Citation Nr: 21022530 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 10-22 080 DATE: April 16, 2021 ORDER Entitlement to a rating in excess of 30 percent for left knee chondromalacia (based on a limitation of extension from August 21, 2008) is denied. Entitlement to an initial rating in excess of 20 percent for left knee limitation of flexion from November 5, 2020, is denied Entitlement to increased initial ratings (10 percent from September 19, 2005, to November 5, 2020, and in excess of 20 percent from that date, based on a limitation of flexion) for right knee arthritis is denied. FINDINGS OF FACT 1. The preponderance of the evidence shows that from August 21, 2008, the left knee chondromalacia was not manifested by ankylosis; subluxation or instability; meniscus injuries; extension limited to 30 degrees; nonunion of the tibia and fibula; or genu recurvatum. 2. The preponderance of the evidence shows that the left knee disability was not manifested by flexion limited to 45 degrees prior to November 5, 2020, or flexion limited to 15 degrees from that date. 3. The preponderance of the evidence shows that prior to November 5, 2020, the right knee disability was not manifested by ankylosis; subluxation or instability; meniscus injuries; flexion limited to 30 degrees; extension limited to 10 degrees; nonunion of the tibia and fibula; or genu recurvatum. 4. The preponderance of the evidence shows that from November 5, 2020, the right knee disability was not manifested by ankylosis; subluxation instability; meniscus injuries; flexion limited to 15 degrees; extension limited to 10 degrees; nonunion of the tibia and fibula; or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for left knee chondromalacia from August 21, 2008, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.71A, Diagnostic Codes 5256-5263. 2. The criteria for a rating in excess of 20 percent for left knee limitation of flexion from November 5, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.71A, Diagnostic Code 5260. 3. The criteria for ratings in excess of 10 percent prior to November 5, 2020, and in excess of 20 percent from that date for right knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.71A, Diagnostic Codes 5256-5263 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1979 to August 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from February 2009 and February 2011 ratings decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Little Rock, Arkansas. The February 2009 rating decision, in pertinent part, granted an increased, 30 percent rating for left knee chondromalacia from August 21, 2008. The February 2011 rating decision granted service connection for degenerative arthritis of the right knee and assigned a 10 percent rating from September 19, 2005. In July 2012, the Veteran testified at a personal hearing before a Veterans Law Judge (VLJ) who has since retired. In June 2020, the Veteran indicated she did not wish to appear at another Board hearing before a different VLJ. In December 2013, November 2016, and August 2020, the Board remanded the matters to the Agency of Original Jurisdiction (AOJ) for additional development. An interim, November 2020 rating decision granted an increased, 20 percent rating for right knee arthritis from November 5, 2020, and a separate, 20 percent rating for left knee limitation of flexion from November 5, 2020. The Board notes entitlement to a total disability rating based on individual unemployability (TDIU) was also remanded in August 2020. However, a December 2020 rating decision granted entitlement to TDIU from July 24, 2008. If the Veteran disagrees with the effective date, she or her representative should file a supplemental claim, request for higher-level review, or notice of disagreement. As there remains no case or controversy concerning whether the Veteran is entitled to a TDIU rating, that issue is no longer in appellate status. INCREASED RATINGS Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, 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 there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, including degree of disability, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Under Diagnostic Code 5256, a 30 percent rating is assigned for knee ankylosis with a favorable angle in full extension, or in slight flexion between zero and 10 degrees; a 40 percent rating for knee ankylosis in flexion between 10 degrees and 20 degrees; a 50 percent rating for knee ankylosis in flexion between 20 degrees and 45 degrees; and a 60 percent rating for extremely unfavorable knee ankylosis, in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Under Diagnostic Code 5257, a 10 percent rating is assigned for slight recurrent subluxation or lateral instability of a knee; a 20 percent rating for moderate recurrent subluxation or lateral instability; and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 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, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, a noncompensable rating is assigned for flexion limited to 60 degrees; a 10 percent rating for flexion limited to 45 degrees; a 20 percent rating for flexion limited to 30 degrees; and 30 percent for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is assigned for extension limited to 5 degrees; a 10 percent rating for extension limited to 10 degrees; a 20 percent rating for extension limited to 15 degrees; a 30 percent rating for extension limited to 20 degrees; a 40 percent rating for extension limited to 30 degrees; and a 50 percent rating for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5262, a 10 percent rating is assigned for malunion of tibia and fibula with slight knee or ankle disability; 20 percent rating for malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating for malunion of the tibia and fibula with marked knee or ankle disability; and a 40 percent rating for nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, a 10 percent rating is assigned for genu recurvatum. The Board notes new criteria for rating the musculoskeletal system, including knee disabilities, became effective February 7, 2021. Accordingly, if any of the new criteria is more favorable to the Veteran after that date, the Board would consider the Veteran’s appeals under the new criteria from February 7, 2021. See Kuzma v. Principi, 341 F.3d 1327 (2003). However, the Veteran’s knee disabilities are currently rated under Diagnostic Codes 5260 and 5261, which were not changed. