Citation Nr: 21024483 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 13-27 900 DATE: April 22, 2021 ORDER For the entire period on appeal, entitlement to a rating in excess of 20 percent for right shoulder status post acromioclavicular joint separation with shoulder impingement syndrome (right shoulder disability) is denied. Prior to September 14, 2017, entitlement to a rating in excess of 20 percent for residuals of right knee surgery is denied. Beginning September 14, 2017, the Veteran’s “residuals of right knee surgery” disability is recharacterized into two separate disabilities: residuals of right knee surgery with instability evaluated as 20 percent disabling; and residuals of right knee surgery with limitation of motion, evaluated as 30 percent disabling. To this extent, the appeal is granted. Prior to September 30, 2016, a rating in excess of 10 percent for degenerative joint disease of the left knee (left knee disability) is denied. From September 30, 2016 through September 13, 2017, a 20 percent rating, but no higher, for left knee limitation of extension, is granted, subject to the rules and regulations governing the payment of VA monetary benefits. Since September 14, 2017, a rating in excess of 10 percent for a left knee disability is denied. REMANDED Entitlement to service connection for a low back condition is remanded. FINDINGS OF FACT 1. The most probative evidence of record is against finding that the Veteran's shoulder disability was manifested by ankylosis, malunion of the humerus with marked deformity, recurrent dislocation at the scapulohumeral joint, fibrous union, false flail joint, flail shoulder, or right shoulder motion limited to midway between side and shoulder level or less. 2. Prior to September 14, 2017, the probative evidence indicates that the Veteran’s right knee disability was manifested by limitation of motion, stiffness, pain, tenderness with palpation, swelling, subjective sensations of popping and instability, weakness, and moderate laxity; it was not manifested by flexion limited to at least 45 degrees, extension limited to at least 10 degrees, or recurrent subluxation. 3. Since September 14, 2017, the probative evidence indicates that the Veteran’s right knee disability was manifested by limitation of motion, stiffness, pain, tenderness with palpation, swelling, subjective sensations of popping and instability, weakness, and moderate laxity; it was not manifested by flexion limited to at least 45 degrees, extension limited to at least 30 degrees, or recurrent subluxation. 4. Prior to September 30, 2016, the probative evidence indicates the Veteran’s left knee disability was manifested by limitation of motion, pain, tenderness with palpation, and swelling; it was not manifested by flexion limited to 45 degrees, extension limited to 10 degrees, recurrent subluxation, or lateral instability. 5. From September 30, 2016 through September 13, 2017, the probative evidence indicates the Veteran’s left knee disability was manifested by limitation of motion, pain, tenderness with palpation, weakness, and effusion; it was not manifested by flexion limited to at least 45 degrees, extension limited to at least 20 degrees, recurrent subluxation, or lateral instability. 6. From September 14, 2017, the Veteran’s left knee disability was manifested by limitation of motion, pain, tenderness to palpation, and effusion; it was not manifested by flexion limited to at least 45 degrees, extension limited to at least 10 degrees, recurrent subluxation, or lateral instability. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for a rating in excess of 20 percent for a right shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5200-5203. 2. Prior to September 14, 2017, the criteria for a rating in excess of 20 percent for residuals of right knee surgery have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5256-5263. 3. From September 14, 2017, entitlement to a rating of 20 percent for residuals of right knee surgery with instability (formerly residuals of right knee surgery) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 4. From September 14, 2017, the criteria for a rating of 30 percent for residuals of right knee surgery with limitation of motion (formerly residuals of right knee surgery) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5260, 5261. 5. Prior to September 30, 2016, the criteria for a rating in excess of 10 percent for left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5256-5263. 6. From September 30, 2016 through September 13, 2017, the criteria for a 20 percent rating, but no higher, for left knee limitation of extension have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 7. From September 14, 2017, the criteria for a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1982 to October 1990. He also had prior service in the Army Reserve, to include a period of active duty for training (ACDUTRA) from July 1980 to November 1980. These matters are before the Board of Veterans’ Appeals (Board) on appeal a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were last before the Board in January 2019, when they were remanded for additional development. In August 2016, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing. A transcript of his testimony is of record. A September 2014 rating decision granted a temporary total rating for the Veteran’s right shoulder disability from December 18, 2013 through February 28, 2014. As a 100 percent rating is the maximum rating assignable, that period is not for consideration. The Veteran has perfected appeals regarding the issues of entitlement to service connection for diabetes mellitus and obstructive sleep apnea. He requested a Travel Board hearing regarding these issues. As he is still awaiting his requested hearing, these issues are not ripe for adjudication. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2020). A claimant may experience multiple distinct degrees of disability that result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. 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 inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 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 may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2020); see also 38 C.F.R. §§ 4.45, 4.59 (2017). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 1. Entitlement to a rating in excess of 20 percent for a right shoulder disability The Veteran’s right shoulder disability has been evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under that code, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2020). The Board notes that Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Effective February 7, 2021, Diagnostic Code 5201 was amended to clarify that loss of motion of the arm includes either flexion or abduction. 85 Fed. Reg. 76453 (Nov. 30, 2020). Diagnostic Codes 5201 and 5202 were also amended to clarify that “shoulder level” is defined as 90 degrees and “midway” is defined as 45 degrees. Id. As these amendments clarified rather than revised the rating criteria, they do not change the analysis or outcome of the claim. At his March 2010 VA shoulder examination, the Veteran reported increased pain and stiffness in his right shoulder. He reported daily pain that was a 4 out of 10, which increased to a 7 out of 10 during flare-ups. He denied incapacitating episodes of shoulder pain, shoulder instability, or shoulder dislocation. He endorsed occasional right shoulder swelling. Upon examination, there was evidence of right shoulder pain, weakness, and daily or more often locking episodes. There was no evidence of redness, warmth, tenderness, deformity, giving way, instability, stiffness, incoordination, decreased speed of joint motion, decreased muscle strength, dislocation or subluxation, or effusions. Upon range of motion testing, the Veteran had right shoulder flexion to 145 degrees, abduction to 120 degrees, internal rotation to 50 degrees, and external rotation to 85 degrees. There was no evidence of pain during initial or repetitive use testing and no additional functional loss with repetitive use testing. The examiner opined that the Veteran did not have significant right shoulder weakness. However, it was noted that the Veteran’s shoulder disability limited his choice of physical and recreational activities did not have other significant effects on his usual daily activities. An April 2010 record from Dr. Takahashi notes that musculoskeletal examination revealed no joint pain or decreased range of motion. In his June 2010 notice of disagreement, the Veteran reported constant right shoulder pain that required shots to temporarily regain use of it. Physical therapy records from June 2012 and August 2012 note that the Veteran had right shoulder active flexion to 155 degrees and abduction to 140 degrees. The physical therapist provided conflicting motion findings for internal and external rotation. Right shoulder muscle strength was 5/5 for flexion, internal rotation, and extension. It was 4/5 for abduction, external rotation, and supraspinatus. A September 2012 treatment record from Dr. Rodriguez noted that during vacation the Veteran had engaged in swimming and other physical activity and subsequently developed severe right shoulder pain. He opined that the Veteran’s right shoulder symptoms had previously been stable, but he now had marked decrease in his range of motion and stamina. Range of motion findings were not provided. A January 2013 record from Dr. Rodriguez noted that the Veteran had full range of motion and full muscle strength in his right shoulder. A March 2013 physical therapy record noted that the Veteran had right shoulder active flexion to 160 degrees, abduction to 160 degrees, internal rotation to 90 degrees, and external rotation to 50 degrees. Physical therapy records from May 2013 and June 2013 again note that the Veteran had right shoulder active flexion to 160 degrees and abduction to 160 degrees. However, those records contained conflicting findings regarding internal and external rotation. All the records indicated that muscle strength testing was 5/5 for flexion, abduction, internal rotation, external rotation, extension, and supraspinatus. At his June 2013 VA shoulder examination, the Veteran reported flare-ups characterized by increased pain and decreased motion. Upon testing, he had right shoulder flexion to 155 degrees with evidence of pain at 145 degrees, abduction to 145 degrees with evidence of pain at 130 degrees. There was no additional loss of motion with repetitive use testing. The examiner opined that the Veteran had functional impairment in the form of less movement than normal and pain on movement. Muscle strength testing was 5/5 for flexion and abduction. Upon inspection, the Veteran’s right shoulder was normal in appearance with no evidence of effusion, redness, warmth, mechanical symptoms, recurrent dislocation, crank apprehension, or tenderness to palpation. Hawkins’ impingement, empty-can, and cross-body adduction testing were positive. External rotation and lift-off testing were negative. The examiner opined that the Veteran would have moderate weakness, moderate fatigability, mild incoordination, and a 20 to 25-degree reduction in range of motion during painful flare-ups. A July 2013 VA treatment record noted that the Veteran reported right shoulder pain. Upon testing, he had full range of motion but was noted to have pain. In an August 2013 addendum, the June 2013 VA examiner opined that the Veteran’s right shoulder condition was worsening and was now mild to moderate in severity. The examiner opined that during flare-ups, the Veteran would have approximately a 20-degree loss in his range of motion, moderate weakness, moderate fatigability, and mild incoordination. An August 2013 VA orthopedic record noted that the Veteran had ongoing shoulder pain with overhead movement. He reported attending physical therapy with minimal improvement. He endorsed some improvement with cortisone injections. Upon testing, he had active flexion to 140 degrees, abduction to 130 degrees, internal rotation to “L5,” and external rotation to 80 degrees. Muscle strength was 5/5 for flexion, abduction, internal rotation, and external rotation. A September 2013 record from Dr. Wagner noted that the Veteran had right shoulder pain that worsened with overhead reaching and heavy lifting. The Veteran described the pain as constant and sharp. Upon examination, he had full range of motion