Citation Nr: 21023928 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 08-02 149 DATE: April 21, 2021 ORDER A 20 percent rating, but no higher, from August 10, 2005 to June 13, 2013 for service-connected status post left knee meniscal repair prior is granted. An increased rating of more than 60 percent for service-connected status post left total knee arthroplasty from August 1, 2014 to January 7, 2016 is denied. A total evaluation for status post left knee explant with prostalac from January 7, 2016 to March 1, 2017 is granted. An increased rating of more than 60 percent for status post left knee explant with prostalac (hereinafter “left knee disability”) from March 1, 2017 is denied. REMANDED The issue of a total disability based on individual unemployability (TDIU) prior to August 1, 2014 is remanded. FINDINGS OF FACT 1. Prior to June 13, 2013, the Veteran’s left knee disability was manifested by forward flexion limited to 20 degrees. 2. The Veteran was in receipt of a 100 percent temporary rating one year following his total knee replacement on June 13, 2013 under Diagnostic Code 5055 and was rated at the maximum schedular rating of 60 percent from August 1, 2014 to January 7, 2016. 3. From January 7, 2016 to March 1, 2017, the Veteran had a left knee explant with prostalac which is the functional equivalent of a prosthesis replacement. 4. From March 1, 2017, the Veteran was rated at the maximum schedular rating of 60 percent for his left knee disability. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating, but no higher, for a left knee disability prior to June 13, 2013 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 2. The criteria for an increased rating more than 60 percent for a left knee disability from August 1, 2014 to January 7, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 3. The criteria for a total evaluation for a left knee disability from January 7, 2016 to March 1, 2017 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 4. The criteria for an increased rating more than 60 percent for a left knee disability from March 1, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from November 1964 to March 1965; April 1968 to February 1970; and from September 1970 to December 1972. He died in 2018. The Appellant in this case is the Veteran’s surviving spouse who is properly substituted. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’s appeal was originally before the Board in January 2012 and remanded. The appeal was again remanded in December 2012. In June 2013, the Board denied the claims. The Veteran appealed the Board’s decision to the United States Court of Veterans Claims (Court). In March 2014, the Court granted a joint motion for remand (JMR) which vacated the June 2013 Board decision. In June 2014, October 2016, January 2020 and November 2020 the Board again remanded the appeal. Increased Rating for the Left Knee Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider entitlement to “staged” ratings to compensate for times since filing the claim (or even during the year prior) when the disability may have been more severe than at other times during the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Raters must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss considering 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.1. The guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight-bearing are related considerations. 38 C.F.R. § 4.45. Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes through the senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran filed his claim for TDIU based on his service-connected left knee disability on August 10, 2006. In the March 2007 rating decision on appeal, the RO continued the 10 percent rating assigned since December 1, 1989 for the Veteran’s left knee disability under Diagnostic Code 5257. The current appeal period before the Board is from August 10, 2005, the date of his TDIU claim, and the one-year “look back” period. Gaston v. Shinseki, 605 F.3d 979, 982 Fed. Cir. (2010). In a March 2013 rating decision, the RO indicated that it had evaluated the Veteran’s left knee disability under Diagnostic Codes 5010-5260. This hyphenated code indicates that the service-connected disability is traumatic arthritis and it is rated as if the residual condition is a limitation of knee flexion under Diagnostic Code 5260. Additionally, the Veteran’s service-connected left knee disability has been evaluated as 60 percent disabling from August 1, 2014 to January 7, 2016 and from March 1, 2016 under Diagnostic Code 5055. Therefore, the Board will review the Appellant’s contentions in the context of the following Diagnostic Codes applicable to the knee. Diagnostic Code 5256 provides ratings for ankylosis of the knee. A 30 percent rating is warranted for a favorable angle in full extension or in slight flexion between 0 and 10 degrees. A 40 percent rating is warranted for a knee in flexion between 10 and 20 degrees. A 50 percent rating is warranted for a knee in flexion between 20 and 45 degrees. A 60 percent rating is warranted for a knee in extremely unfavorable flexion, at an angle of 45 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Diagnostic Code 5257 provides ratings for recurrent subluxation or lateral instability. Slight disability warrants a 10 percent rating and a moderate disability warrants a 20 percent rating. Severe disability warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). Terms such as “slight,” “moderate,” and “severe” are not defined in the regulatory criteria, and the Board must consider their applicability to