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5263). And as will be further explained below, the Board finds separate ratings under other Diagnostic Codes are not warranted. Accordingly, the Board finds the new criteria, while reviewed, is not applicable to the Veteran’s appeals and will not be address it in detail. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Entitlement to a rating in excess of 30 percent for left knee chondromalacia. The Board has reviewed the record and finds the preponderance of the evidence shows that the left knee chondromalacia has not been manifested by ankylosis; subluxation or instability; meniscus injuries; extension limited to 30 degrees; malunion or nonunion of the tibia and fibula; or genu recurvatum from August 21, 2008. Therefore, the criteria for a rating in excess of 30 percent for left knee chondromalacia are not met at any time during the pendency of the appeal. The Board notes any limitation of flexion during the period on appeal will be addressed in the section below. In this regard, multiple VA examinations and treatment records indicate there is not left knee ankylosis, subluxation of instability, meniscal injuries, nonunion of the tibia and fibula, or genu recurvatum. Accordingly, the Board finds the left knee chondromalacia does not warrant an increased rating under Diagnostic Code 5256, 5257, 5258, 5259, 5262, or 5263. As left knee limitation of flexion will be addressed below, the remaining question is whether left knee extension has been limited to 30 degrees or more. Based on a comprehensive review of the record, the Board concludes a preponderance of the evidence shows that the Veteran's left knee extension has not been limited beyond 30 degrees. In this regard, the Veteran was provided a VA left knee examination in November 2008. She reported left knee pain that flared up with ambulatory activities and that the knee locked and swelled intermittently. The examiner noted there was weakness with the flare-ups, but not additional loss of motion. On range-of-motion testing, extension was to 25 degrees with pain at that point. There was no additional loss of motion, weakness, fatigability, or functional impairment following repetitive testing. In a May 2009 letter, the Veteran’s treating gastroenterologist opined she could not work due to constant knee pain and arthritis, but did not address any specifics of the nature of the disability. At a November 2009 hearing before a Decision Review Officer at the AOJ, the Veteran reported she had daily pain, which she rated as 8/10. She asserted she was unable to work because of the knee disability due to the effects of pain medication, which made her drowsy and prevented her from driving, but did not discuss physical limitations in detail. On December 2009 VA examination, the examiner noted there was mild swelling and tenderness to palpation but that the Veteran could extend her knee to 10 degrees, at which point she had to stop due to pain. There was no additional loss in range of motion due to pain, fatigue, weakness, or incoordination on repeated testing. An August 2010 chiropractor treatment record notes there was tenderness and edema of the left knee on examination, but the Veteran was able to extend her left knee to 0 degrees with discomfort. She was able to do the same in October 2010. September 2010 and December 2010 VA treatment records note the Veteran complained of constant bilateral knee pain with occasional flare-ups that made it difficult to walk. The September 2010 treatment record notes examination did not reveal instability, but that there was pain with flexion and extension. Range-of-motion testing results were not provided. Any specific of the nature of the disabilities was not addressed in December 2010. A June 2011 VA treatment record notes the Veteran reported her legs had been locking up on her, but there is no indication she had a meniscal condition. The treatment provider noted there was bilateral knee crepitus and a decreased range of motion due to pain. An August 2011 orthopedic consultation report notes the Veteran explained that she meant that it gave way, not actually locked up. The provider noted she had marked pain on extension of both knees, worse on the left, but was able to extend them “pretty much straight.” At a March 2012 VA knee examination, the Veteran reported flare-ups of the left knee that caused it to swell if she walked any distance greater than about three blocks. She denied any locking or giving way. On range-of-motion testing, there were no limitations of extension. At the July 2012 Board hearing, the Veteran reported she wore knee braces to keep her knees from swelling and that she could not stretch her legs or squat due to knee pain. But she noted she tried to keep up with normal activities like walking, driving, and walking up stairs. In April 2013, the Veteran submitted an aid and attendance examination report that notes she had difficulty bending her lower extremities, stooping, and standing for extended periods of time, which limited her ability to clean her home. The Veteran was provided a VA knee examination in January 2014. She reported she had