for flexion, extension, abduction, external rotation, and internal rotation. He endorsed pain with any motion above shoulder height and tenderness to palpation of the acromioclavicular (AC) joint and distal clavicle. In a September 2013 addendum, a VA clinician clarified that the August 2013 VA examiner’s estimate of a 20-degree loss in motion, “should be assessed as a 10 degree loss in abduction and a 10 degree loss in flexion.” A March 2014 record from Dr. Wagner stated that the Veteran was three months post right shoulder surgery and was doing fine. It was noted that he continued to attend physical therapy to improve his range of motion and strength. The Veteran reported ongoing pain in the anterior shoulder region that was worse at night and with reaching behind his back. Upon examination, he had flexion to 160 degrees and abduction to 140 degrees. Rotator cuff testing revealed good strength but was notable for tenderness with abduction and external rotation. Physical therapy records from April 2014 note that the Veteran reported less shoulder pain. Upon testing, he had active flexion to 130 degrees, abduction to 100 degrees, internal rotation to 90 degrees, and external rotation to 40 degrees. Muscle strength testing was 3+/5 for flexion and supraspinatus, 3/5 for abduction, 4-/5 for external rotation, and 4/5 for extension and internal rotation. Records from Dr. Rodriguez from July 2014 and August 2014 note that the Veteran had been doing well following his right shoulder surgery until recently when he experienced increased pain with movement. He described the pain as a sharp constant pain and rated it as a 7 or 8 out of 10. Upon examination, he had tenderness to palpation of the AC joint and crepitus but had full range of motion. An August 2014 record from Dr. Wagner noted that the Veteran reported that his shoulder pain was gone, his strength was back, and he was doing great until last week when he began having pain. On examination, he had good muscle strength. However, he was noted to be “lacking a little bit of motion,” have tenderness to palpation, and mildly increased pain during muscle strength testing. At his August 2016 hearing, the Veteran stated he had shoulder pain and was unable to sustain any kind of weight over his shoulder. He noted difficulty with repetitive tasks and impaired mobility above shoulder level. He stated that lifting as little as five pounds significantly worsened his shoulder symptoms and that he sometimes required a shoulder sling during flare-ups. A May 2016 VA record noted that the Veteran endorsed left shoulder pain but denied any other arthralgias, joint swelling, or joint stiffness, including in his right shoulder. Upon examination, there was no evidence of right shoulder deformity, tenderness, effusion, or decreased range of motion. At his September 2016 VA shoulder examination, the Veteran reported that he was right hand dominant. He endorsed flare-up characterized by decreased range of motion due to pain. Upon range of motion, he had flexion to 145 degrees, abduction to 155 degrees, external rotation to 65 degrees, and internal rotation to 80 degrees. Pain was evident throughout range of motion testing. Repetitive use testing was performed without any additional functional loss. Muscle strength was 5/5 for flexion and abduction. Hawkins’ impingement, empty-can, external rotation, lift-off subscapularis, and cross-body adduction testing was positive. Palpation of the AC joint was notable for tenderness. The examiner indicated that there was no evidence of shoulder instability, dislocation, labral pathology, flail shoulder, false flail shoulder, fibrous union of the humerus, or malunion of the humerus. The Veteran denied using any assistive devices. The examiner opined that the Veteran’s right shoulder condition was moderate in its severity had improved slightly as a result of surgery. A September 2016 disability benefits questionnaire (DBQ) from Dr. Rodriguez noted that the Veteran had right knee flexion to “+118” degrees with pain, abduction to 110 degrees with pain, external rotation “-10 to neutral,” and internal rotation to “+50” degrees with pain. While Dr. Rodriguez indicated that the Veteran was unable to perform repetitive use testing and noted that the Veteran had additional limitations post repetitive use testing, no explanation was provided. Dr. Rodriguez noted that there was pain with active, passive, and/or repetitive use testing and in weight-bearing or non-weight-bearing that contributed to functional loss. However, no explanation was provided clarifying during which testing the pain occurred. Regarding functional loss, Dr. Rodriguez opined that the Veteran had less movement than normal, weakened movement, excess fatiguability, incoordination, pain on movement, atrophy or disuse, and disturbance of locomotion. Muscle strength was “-4/5” for flexion and abduction. Hawkins’ impingement, empty-can, lift-off subscapularis testing was positive. External rotation testing was negative. Dr. Rodriguez stated that the Veteran had malunion of the clavicle or scapula and dislocation of the clavicle or scapula, but did not have a flail shoulder, false flail shoulder, fibrous union of the humerus, or malunion of the humorous. Dr. Rodriguez opined that the Veteran had severe pain, decreased strength, and an inability to lift or weight bear. An April 2017 VA record noted that the Veteran endorsed left shoulder pain but denied any other arthralgias, joint swelling, or joint stiffness. Upon examination, there was no evidence of right shoulder deformity, tenderness, effusion, or decreased range of motion. At his January 2020 VA shoulder examination, the Veteran reported being right handed. He endorsed persistent right shoulder limitations, including pain at the end point of flexion. He also noted rare right shoulder flare-ups, characterized by increased pain with overhead activity. He stated flare-ups lasted approximately two hours and impaired further overhead activity. He denied using any assistive device. Upon range of motion, he had flexion to 105 degrees, abduction to 110 degrees, and external and internal rotation to 80 degrees. There was no evidence of pain with passive motion or non-weight bearing. Pain was noted with active