symptoms reported in the record in a manner that is “equitable and just.” See 38 C.F.R. § 4.6. The provisions of Diagnostic Code 5257 have been revised effective February 7, 2021. Under the revised provisions recurrent subluxation or instability warrants a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. A 20 percent rating is warranted for an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation due to a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation. Additionally, under Diagnostic Code 5257 revised provisions, patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Diagnostic Code 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 provides that a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Limitation of flexion to 60 degrees warrants a noncompensable rating. Limitation of flexion to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5261 provides ratings based on limitation of the extension of the leg. Limitation of extension to 5 degrees warrants a noncompensable rating. Extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Diagnostic Code 5262 provides ratings for impairment of the tibia and fibula. A 10 percent rating is warranted for malunion with slight knee or ankle disability. A 20 percent rating is warranted for malunion with moderate knee or ankle disability. A 30 percent rating is warranted for malunion with marked knee or ankle disability. A 40 percent rating is warranted for nonunion, with loose motion, requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2020). The provisions of Diagnostic Code 5262 have been revised effective February 7, 2021. Under these revisions a noncompensable rating is warranted for medial tibial stress syndrome (MTSS) or shin splints requiring treatment less than 12 consecutive months, for one or both lower extremities. A 10 percent rating is warranted for treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, for one or both lower extremities. A 20 percent rating is warranted for MTSS or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, for one lower extremity. A 30 percent rating is warranted for MTSS or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, for both lower extremities. The average normal range of motion of the knee is flexion from 0 to 140 degrees and extension from 140 to 0 degrees. 38 C.F.R. § 4.71, Plate II. In every instance where the schedule does not provide a 0 percent rating for a diagnostic code, a 0 percent rating shall be assigned when the requirements for a compensable rating are not met. See 38 C.F.R. § 4.31. Diagnostic Code 5055 provides that a prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. A September 2005 private treatment record reflects that the Veteran had an antalgic gait, he squatted poorly, and had no crepitation about the knees or effusion. Range of motion of the knees was noted as 0 to 120 degrees. There was no instability and the McMurray test was negative. In February 2007, the Veteran’s private physician who performed a previous knee meniscectomy noted that the Veteran had severe debilitating post-traumatic arthritis of the left knee for years. The physician noted that there was significant varus of the left knee with mild effusion and tenderness in the medial joint line and the Veteran had patellofemoral crepitation and that the Veteran needed a knee replacement for pain relief. At the January 2007 knee VA examination, the examiner noted the Veteran had arthritis in the left knee, instability, pain, stiffness, and weakness. There were no episodes of dislocation or subluxation or locking. There was repeated effusion. Flareups were severe and occurred weekly when he could not walk for one to two days. The Veteran had an antalgic gait. The Veteran’s knee range of motion was flexion limited to 100 degrees with pain beginning at 35 degrees and pain ending at 0 degrees on active range of motion. On passive range of motion, flexion was limited to 100 degrees with pain beginning at 20 degrees and pain ending at 0 degrees. There was additional limitation of motion on repetitive use and flexion limited to 20 degrees due to pain. The Veteran did not have Osgood-Schlatter’s disease, a mass behind the knee, grinding, instability, a patellar abnormality or meniscus abnormality. There was crepitation and the knee clicked and snapped. The examiner noted there were moderate effects of the Veteran’s knee disability in completing chores and traveling; severe in shopping and engaging in recreational activities and preventing exercise and sports. A May 2008 VA joints examiner noted the Veteran had been receiving Social Security Administration (SSA) benefits for his disabilities since March 2006. On physical examination, the Veteran had a marked limp and he reported his left knee pain was chronic. At the July 2009 knee VA examination, the Veteran had from pain, weakness, stiffness, swelling, instability, giving way, locking, fatigability and lack of endurance. There were no flareups, episodes of dislocation or any recurrent subluxation reported. There was no prosthesis or ankylosis. There was valgus deformity of the left knee. Range of motion was limited to 95 degrees on flexion and unlimited on extension. The varus/valgus of medial and lateral collateral ligaments were normal. The anterior and posterior cruciate ligaments were normal. The McMurray’s test was negative in the medial and lateral meniscus. The Veteran reported pain on initial range of motion and there was also objective evidence of painful motion edema, tenderness, abnormal movement and guarding of movement. On additional range of motion testing flexion was limited