daily flare-ups that decreased her knee range of motion by 80 percent with any activity. However, on initial and repeated range-of-motion testing, left knee extension was to 0 degrees with no objective evidence of pain. The examiner indicated she experienced left movement than normal, pain on movement, swelling, and interference with sitting, standing, and weight-bearing in both knees after repeated use. She could only walk about a quarter of a mile and was not able to stand for more than five minutes. During a May 2017 VA examination, the Veteran reported she wore knee braces episodically and was able to walk a half of a block. She reported having flare-ups of pain with prolonged walking. Left knee extension was to 0 degrees on initial and repeated testing without evidence of pain. An August 2018 VA treatment record notes she complained of increasing leg pain and weakness, making it difficult to use the outside steps of her house. The Veteran was provided another VA knee examination in September 2018. She reported she could not squat, walk or drive long distances, or stand for long periods of time and needed help dressing. She reported flare-ups caused her left knee to lock up. On initial range-of-motion testing, left knee extension was to 0 degrees without pain. However, the Veteran indicated she could not perform repeat testing due to pain. The examiner indicated the range of motion was variable after repeated use and during flare-ups. At its worst, she could not move her knees at all due to pain, fatigue, weakness, and lack of endurance, but there were also times the range-of-motion loss was minimal. The Veteran reported having knee pain and stiffness at her most recent VA knee examination in November 2020. She reported having daily flare-ups of pain in both knees that lasted several hours. On initial and repeated testing, left knee extension was to 0 degrees, but with pain. Notably, the examiner opined extension was not limited after repeated use or during flare-ups. The examiner noted she had difficulty standing for more than 15 minutes and walking for more than 400 feet. In conclusion, the Board finds that the preponderance of the evidence shows that the criteria for a rating in excess of 30 percent for the Veteran’s left knee limitation of extension from August 21, 2008. The Board acknowledges the Veteran reported experiencing flare-ups that limited functional ability throughout the appeal period, but the record does not indicate the flare-ups were severe enough to warrant a finding that the limitation of motion caused by flare-ups and repetitive use amounted to a functional impairment commensurate with left knee extension being limited to 30 degrees or more. Entitlement to an initial rating in excess of 20 percent for left knee limitation of flexion from November 5, 2020. The Board has reviewed the record and finds the preponderance of the evidence shows that the left knee disability was not manifested by flexion limited to 45 degrees prior to November 5, 2020, or flexion limited to 15 degrees from that date. At the November 2008 examination, left knee flexion was to 105 degrees with pain beginning at 90 degrees. At the December 2009 VA examination, flexion was to 80 degrees, at which point she stopped due to pain. There was no additional loss in range of motion due to pain, fatigue, weakness, or incoordination on repeated testing. An August 2010 chiropractor treatment record notes there was tenderness and edema of the left knee on examination, but on range-of-motion testing, flexion was to 120 degrees with discomfort. In October 2010, flexion was to 125 degrees. September 2010 and December 2010 VA treatment records note the Veteran complained of constant bilateral knee pain with occasional flare-ups that made it difficult to walk. The September 2010 treatment record notes examination did not reveal instability, but that there was pain with flexion and extension. Range-of-motion testing results were not provided. Any specific of the nature of the disabilities was not addressed in December 2010. A June 2011 VA treatment record notes the Veteran reported her legs had been locking up on her, but there is no indication she had a meniscal condition. The treatment provider noted there was bilateral knee crepitus and a decreased range of motion due to pain. An August 2011 orthopedic consultation report notes the Veteran explained that she meant that it gave way, not actually locked up. The provider noted flexion was to 130 degrees, but with pain. At the March 2012 VA knee examination, the Veteran reported flare-ups of the left knee that caused it to swell if she walked any distance greater than about three blocks. She denied any locking or giving way. On initial range-of-motion testing, left knee flexion was to 60 degrees, but with pain beginning at 45 degrees. After repetitive testing, flexion was to 60 degrees. However, the examiner noted an adequate assessment of the flexion was prevented due to the Veteran’s pain and muscle guarding and that the Veteran was able to flex both knees to 90 degrees when seated. At the July 2012 Board hearing, the Veteran reported she wore knee braces to keep her knees from swelling and that she cannot stretch her legs or squat due to knee pain. But she noted she tried to keep up with normal activities like walking, driving, and walking up stairs. In April 2013, the Veteran submitted an aid and attendance examination report that notes she had difficulty bending her lower extremities, stooping, and standing for extended periods of time, which limited her ability to clean her home. The Veteran was provided a VA knee examination in January 2014. She reported she had daily flare-ups that decreased her knee range of motion by 80 percent with any activity. However, left knee flexion was to 80 degrees with pain beginning at that point