flexion. Repetitive use testing was performed without additional functional loss. There was no evidence of crepitus. Pain was noted with palpation. Muscle strength was 5/5 for flexion and abduction. Hawkins’ impingement, empty-can, external rotation, and lift-off subscapularis, and cross-body adduction testing was negative. The examiner opined that there was no evidence of shoulder instability, dislocation, labral pathology, or humerus impairment. The examiner noted the Veteran’s history of a right AC separation but opined that it did not affect range of motion or cause tenderness to palpation of the AC joint. Regarding repeated use over time and flare-ups, the examiner opined that the Veteran would have an additional loss of 10-15 degrees with flexion and abduction. After reviewing the evidence of record, the Board finds that the evidence is against a rating in excess of 20 percent for the Veteran’s right shoulder disability. The Board acknowledges the Veteran’s lay reports of ongoing symptoms and functional loss due to pain, flare-ups, decreased weight-bearing, and fatiguability. However, even considering the Veteran’s lay reports of symptoms and functional loss, the degree of additional limitation reflected by the Veteran, would not result in symptoms that more nearly approximate limitation of motion of the arm midway between side and shoulder level. To the contrary, the VA examination reports, VA treatment records, and private treatment records consistently indicate that, even during flare-ups, his right shoulder motion exceeded 45 degrees. The Board acknowledges the representative’s assertion that the September 2013 addendum opinion, which clarified the June 2013 VA examiner’s opinions regarding functional loss during flare-ups, was inadequate. Specifically, the representative asserted that because the September 2013 VA clinician did not examine the Veteran she had “no idea what was actually going on with him.” See August 2016 Hearing Transcript at 4. While the Board acknowledges that the clinician did not physically examine the Veteran, she reviewed the Veteran’s claims file and her opinion is consistent with the weight of the VA and private treatment records. Moreover, even disregarding the September 2013 clarifying opinion, the June 2013 examination report and August 2013 addendum opinion indicated that the Veteran would have, at worst, 130 degrees of flexion and 120 degrees of abduction. See June 2013 VA examination report (noting flexion to 155 degrees and abduction to 145 degrees, with approximately 20-25-degree loss in motion during flare-ups). Accordingly, the criteria for a rating in excess of 20 percent has not been met. The Board has considered whether any other diagnostic codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the Veteran’s symptoms warrant a higher rating under a different diagnostic code. Specifically, the evidence of record consistently indicated that the Veteran did not have ankylosis or any type of humerus impairment. See e.g., VA examination reports from September 2014 and January 2020 and September 2016 DBQ. The Board acknowledges that the September 2016 DBQ from Dr. Rodriguez noted that the Veteran had malunion of the clavicle or scapula and dislocation of the AC or sternoclavicular. Even assuming arguendo, that these findings were not internally inconsistent, it would not result in a rating in excess of the current 20 percent rating. Thus, the Board finds that the preponderance of the evidence is against granting a rating in excess of 20 percent. The Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 2. Entitlement to a rating in excess of 20 percent for a right knee disability for the period prior to September 14, 2017 3. Entitlement to a rating in excess of 30 percent for a right knee disability since September 14, 2017 4. Entitlement to a rating in excess of 10 percent for a left knee disability The Veteran’s left knee disability has been rated under Diagnostic Code 5260-5010 based on osteoarthritis with noncompensable painful motion. See e.g., October 2008 rating decision; October 2020 Supplemental Statement of the Case (continuing a 10 percent rating for painful motion of the knee). The most recent rating code sheets indicate that the Veteran’s right knee disability was rated as 20 percent disabling prior to September 14, 2017 and 30 percent disabling thereafter under 38 C.F.R. § 4.71a, Diagnostic Code 5260 for limitation of flexion. Nevertheless, the evidence reflects that the Veteran’s right knee disability was not manifested by or rated based on limitation of flexion. In this regard, a January 1992 rating decision granted a 20 percent rating based on moderate instability under Diagnostic Code 5257. A March 1993 rating decision continued a 20 percent rating for lateral instability under Diagnostic Code 5257. A May 2003 rating decision continued a 20 percent rating noting that the Veteran had noncompensable flexion to 95 degrees and reports of “instability.” For unknown reasons, and presumably due to an administrative error, the RO changed the rating decision code sheet from Diagnostic Code 5257 to 5260 (limitation of flexion). The October 2008 and June 2010 rating decisions continued the 20 percent rating under Diagnostic Code 5260 despite stating that, respectively, the Veteran had flexion to 90 and 110 degrees and that flexion of 30 degrees or less was required for a 20 percent rating under Diagnostic Code 5260. For this reason, the Board is correcting the diagnostic code for the Veteran’s 20 percent rating for his right knee disability from Diagnostic Code 5260 back to Diagnostic Code 5257. Additionally, while the October 2020 rating decision code sheet indicates that the Veteran’s existing 20 percent right knee rating under Diagnostic Code 5260 was increased to 30 percent effective September 14, 2017, the narrative of the decision indicates that the 30 percent rating was granted for limitation of extension. See June 2018 rating decision (assigning a 30 percent rating for “extension of 20 to 29 degrees”). Thus, the Board is changing the diagnostic code for the 30 percent rating, which was granted effective September 14, 2017, from Diagnostic Code 5260 to 5261 (limitation of extension). However, as the Veteran had previously been rated based on symptoms of instability, the proper course of action was actually to grant a separate rating based on limitation of extension when the range of motion supported a compensable rating. For this reason, effective September 14, 2017, the Board is changing the “residuals of right knee surgery” disability into two separately compensated disabilities: residuals of right knee surgery with instability, rated as 20 percent disabling; and residuals of right knee surgery with limitation of motion, rated as 30 percent disabling. The Board is free to change the diagnostic code or codes used when appropriate based on the facts of the case, provided that any such change is specifically explained. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (stating the assignment of a particular diagnostic code is “completely dependent on the facts of a particular case”); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Furthermore, these changes do not in any way sever service connection for the Veteran’s right knee disability. See Read v. Shinseki, 651 F. 3d. 1296,1302-1302 (Fed. Cir. 2011) (holding that reassignment of a diagnostic code does not sever service connection when the diagnostic code is changed to more accurately reflect the nature of the Veteran's disability). Additionally, the changes do not result in a reduction of the Veteran’s combined rating. To the contrary, effective September 14, 2017, changing the Diagnostic Codes and assigning two separate ratings results in an increased combined rating for the Veteran’s right knee rather than a single 30 percent rating. Accordingly, for the period prior to September 14, 2017, the Board finds that the Veteran was in receipt of a 20 percent rating under Diagnostic Code 5257 based on moderate right knee lateral instability. Effective from September 14, 2017, his 20 percent rating under Diagnostic Code 5257 for moderate laxity is continued and he is granted a separate 30 percent rating for right knee limitation of motion under Diagnostic Code 5261. Having resolved these administrative issues, the Board will now address the underlying merits of the claims. Limitation of motion of knee joints is rated under Diagnostic Code 5260 for flexion, and Diagnostic Code 5261 for extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261 (2020). Under Diagnostic Code 5260, flexion that is limited to 60 degrees warrants a 0 percent rating; flexion that is limited to 45 degrees warrants a 10 percent rating; flexion that is limited to 30 degrees warrants a 20 percent rating; and flexion that is limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2020). Under Diagnostic Code 5261, extension that is limited to 5 degrees warrants a 0 percent rating; extension that is limited to 10 degrees warrants a 10 percent rating; extension that is limited to 15 degrees warrants a 20 percent rating; extension that is limited to 20 degrees warrants a 30 percent rating; extension that is limited to 30 degrees warrants a 40 percent rating; and extension that is limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2020). Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2020). Under Diagnostic Code 5257, recurrent subluxation or lateral instability of the knee warrants a 10 percent rating when it is slight, a 20 percent rating when it is moderate, and a 30 percent rating when it is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257(2020). The terms “slight,” “moderate,” and “severe” are not defined. Thus, rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just” as contemplated by the requirements of the law. 38 C.F.R. § 4.6 (2020). The Board notes VA amended the criteria for rating disabilities of the musculo-skeletal system effective from February 7, 2021. The new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both the old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply the current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Board is not precluded from applying prior versions of the regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. In pertinent part, effective February 7, 2021, Diagnostic Code 5257 provides that a 10 percent rating is warranted 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 (e.g., cane(s), crutch(es), walker) or bracing for ambulation; a 20 percent rating for a sprain, incomplete ligament tear, complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, and a medical provider prescribes a brace or assistive device for ambulation; and a 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. 85 Fed. Reg. 76453 (Nov. 30, 2020). Effective February 7, 2021, Diagnostic Code 5257, provides that 10 percent rating 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 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; and a 30 percent rating 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 walker. Id. Note (1) to Diagnostic Code 5257 provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) provides that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id. At a March 2010 VA knee examination the Veteran reported increased knee pain and weakness. He rated the pain as a 5 out of 10 and noted that it increased to an 8 out of 10 during flare-ups. He reported that flare-ups occurred with walking on stairs and while carrying something heavy. He endorsed bilateral knee stiffness and swelling but denied decreased range of motion, instability, or locking. He noted that his walking was limited to one mile. Upon examination, there was no evidence deformity, effusion, redness, warmth, giving way, incoordination, decreased joint speed, dislocation, subluxation, locking, abnormal weight bearing, Osgood-Schlatter’s disease, crepitation, clicks or snaps, grinding, instability, or patellar or meniscus abnormality in either knee. There was evidence of pain, stiffness, weakness, swelling, and repeated effusion. The was also tenderness with palpation of the medial joint line of the right knee, but no tenderness in the left knee. He had right knee flexion to 110 degrees, left knee flexion to 135 degrees, and bilateral extension to five degrees. There was no evidence of pain with motion or additional loss of motion following repetitive use testing. Muscle strength testing was 5/5 