to 105 degrees and extension was unlimited. Gait was normal. There were no signs of abnormal weightbearing. The examiner indicated the Veteran was limited to sedentary employment only. At the February 2012 knee VA examination, the Veteran reported experiencing flareups described as the Veteran having intermittent pain in the knee which caused him to fall. Initial range of motion revealed flexion limited to 120 degrees with painful motion beginning at 120 degrees and extension was unlimited. On repetitive use testing, forward flexion was limited to 125 degrees and extension was unlimited. No additional limitation in range of motion of the knee on repetitive use testing was noted. The examiner noted the Veteran had less movement than normal, pain on movement, disturbance of locomotion, interference with sitting, standing, and weight-bearing. There was tenderness or pain to palpation for joint line or soft tissues. Muscle strength was normal in knee flexion and extension. Joint stability tests yielded normal findings. There was no evidence or history of recurrent patellar subluxation or dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had meniscal surgery due to a meniscus semilunar cartilage condition which resulted in frequent episodes of joint “locking” and joint pain. The Veteran did not have a total knee joint replacement. There were no scars on the left knee and the Veteran did not use any assistive devices for his knee. Diagnostic testing revealed arthritis but no patellar subluxation. The examiner concluded that the Veteran’s left knee impacted his ability to work because knee pain limited walking for long periods, standing and/or squatting for long periods. At an April 2013 general VA examination, the Veteran reported flareups with pain with walking or standing especially on concrete and prolonged sitting. Initial range of motion revealed flexion limited to 110 degrees with painful motion beginning at 70 degrees and extension was unlimited with no objective evidence of painful motion. On repetitive use testing forward flexion was limited to 110 degrees and unlimited on extension. The examiner also noted functional impairments of weakened movement, pain on movement, disturbance of locomotion and interference with sitting, standing, and weight-bearing. There was tenderness or pain to palpation for joint line or soft tissues. Muscle strength was with active movement against some resistance in knee flexion and extension. Joint stability tests yielded normal findings. There was no evidence or history of recurrent patellar subluxation or dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had meniscal surgery due to a meniscus semilunar cartilage condition which resulted in a meniscal tear, frequent episodes of joint “locking,” pain and effusion. The Veteran did not have a total knee joint replacement. There was a scar associated with the Veteran’s left knee that was not painful or unstable or of a total area greater than 39 square centimeters. The Veteran required the use of a knee brace and cane on a regular basis and a walker on an occasional basis. Diagnostic testing revealed arthritis but no patellar subluxation. The examiner concluded the Veteran’s left knee did impact his ability to work as he had restrictions provided by the social security administration, on prolonged sitting, standing, or bending. The Veteran had left total knee replacement in June 2013. At the June 2014 knee VA examination, the Veteran reported intermittent pain and his knee would pop at night. He had flareups with throbbing pain that was aggravated by standing, walking, climbing, and squatting. Initial range of motion revealed flexion limited to 100 degrees with no objective evidence of painful motion and extension was unlimited with no objective evidence of painful motion. On repetitive use testing forward flexion was limited to 100 degrees and unlimited on extension. Weakened movement and swelling were noted as functional impairments. There was no tenderness or pain to palpation for joint line or soft tissues. Muscle strength was with active movement against some resistance in knee flexion and extension. Joint stability tests yielded normal findings. There was no evidence or history of recurrent patellar subluxation or dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had meniscal surgery due to a meniscus semilunar cartilage condition that resulted in a meniscal tear. The Veteran’s post-total knee replacement residuals included intermediate degrees of weakness, pain or limitation of motion and popping, locking, and swelling. There was a scar associated with the Veteran’s left knee that was not painful or unstable or of a total area greater than 39 square centimeters. The Veteran required the regular use of a cane for his knee disability but no patellar subluxation. The examiner concluded that the Veteran’s left knee had an impact on his ability to work as the Veteran would have difficulty with activities that involved standing, walking, climbing and squatting. At a May 2015 knee VA examination, the Veteran did not report flareups. Initial range of motion revealed flexion limited to 40 degrees and extension limited to 10 degrees. The Veteran had pain on flexion and extension. There was no additional limitation of motion on repetitive use testing. Pain and fatigue were factors contributing to functional loss. Contributing factors related to the Veteran’s left knee were less movement than normal, weakened movement, disturbance of locomotion and interference with standing. Muscle strength was with active movement against some resistance. There was reduction in muscle strength due to the Veteran’s left knee disability. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. The Veteran could not perform joint stability testing due to pain. There was no evidence or history of recurrent patellar subluxation or dislocation or shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The examiner noted the Veteran did not have a meniscal condition. There was a scar associated with the Veteran’s left knee that was not painful or unstable or of a total area greater than 39 square centimeters. The Veteran required the constant use of a knee brace and cane to stabilize gait. Diagnostic testing revealed arthritis. The examiner concluded that the Veteran left knee disability had an effect on his ability to work because he was unable to be on his feet for more than a few minutes. In a July 2015 VA addendum opinion it was noted that despite the Veteran’ left knee total arthroplasty he was in constant pain, had limited motion and abnormal gait. A January 2016 VA treatment record notes the Veteran had a left knee explant with a prosthesis with antibiotic-loaded acrylic cement (“prostalac”) on January 7, 2016. Following the Veteran’s death in August 2018 VA obtained an additional medical opinion in May 2020 concerning the level of impairment of the Veteran’s left knee. The examiner indicated that it was more likely than not that the Veteran had pain and weakness from August 2014 to October 2015. The examiner noted the Veteran would not have had a functional left knee joint after removal of the hardware due to chronic infection in 2016. The examiner noted it appeared that the Veteran was fitted for a brace to stabilize the joint but had very little usable function. It was also noted that review of the 2013 VA examination indicated pain with and without weightbearing and passive movement. In an August 2020 VA addendum, the May 2020 examiner clarified that based on his review of the record it is highly likely that the Veteran’s pain, weakness, and limitation of motion was severe during the period from August 2014 to May 2015 as the subsequent removal of hardware in 2016 indicated the severity of the Veteran’s disability. Prior to June 13, 2013 The designation by the RO in the March 2013 rating decision was appropriate in finding the Veteran’s left knee disability more appropriately rated under Diagnostic Code 5260 prior to June 13, 2013. During this period the Veteran was in receipt a 10 percent rating since the appeal period began on August 10, 2005 until June 13, 2013. However, when considering the Veteran’s statements and the medical evidence including Deluca factors, functional loss during flare-ups and the Veteran’s regular need for a brace and cane, the Board finds that a 20 percent rating is warranted for limitation of flexion under Diagnostic Code 5260 from August 2005 to June 13, 2013. For that period, the evidence demonstrates severely limited flexion that more nearly approximates flexion to 20 degrees during that time. See DeLuca, 8 Vet. App. at 205-206; see also Mitchell, 25 Vet. App. at 38; Sharp, 29 Vet. App. at 33. The Veteran’s flexion was limited to 20 degrees due to pain on repetitive use testing according to the January 2007 VA examination report. Additionally, the February 2007 private examiner noted the Veteran had severe impairment due to pain in his left knee for many years and recommended a total knee replacement. This rating fully contemplates all knee symptoms as well as range of motion results. The evidence indicates intermediate degrees of residual weakness, pain, or limitation of motion which have been considered. 38 C.F.R. § 4.71, Diagnostic Code 5260. Further there is no indication in any of the Veteran’s treatment records or examinations that he has ever had impairment of flexion to 15 degrees or extension to 10 degrees, even when painful motion, flare ups, and other types of impairment are taken into consideration. Accordingly, there exists no basis for a rating more than 20 percent for a left knee disability from August 2005 to January 2013. VA’s General Counsel has held that separate ratings under Diagnostic Code 5257 (recurrent subluxation or lateral instability), Diagnostic Code 5260 and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for a disability of the same joint. All the VA examination reports, and treatment records indicate that the Veteran has full range of motion on extension of the left knee. No medical evidence noted recurrent subluxation or lateral instability in the Veteran’s left knee. Additionally, medical treatment records did not reveal the Veteran had ankylosis of the knee (Diagnostic Code 5256), a dislocated semilunar cartilage (Diagnostic Code 5258), a tibia or fibular impairment (Diagnostic Code 5262) or genu recurvatum (Diagnostic Code 5263) associated with his left knee disability. Because of this, separate ratings under these diagnostic codes are not warranted. The Veteran was in receipt of a 10 percent rating for his removal of symptomatic semilunar cartilage from February 7, 2012 to June 13, 2013. This rating is the maximum allowable rating under Diagnostic Code 5259 and the Veteran’s left knee meniscal condition did not warrant a higher rating during that period. Additionally, VA examination reports indicate the Veteran had a related left knee scar, but none of the examiners found they were painful or unstable, or the total area was greater than 39 square cm (6 square inches). Thus, the Board finds a preponderance of the evidence is against finding the Veteran was entitled to a separate compensable rating for his left knee scar. From August 1, 