed. Reg. 76453. The changes made to the rating schedule with regard to the knee pertain to DC 5055 (resurfacing or replacement (prosthesis)), DC 5257 (other impairment of, recurrent subluxation or instability, patellar instability), and DC 5262 (tibia and fibular, impairment of). The Veteran has not undergone resurfacing or replacement of the right knee, and DC’s 5257 and 5262 do not apply, as discussed above. Diagnostic Code 5003 has also been amended to clarify that it only applies to degenerative arthritis other than post-traumatic. No substantive changes were made to DC 5003. Accordingly, the revisions to the rating schedule are not relevant to the evaluation of the Veteran’s right knee disability at this time. Because the preponderance of the evidence is against a higher rating, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Left Knee Prior to June 12, 2018, when the total knee replacement was performed, the Veteran’s left knee chondromalacia patella with degenerative arthritis was rated under DC 5003-5260. The rating criteria under these diagnostic codes, as well as DC 5261, are reviewed above with regard to the right knee. With regard to limitation of flexion, the record shows that prior to June 12, 2018, the Veteran’s left knee flexion consistently exceeded 60 degrees, including after repetitive use testing. The record does not show further limitation of flexion during flare-ups or with repeated use over time that would satisfy the criteria for a rating higher than 10 percent under DC 5260. See DeLuca, 8 Vet. App. at 206-07. Accordingly, the criteria for a rating higher than 10 percent under DC 5260 were not met. With regard to extension, the October 2010 VA examination report shows extension of the left knee to 0 degrees, including after repetitive use testing. The record does not otherwise show limitation of extension prior to May 2017. As of May 16, 2017, which is the date of the Veteran’s initial visit to the orthopedic surgery facility, a separate rating of 10 percent is warranted based on extension limited to 10 degrees. See 38 C.F.R. § 4.71a, DC 5261. The record of that visit constitutes the earliest evidence of an ascertainable increase in disability of the left knee in terms of limitation of extension. See Hazan v. Gober, 10 Vet. App. 511, 519 (1992). The Board notes that unlike the right knee, and with the exception of the November 2017 VA examination report showing a finding of normal extension, the treatment records and VA examination reports consistently show continued limitation of extension of the left knee through December 2019, including after the June 2018 knee replacement was performed. Thus, compensable limitation of extension of the left knee is established effective May 16, 2017. Although the May 16, 2017 record provides a range of “10-15 degrees” of limitation of extension, the records thereafter consistently show limitation of extension to 10 degrees. Accordingly, the balance of the evidence supports a separate rating of 10 percent, but no higher, based on limitation of extension under DC 5261 from May 16, 2017 through June 11, 2018. See id. For the same reasons discussed above with regard to the right knee, separate or higher ratings may not be assigned for arthritis of the left knee or chondromalacia of the left knee. In addition, and again for the reasons discussed above with regard to the right knee, the evidence does not establish instability of the left knee during the period under review, or dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Thus, DC’s 5257 and 5258 do not apply. The record shows that prior to June 12, 2018, the Veteran did not have ankylosis of the left knee, removal of semilunar cartilage, impairment of the tibia and fibula with nonunion or malunion, or genu recurvatum. Thus, DC’s 5256, 5259, 5262, and 5263, which pertain to these conditions, respectively, do not apply. See 38 C.F.R. § 4.71a. The Board finds that a 60 percent rating under DC 5055 is warranted effective August 1, 2019. In this regard, from June 12, 2018, the date of the Veteran’s total left knee replacement, through July 31, 2019, a 100 percent rating was assigned under DC 5055, which pertains to prosthetic replacement of the knee joint. Under DC 5055, a 100 percent rating is be assigned for one year following implantation of the prosthesis. 38 C.F.R. § 4.71a. Thereafter, the knee is to be rated based on residuals, with a minimum rating of 30 percent. Id. For intermediate degrees of residual weakness, pain, or limitation of motion, the knee replacement is to be rated by analogy to diagnostic codes 5266, 5261, or 5262. Id. A 60 percent rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. That is the maximum rating that may be assigned under DC 5055 after the one-year period following the replacement surgery has passed. Here, the RO assigned an automatic rating of 30 percent effective August 1, 2019. The November 2019 rating decision granted a rating of 40 percent under DC 5256 for the Veteran’s total left knee replacement effective September 9, 2019 based on the VA examination conducted on that date, without considering whether the effective date should be assigned back to August 1, 2019. Diagnostic Code 5256 pertains to ankylosis of the knee, and provides, in pertinent part, that a 40-percent rating is assigned for ankylosis of the knee with flexion between 10 degrees and 20 degrees. The February 2020 rating decision granted a 60 percent rating for the Veteran’s total left knee replacement effective November 15, 2019. The 60 percent rating has been assigned under DC 5055 for chronic severe residuals of the Veteran’s left knee replacement, as found in the December 2019 VA examination. The effective date is based on the date he filed an application for a higher rating for his left knee disability (VA Form 21-526EZ). As the evaluation of his left knee disability was already on appeal, basing the effective date of the 60 percent rating on that “claim” was improper. The Board finds that a 60 percent rating based on severe chronic residuals of the Veteran’s total left knee replacement is warranted effective August 1, 2019, the day following termination of the temporary 100 percent rating. The September 2019 and December 2019 VA examination reports, which chronologically are in very close proximity to each other and to the effective date of the termination of the 100 percent rating, support a finding of severe chronic residuals, as found in the December 2019 VA examination report. Separate ratings may not be assigned under both DC 5055 and DC’s 5256, 5260, and 5261, as that would contravene the rule against pyramiding. See 38 C.F.R. § 4.14. Moreover, no other diagnostic code pertaining to the knee provides for a rating higher than 60 percent (excepting the temporary 100 percent rating assigned under DC 5055 following the knee replacement, as discussed above). Accordingly, rating the Veteran’s post-knee replacement residuals under another diagnostic code, including DC 5256, would not be more favorable. As discussed above with regard to the right knee, revisions to the rating schedule as it pertains to the knee went into