bilaterally and anterior drawer, posterior drawer, and McMurry testing were normal. The examiner opined that the Veteran’s knee disabilities limited his choice of physical and recreational activities but did not have significant effects on his usual daily activities. An April 2010 record from Dr. Takahashi noted that musculoskeletal examination revealed no joint pain or decreased range of motion. An April 2010 treatment record from Dr. Rodriguez noted that the Veteran reported right knee pain that was worse with walking or exercise. Upon examination, the Veteran had right knee effusion and tenderness along the patellar joint line. VA treatment records from April 2010 and May 2010 note that the Veteran had increased right knee pain for the past week. He described the pain as a constant sharp pain that prevented him from moving. He denied use of a knee brace, any recent injury, or swelling. Upon examination, both knees had small effusions and joint line tenderness. Right side Lachman testing was positive. The Veteran was noted to have full range of motion. A May 2010 VA orthopedic record noted that the Veteran had bilateral knee pain. He reported that he was able to walk several city blocks but would have pain and popping for the rest of the day. Upon examination, there was mild joint effusion, quadricep atrophy, and tenderness to palpation bilaterally. Upon range of motion testing, he had right knee flexion to 120 degrees, right knee extension to 2 degrees, left knee flexion to 125 degrees, and left knee extension to zero degrees. Varus and valgus stress testing were stable. Right-side Lachman testing revealed 5 millimeters (mm) of instability. An August 2010 VA orthopedic record noted that the Veteran had trace effusion on the right knee and bilateral joint line tenderness. He had flexion to 125 degrees and extension to zero degrees, bilaterally. Muscle strength and varus and valgus stress testing were normal. Right side Lachman testing was positive and anterior drawer testing was +1. The Veteran denied using a brace, cane, or orthotics. In his June 2010 notice of disagreement, the Veteran reported that he had daily knee pain and that he was unable to stand for long periods of time. VA records from September 2010 and October 2010 note small effusion and joint line tenderness in both knees. Right side Lachman testing was positive, but the Veteran was noted to have full range of motion in both knees. A March 2011 treatment record from Dr. Rodriguez noted that the Veteran had right knee pain over the patella area and sensations of instability with weight bearing. He rated his knee pain as a 7 out of 10 and noted it increased with weight bearing and bending. Upon examination, there was effusion with patellar ballottement. The Veteran had full muscle strength and motion in both knees and McMurry, Lachman, and Drawer stability testing were negative, bilaterally. An April 2011 record from the Orthopedic and Fracture Clinic noted that the Veteran’s knee pain severely limited his ability to walk. Right knee examination was notable for pain, tenderness, and edema. Left knee examination was unremarkable. He had right knee flexion to 100 degrees, left knee flexion to 130 degrees, and bilateral extension to zero degrees. Varus and valgus stress, anterior drawer, posterior drawer, and Lachman testing were negative bilaterally. McMurray testing was positive on the right side. A May 2011 VA record noted that right side Lachman testing was positive. The Veteran was noted to have small effusion, joint line tenderness, and full range of motion in both knees. An October 2011 record from Dr. Rodriguez noted that the Veteran had full muscle strength and range of motion in both knees. VA records from July 2012 note that the Veteran had small effusion and joint line tenderness in both knees. Right side Lachman testing was positive, but the Veteran had full range of motion in both knees. The Veteran reported that he “was unable to function well” and required Synvisc injections in both knees. A September 2012 treatment record from Dr. Rodriguez noted that the Veteran had decreased flexion in his bilateral knees. However, specific range of motion findings were not provided. A January 2013 record noted that the Veteran had full muscle strength and range of motion in both knees. A February 2013 record noted that the Veteran had decreased flexion. Muscle strength testing was 4+/5 to 5/5. At his June 2013 VA knee examination, the Veteran reported that his bilateral knee disability had worsened. He endorsed flare-ups with increased pain and decreased motion. He denied using any assistive devices. The Veteran had right knee flexion to 105 degrees with pain at 100 degrees, left knee flexion to 110 degrees pain at 105 degrees, and bilateral extension to zero degrees. There was no additional loss of motion in either knee with repetitive use testing. The examiner opined that the Veteran had functional loss in the form of less movement than normal, pain on movement, and interference with sitting, standing, and weight-bearing. Upon inspection, there was evidence of tenderness to palpation but no evidence of patellar subluxation, or dislocation in either knee. Muscle strength and stability testing were normal bilaterally. The examiner noted that the Veteran had a history of right knee meniscectomy and anterior cruciate ligament (ACL) reconstruction with residual symptoms of right knee stiffness and pain. The examiner opined that the Veteran would have moderate weakness, moderate fatigability, mild incoordination, and approximately 25 degrees of additional loss of motion during painful flare-ups. A July 2013 VA treatment record noted that the Veteran’s right and left knees had small effusions and tenderness in the medial and lateral aspects of the joint lines. Lachman testing was positive on the right side, but the Veteran had full range of motion in both knees. A July 2013 record from Dr. Rodriguez noted decreased range of motion in his right knee. Specific range of motion findings were not provided. In an August 2013 addendum, the June 2013 examiner opined that the Veteran’s bilateral knee condition was worsening and was now moderate in its severity. He again opined that the Veteran would have approximately a 