on initial range-of-motion testing and to 75 degrees after repeated testing. The examiner indicated she experienced left movement than normal, pain on movement, swelling, and interference with sitting, standing, and weight-bearing in both knees after repeated use. She could only walk about a quarter of a mile and was not able to stand for more than five minutes. The examiner noted the Veteran was able to sit with her knees flexed to 90 degrees without pain. During a May 2017 VA examination, the Veteran reported she wore knee braces episodically and was able to walk a half of a block. She reported having flare-ups of pain with prolonged walking. Left knee flexion was to 90 degrees on initial and repeated testing with pain. An August 2018 VA treatment record notes she complained of increasing leg pain and weakness, making it difficult to use the outside steps of her house. The Veteran was provided another VA knee examination in September 2018. She reported she could not squat, walk or drive long distances, or stand for long periods of time and needed help dressing. She reported flare-ups caused her left knee to lock up. On initial range-of-motion testing, left knee flexion was to 73 degrees. However, the Veteran indicated she could not perform repeat testing due to pain. The examiner indicated the range of motion was variable after repeated use and during flare-ups. At its worst, she could not move her knees at all due to pain, fatigue, weakness, and lack of endurance, but there were also times the range-of-motion loss was minimal. The Veteran reported having knee pain and stiffness at her most recent VA knee examination in November 2020. She reported having daily flare-ups of pain in both knees that lasted several hours. On initial testing, left knee flexion was to 60 degrees, but with pain. Flexion was further limited to 50 degrees on repeated testing. The examiner opined left flexion was limited to 40 degrees after repeated use and 30 degrees during flare-ups. The examiner noted she had difficulty standing for more than 15 minutes and walking for more than 400 feet. In conclusion, the Board finds that the preponderance of the evidence shows that the criteria for a compensable rating for left knee flexion prior to November 5, 2020, and a rating in excess of 20 percent from that date are not met. The Board acknowledges the Veteran reported experiencing flare-ups that limited functional ability throughout the appeal period, but the record does not indicate the flare-ups were severe enough to warrant a finding that the limitation of motion caused by flare-ups and repetitive use amounted to a functional impairment commensurate with flexion being limited to 45 degrees prior to November 5, 2020, or flexion being limited to 15 degrees from that date. Notably, she reported having daily flare-ups but the VA examinations repeatedly showed the flexion was not limited to that extent. In addition, the March 2012 and January 2014 examiners noted she could flex both knees to 90 degrees while seated. Entitlement to an initial rating in excess of 10 percent for right knee arthritis prior to November 5, 2020, and in excess of 20 percent from that date. The Board has reviewed the record and finds the preponderance of the evidence shows that, the right knee disability was not manifested by ankylosis; subluxation or instability; meniscus injuries; flexion limited to 30 degrees; extension limited to 10 degrees; nonunion of the tibia and fibula; or genu recurvatum prior to November 5, 2020, or flexion limited to 15 degrees or extension limited to 10 degrees from that date. The Veteran was provided a VA examination for his service-connected left knee disability in November 2005, but the examiner at least partially examined the right knee. On range-of-motion testing, extension was to 0 degrees and flexion was to 110 degrees. The examiner also indicated there was recurrent subluxation to a slight degree and crepitus. An August 2006 VA treatment record notes there was some loss of flexion in the right knee, but measurements were not provided. No instability or swelling was noted. During a December 2010 VA examination, the Veteran denied any right knee dislocation, subluxation, and instability. The examiner noted extension was to 0 degrees and flexion was to 190 degrees on range-of-motion testing. The Board notes it appears the examiner erred in describe the flexion range of motion because such range would be beyond a fully closed knee, but he did not indicate flexion was limited to 30 degrees or less in any way. The examiner noted there was no additional weakness, fatigability, discoordination, additional restrictive range of motion, or loss of joint function against resistance after repetitive testing. The August 2010 chiropractor treatment record notes the right knee joint was stable. There was tenderness and edema to palpation, but the range of motion was 0 to 110 degrees with discomfort. The range of motion remained the same in October 2010. September 2010 and December 2010 VA treatment records note the Veteran complained of constant bilateral knee pain with occasional flare-ups that made it difficult to walk. The September 2010 treatment record notes examination did not reveal instability, but that there was pain with flexion and extension. Range-of-motion testing results were not provided. Any specific of the nature of the disabilities was not addressed in December 2010. A June 2011 VA treatment record notes the Veteran reported her legs had been locking up on her, but there is no indication she had a meniscal condition. The treatment provider noted there was bilateral knee crepitus and a decreased range of motion due to pain. An August 2011 orthopedic consultation report notes the Veteran reported her right knee was painful and would lock and swell up. The provider noted the Veteran