2014 to January 7, 2016 As noted, the Veteran underwent total knee replacement on June 13, 2013 and was assigned a total evaluation from June 13, 2013, the date of the Veteran’s total knee replacement surgery until July 31, 2014, the last day of the month following a one-year, 100 percent rating following implantation of his prosthesis and assigned a 60 percent rating from August 1, 2014 to January 7, 2016 under Diagnostic Code 5055. As 60 percent is the maximum schedular rating allowable under Diagnostic Code 5055 after a 100 percent disability rating for one year following implantation of prosthesis, which the Veteran was granted. The rule against pyramiding prohibits compensating twice for the same manifestations. A rating under Diagnostic Code 5055 encompasses all identifiable residuals of post total knee replacement, including limitation of motion and functional impairment due to pain on motion. Separate ratings for limitation of flexion (Diagnostic Code 5260) and/or limitation of extension (Diagnostic Code 5261) are not appropriately assigned. No other diagnostic code regarding knee disabilities would allow the Veteran a rating higher than 60 percent. Pursuant to 38 C.F.R. § 4.68, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation of the elective level, where amputation to be performed. diagnostic codes 5162 through 5164, regarding amputation approximately at the knee, only allow for a maximum 60 percent disability rating. The Veteran’s left knee disorder would not have been appropriately evaluated at a rating more than 60 percent. The Board has also evaluated if the Veteran’s was entitled to any separate compensable ratings for the knee however, medical treatment records did not reveal the Veteran had ankylosis of the knee (Diagnostic Code 5256), recurrent subluxation or lateral instability (Diagnostic Code 5257), a dislocated semilunar cartilage (Diagnostic Code 5258), a tibia or fibular impairment (Diagnostic Code 5262) or genu recurvatum (Diagnostic Code 5263) associated with his left knee disability. Thus, separate compensable ratings are not warranted during this period. Although the Veteran has been noted on examination to have a scar of the left knee, associated with his service-connected left knee disability, as the scar was not shown during the period on appeal to be unstable or painful; deep and covering an area of at least 6 square inches; superficial and covering an area of 144 square inches or greater; or otherwise symptomatic, a separate rating under Diagnostic Codes 7800-7805 is not warranted. From January 7, 2016 to March 1, 2017 and from March 1, 2017 The Veteran was entitled to a total evaluation for one year following his temporary total evaluation concluding on March 1, 2016 pursuant to Diagnostic Code 5055. The evidence indicates the Veteran had a left knee explant with prostalac on January 7, 2016. VA treatment records note the Veteran prosthesis was taken out due to chronic infection and replaced with an antibiotic spacer. The spacer is the functional equivalent of a prosthesis replacement warranting the full provisions under Diagnostic Code 5055. Following the expiration of the one year total evaluation, the 60 percent rating in effect should not be disturbed as the August 2020 examiner indicated the severity of the Veteran’s left knee prior to his January 2016 surgery and the Veteran likely experienced chronic severe pain as the initial prosthesis caused a chronic infection of the left knee. Accordingly, as 60 percent is the maximum schedular rating allowable under Diagnostic Code 5055 after a 100 percent disability rating for one year following implantation of prosthesis, there are no other diagnostic codes regarding knee disabilities which would allow the Veteran a rating higher than 60 percent. Thus, a rating more than 60 percent from March 1, 2017 is denied. The Board has also evaluated if the Veteran’s was entitled to any separate compensable ratings for the knee however, medical treatment records did not reveal the Veteran had ankylosis of the knee (Diagnostic Code 5256), recurrent subluxation or lateral instability (Diagnostic Code 5257), a dislocated semilunar cartilage (Diagnostic Code 5258), a tibia or fibular impairment (Diagnostic Code 5262) or genu recurvatum (Diagnostic Code 5263) associated with his left knee disability. Thus, separate compensable ratings are not warranted during this period. In summary, from August 10, 2005 to June 13, 2013 a disability rating of 20 percent, but no higher, for a left knee disability has been demonstrated. Additionally, from August 1, 2014 to January 7, 2016, a disability rating more than 60 percent for a left knee disability has not been demonstrated. From January 7, 2016 to March 1, 2017, a total evaluation has been demonstrated. Lastly, from March 1, 2017, a disability rating more than 60 percent has not been demonstrated. REASONS FOR REMAND The issue a TDIU prior to August 1, 2014 is remanded. The matter is REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: 1. BACKGROUND FOR THE ADJUDICATOR: The Board has granted increased rating during the appeal period before August 1, 2014. A remand is warranted for the RO to implement the Board’s decision and re-adjudicate TDIU prior to August 1, 2014, in the first instance. (Continued on the next page) 2. Re-adjudicate the claim of entitlement to a TDIU prior to August 1, 2014. If any benefit remains denied, a supplemental statement of the case must be provided to the Appellant. After she has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. McDuffie, 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.