25-degree loss in motion from baseline during flare-ups. In a September 2013 addendum, a VA clinician clarified that the June 2013 VA examiner’s estimates of an additional 25 degree loss in motion during flare-ups was for the Veteran’s bilateral flexion and that he would not experience any loss in extension. In a December 2014 statement, the Veteran reported that his knees were getting worse, that he was having increased pain, and a decreased ability to stand. A May 2014 VA record noted that the Veteran’s right and left knees had small effusions and tenderness. Lachman testing was positive on the right side, but the Veteran had full range of motion in both knees. An August 2014 Dr. Rodriguez record noted that the Veteran had full range of motion in his lower extremities. An October 2014 VA record noted that the Veteran reported worsening right knee pain. Treatment records from Dr. Rodriguez from October 2014 and November 2014 note that the Veteran had decreased knee flexion but full muscle strength. Specific range of motion findings were not provided. A November 2014 VA orthopedic record noted that the Veteran reported bilateral knee pain and swelling, but denied any catching or locking in either knee. He reported walking up to one mile a day. Inspection revealed bilateral lateral joint line tenderness to palpation. Muscle strength testing was 5/5 bilaterally. VA records from May 2015, June 2015, and May 2016 noted that the Veteran reported chronic knee pain. Upon examination, he had small effusion, joint line tenderness, and a positive right knee Lachman test. He was noted to have full range of motion in both knees. At his August 2016 hearing, the Veteran reported knee pain that progressed throughout the day. He also reported swelling with prolonged standing and noted that the swelling increased his mobility issues. The representative also asserted that the Veteran had ongoing “cartilage issues” that warranted a separate rating. In a September 30, 2016 correspondence, Dr. Rodriguez noted that the Veteran’s knee problems affected his gait and caused limping. In the corresponding DBQ, he noted that the Veteran had flare-ups characterized by an inability to stand for short to long periods and difficulty getting up from low chairs. He stated that the Veteran was unable to kneel, put weight on either knee, stoop, or squat. The Veteran was noted to have right knee flexion to “+98,” extension to “-8” left knee flexion to “+108,” and extension “-15.” Dr. Rodriguez stated that the Veteran was unable to perform repetitive use testing in either knee. However, no explanation was provided as to why repetitive use testing could not be performed. Dr. Rodriguez also checked “yes” in response to “Are any ROM movements painful on active, passive, and/or repetitive use testing” and “Is there pain when the joint is used in weight-bearing or non-weight bearing.” Again, no explanation was provided to identify the type of motion that was painful or whether the was pain with weight-bearing, non-weight-bearing, or both. Regarding functional loss, Dr. Rodriguez stated that, bilaterally, the Veteran had less movement than normal, weakened movement, excess fatiguability, incoordination, pain on movement, swelling, atrophy of disuse, instability of station, interference of sitting, interference of standing, and recurrent effusions. It was further noted that the Veteran had disturbance of locomotion and deformity in his right knee. Muscle strength testing was +3/5 for right knee flexion, -4/5 for right knee extension, and -4/5 for left knee flexion and extension. Dr. Rodriguez stated that there was no recurrent subluxation in either knee or left knee lateral instability. He opined that the Veteran had moderate right knee lateral instability. It was noted that joint stability testing revealed 1+ right knee medial instability and 1+ left knee anterior instability. Dr. Rodriguez noted that the Veteran’s right knee status post meniscal tear, resulted in frequent episodes of joint locking and frequent episodes of bilateral knee pain, but did not result in a meniscal dislocation or frequent episodes of joint effusion. It was noted that the Veteran did not require any assistive devices for ambulation. A March 2017 VA record noted that the Veteran reported that he began having issues with his right knee yesterday. He reported severe pain and stated he could hardly put weight on it. He requested a knee brace to assist with ambulation. An April 2017 VA record noted that subsequent to the Veteran’s ACL reconstruction and meniscectomy he had persistent pain and swelling that was aggravated by walking. Upon examination, he had small effusion, joint line tenderness, and a positive right knee Lachman test. He was noted to have full range of motion in both knees. At a September 14, 2017 VA knee examination, the Veteran reported that he had constant horrible right knee pain. He also reported left knee pain, which he described as less severe. He endorsed popping and grinding in both knees, right knee swelling, and a “catching sensation in his left knee. The Veteran reported that walking stairs, stooping, or squatting aggravated his knee disabilities. He endorsed flare-ups, which lasted two days and limited his activities. He reported using a right knee brace. The Veteran had right knee flexion from 15 to 110 degrees, left knee flexion from 0 to 130 degrees, right knee extension from 110 to 0 degrees, and left knee extension from 130 to 0 degrees. There was no evidence of crepitus but there was evidence of pain with bilateral flexion and right knee extension. The examiner opined that the Veteran’s pain resulted in functional loss. There was no additional functional loss with repetitive use testing. On examination, there was tenderness to palpation of the right lateral joint line, anterior medial and medial joint line, patella tendon, and popliteal fossa. There was also had tenderness along the left medial joint line. Muscle strength testing was 5/5 bilaterally. There was no recurrent subluxation, lateral instability, or recurrent effusion in either knee. The examiner noted the Veteran’s right knee status post partial meniscectomy and opined that he had no current residual symptoms. Regarding additional limitations