explained that she meant that it gave way, not actually locked up. The provider noted she had marked pain on extension of both knees, worse on the left, but was able to extend them “pretty much straight.” Flexion was to 130 degrees, but with pain. The March 2012 VA examination report shows the right knee flexion was to 100 degrees with pain beginning at 80 degrees and extension to 0 degrees with no objective evidence of pain on initial testing. The range of motion remained the same on repetitive testing. As noted, the examiner indicated an adequate assessment of the flexion was prevented due to the Veteran’s pain and muscle guarding and that the Veteran was able to flex both knees to 90 degrees when seated. At the July 2012 Board hearing, the Veteran reported she wore knee braces to keep her knees from swelling and that she cannot stretch her legs or squat due to knee pain. But she noted she tried to keep up with normal activities like walking, driving, and walking up stairs. In April 2013, the Veteran submitted an aid and attendance examination report that notes she had difficulty bending her lower extremities, stooping, standing for extended periods of time, which limited her ability to clean her home. The Veteran was provided a VA knee examination in January 2014. She reported she had daily flare-ups that decreased her knee range of motion by 80 percent with any activity. However, right knee range of motion was 0 to 85 degrees, with pain beginning at that point, on initial and repeated testing. The examiner indicated she experienced left movement than normal, pain on movement, swelling, and interference with sitting, standing, and weight-bearing in both knees after repeated use. She could only walk about a quarter of a mile and was not able to stand for more than five minutes. The examiner noted the Veteran was able to sit with her knees flexed to 90 degrees without pain. During a May 2017 VA examination, the Veteran reported she wore knee braces episodically and was able to walk a half of a block. She reported having flare-ups of pain with prolonged walking. However, right knee range of motion was 0 to 90 degrees, with flexion causing pain. An August 2018 VA treatment record notes she complained of increasing leg pain and weakness, making it difficult to use the outside steps of her house. The Veteran was provided another VA knee examination in September 2018. She reported she could not squat, walk or drive long distances, or stand for long periods of time and needed help dressing. On initial testing, right knee range of motion was 0 to 80 degrees with evidence of pain on extension and flexion. The range of motion was 0 to 75 degrees on repeated testing. The examiner indicated the range of motion was variable after repeated use and during flare-ups. At its worst, she could not move her knees at all due to pain, fatigue, weakness, and lack of endurance, but there were also times the range-of-motion loss was minimal. The Veteran reported having knee pain and stiffness at her most recent VA knee examination in November 2020. She reported having daily flare-ups of pain in both knees that lasted several hours. On initial testing, right knee range of motion was 0 to 60 degrees with pain. Flexion was further limited to 50 degrees on repeated testing. The examiner opined left flexion was limited to 40 degrees after repeated use and 30 degrees during flare-ups. Extension was not limited. The examiner noted she had difficulty standing for more than 15 minutes and walking for more than 400 feet. In conclusion, the Board finds that the preponderance of the evidence shows that the criteria for an initial rating in excess of 10 percent for right knee arthritis from September 19, 2005, to November 5, 2020, and in excess of 20 percent from that date are not met. The Board acknowledges the November 2005 VA examiner indicated there was mild recurrent subluxation of the right knee, but as noted the examination was arranged for the left knee and it’s not clear to what extent the examiner evaluated the right knee. Notably, the examiner also noted there was mild recurrent subluxation of the left knee, but opined the effect of the left knee disability on the Veteran’s daily activities was absent. In addition, no other medical evidence, including an August 2006 VA treatment record, indicates there was recurrent subluxation or instability of the right knee at any point during the period on appeal. In fact, the Veteran denied any right knee subluxation during the December 2010 VA examination. Accordingly, the Board finds a preponderance of the evidence indicates the Veteran did not have recurrent subluxation of the right knee. The Board also acknowledges the Veteran reported experiencing flare-ups that limited functional ability throughout the appeal period, but the record does not indicate the flare-ups were severe enough to warrant a finding that the limitation of motion caused by flare-ups and repetitive use amounted to a functional impairment commensurate with right knee flexion being limited to 30 degrees or extension being limited to 10 degrees prior to November 5, 2020 or flexion being limited to 15 degrees or extension being limited to 10 degrees from that date. Notably, she reported having daily flare-ups of pain but the VA examinations repeatedly showed flexion and extension was not limited to that extent. In addition, the March 2012 and January 2014 examiners noted she could flex both knees to 90 degrees while seated. Accordingly, the Board finds that the most probative evidence of records shows that the criteria for increased ratings for the left and right knee disabilities are not met, and the appeals must be denied. 38 C.F.R. § 4.71a. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board William A. Skowronski, 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.