effect on February 7, 2021, and may not be applied prior to that date. These revisions are not relevant to the evaluation of the Veteran’s left knee disability, for the same reasons discussed above with regard to the right knee. The Board notes that DC 5055 was also amended to include resurfacing of the knee. Under new DC 5055, the time period for the assignment of the 100 percent rating following implantation of the prosthesis or resurfacing is limited to 4 months. It also specifies that the rating criteria for residuals only apply to prosthetic replacement of the knee joint, and that the minimum evaluation of 30 percent only applies to a total replacement, not resurfacing. Resurfacing is to be evaluated under diagnostic codes 5256 through 5262 at the conclusion of the 100 percent evaluation period. The Veteran has not undergone resurfacing of the knee, and it is clear that the revisions to DC 5055 are not otherwise applicable to his June 2018 knee replacement. In sum, a rating higher than 10 percent for the Veteran’s left knee disability prior to May 16, 2017 is denied. A separate rating of 10 percent based on limitation of extension under DC 5261 is granted from May 16, 2017 through June 11, 2018. Finally, an earlier effective date of August 1, 2019 is granted for the 60 percent rating based on chronic severe residuals of the total knee replacement under DC 5055. Because the preponderance of the evidence is against ratings higher than those assigned, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected bilateral knee disabilities, is remanded. The Board finds that a new medical opinion must be obtained on the issue of secondary service connection for the Veteran’s cervical spine disability. The Board remanded the claim in March 2020 in part for a VA medical as to whether his cervical spine disability is proximately due to his service-connected bilateral knee disabilities, or has been aggravated beyond its natural progression by his knee disabilities. See 38 C.F.R. § 3.310. The Board instructed that the opinion should consider whether an altered gait resulting from his knee disabilities caused his cervical spine disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Moreover, remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes the Board a concomitant duty to insure compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268, 271 (1998); but see D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board’s remand directives is required under Stegall). A VA examination was performed in November 2020. In the November 2020 VA medical opinion, the examiner concluded that the Veteran’s cervical spine disability is less likely than not related to his bilateral knee disabilities, stating there are many causes of neck and shoulder pain, but no clinical evidence that knee pain can develop into shoulder pain. The opinion does not address whether an altered gait resulting from the Veteran’s knee disabilities caused or aggravated his cervical spine condition, as instructed by the Board. In addition, the examiner stated that the Veteran’s cervical spine condition was not aggravated beyond natural progression by his service-connected knee disabilities, but did not provide an explanation for that finding. Accordingly, a new VA medical opinion must be obtained that addresses the above issues. See id. 2. Entitlement to service connection for a cardiac disability, to include as secondary to service-connected hypertension, is remanded. The Board finds that a new medical opinion must be obtained on the issue of secondary service connection for the Veteran’s coronary artery disease (CAD). The August 2020 VA medical opinion concludes that it is less likely than not that the Veteran’s CAD was caused or related to his service-connected hypertension. In explanation, the examiner stated that the Veteran has numerous risk factors for CAD including a strong family history or genetic predisposition as there were multiple members of his family with CAD including his father and two or three siblings, obesity, hyperlipidemia, prior smoking history, male gender, and advanced age of seventy years at the time of his CAD diagnosis. The opinion concludes that these risk factors make the Veteran’s CAD less likely than not due to hypertension. However, the opinion does not address whether the hypertension itself is a risk factor for CAD and, if so, why that factor is not at least as likely as not a cause of the Veteran’s CAD as the other risk factors listed in the opinion. Moreover, the opinion does not address whether the Veteran’s hypertension may have aggravated his CAD beyond natural progression. See 38 C.F.R. § 3.310(b) (providing for secondary service connection based on aggravation); El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that a medical opinion that a claimed disability is “not due to,” “not caused by,” or “not related to” a service-connected disability is insufficient to address the issue of aggravation under § 3.310(b)). As a final matter, the Board notes that the Veteran has a combined disability rating of 80 percent, with service-connected disabilities of the bilateral knees, right shoulder, and lumbar spine, among other service-connected disabilities. He should be asked whether he wishes to claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities at this juncture. See 38 C.F.R. § 4.16. The matters are REMANDED for the following action: 1. Ask the Veteran whether he wishes to file a claim for TDIU due to his service-connected disabilities. He should be informed of the requirements for substantiating a claim for TDIU. 2. Obtain a new VA medical opinion on the issue of secondary service connection for the cervical spine disability, as follows. The examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran’s cervical spine disability has been caused or aggravated beyond natural progression by his service-connected bilateral knee disabilities. In particular, the examiner should address whether an altered gait resulting from the knee disabilities caused or aggravated the cervical spine disability. (The November 2020 VA medical opinion does not address that issue.) The examiner must separately address the issues of causation and aggravation, and provide complete explanations in support of the conclusions reached. 3. Obtain a new VA medical opinion as to whether it is at least as likely as not that the Veteran’s coronary artery disease (CAD) has been caused or aggravated beyond natural progression by his service-connected hypertension. Specifically, while the August 2020 opinion notes that the Veteran has several risk factors for CAD such as family history and age, the examiner should address whether hypertension itself is a risk factor for CAD and, if so, whether it is at least as likely not that it caused or aggravated the Veteran’s CAD as the other risk factors listed in the opinion. The examiner must separately address the issues of causation and aggravation, and provide complete explanations in support of the conclusions reached P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rutkin, 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.