during flare-ups, the examiner opined that the Veteran would have right knee pain, fatigue, lack of endurance, and incoordination as well as left knee pain. The examiner estimated that during flare-ups the Veteran would have right knee flexion to 100 degrees, left knee flexion to 125 degrees, right knee extension to 20 degrees, and left knee extension to zero degrees. The examiner stated the Veteran’s right knee was moderate to severe in severity and his left knee was mild in severity. VA records from March 2018 and January 2019 noted that the Veteran had chronic pain in his knees. Examination revealed small effusion and joint line tenderness in both knees. Right knee Lachman testing was positive. The Veteran was noted to have full range of motion in both knees. A June 2019 VA record noted the Veteran reported increased right knee pain for the past three weeks. He requested a new right knee brace. A July 2019 VA record noted he was prescribed a hinged neoprene right knee brace. Upon examination, it was noted that he lacked approximately 10 degrees of flexion in his right knee. A January 16, 2020 VA record noted that the Veteran reported that his knee had been bothering him more, but he still retained adequate performance of his activities of daily living. Examination revealed small effusion and joint line tenderness in both knees. It was noted that right knee Lachman testing was positive. The Veteran was noted to have full range of motion in both knees. At a January 2020 VA knee examination, the Veteran reported persistent bilateral knee pain that was worse on the right side. He noted that his job involved extended walking, which resulted in flare-ups that he rated as an 8 out of 10. He noted that the flare-ups varied in frequency and lasted a few hours during which time extended walking, kneeling, and crawling was impaired. He reported using a right knee brace for comfort during flare-ups. He had right knee flexion to 90 degrees, left knee flexion to 140 degrees, and bilateral extension to zero degrees. There was no evidence of pain or crepitus in either knee with palpation, weight bearing, or during active or passive range of motion. Repetitive use testing was performed without any additional functional loss in either knee. Muscle strength was 5/5 for flexion and extension in both knees with no evidence of muscle atrophy. Joint stability testing, including Lachman, posterior drawer, medial instability, and lateral instability testing, were normal bilaterally. The examiner indicated that there was no recurrent patellar dislocation or tibial and/or fibular impairment in either knee. He was noted to have a right knee meniscus condition, but the examiner opined that there were no current symptoms. Regarding repeated use, the examiner opined that the Veteran would have an additional loss of 5-10 degrees of flexion in his right knee due to pain and no additional loss in motion in his left knee. Regarding flare-ups, the examiner opined that due to pain, the Veteran would have an additional loss of 10-15 degrees of right knee flexion and 10 degrees of left knee flexion. Regarding additional limitations, the examiner noted that the Veteran had disturbance of locomotion as he was limited to walking approximately one mile. After reviewing the evidence, the Boards finds that a rating in excess of 20 percent for right knee lateral instability have not been met. A disability rating of 30 percent under Diagnostic Code 5257 requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). In the present case, the Veteran’s right knee disability has been manifested by, at most, moderate instability. See September 2016 DBQ (characterizing right knee lateral instability as moderate). While the Veteran reported subjective instability and had objective instability in the form of 1+ Lachman testing, there is no evidence suggesting that the Veteran’s right knee lateral instability more nearly approximate severe instability. As such, a rating in excess of 20 percent is not warranted. The Board also considered whether a higher or separate rating was warranted for limitation of motion any time prior to September 14, 2017. However, the evidence is against finding that the Veteran’s right knee disability was manifested by compensable limitation of motion. Even considering painful motion and flare-ups, the Veteran did not have limitation of motion that more nearly approximated flexion limited to 45 degrees and extension limited to 10 degrees. At worst, he had right knee flexion to 80 degrees and extension to 8 degrees. The Board acknowledges that the September 2016 DBQ from Dr. Rodriguez noted extension to 8 degrees, which exceeds the limitation required for a noncompensable rating. Nevertheless, the other evidence of record consistently indicated that the Veteran had extension between five and zero degrees. See March 2010 VA examination report (noting extension to five degrees); May 2010 VA orthopedic record (noting extension to two degrees); and VA records from June 2015, May 2016, and April 2017 (noting full range of motion). As such, the Board finds that this single instance of extension limited more than five degrees does not support a finding that the Veteran’s extension more nearly approximated extension limited to 10 degrees, which would meet the criteria for a 10 percent rating. Accordingly, the criteria for a compensable rating under Diagnostic Codes 5260 or 5261 have not been met. 38 C.F.R. § 4.71a. As noted above, effective September 14, 2017, the RO increased the 20 percent rating to a 30 percent rating for the Veteran’s right knee disability based on limitation of extension. However, as the Veteran had previously been rated based on symptoms of instability, the proper course of action was actually to grant a separate rating based on limitation of extension when the range of motion supported a compensable rating. Thus, the Board finds that effective September 14, 2017, a separate 30 percent rating is warranted for limitation of extension under Diagnostic Code 5261. The evidence is against finding that a compensable rating for right knee limitation of flexion or a rating in excess of 30 percent for right knee limitation of extension is warranted. Even considering painful motion and flare-ups, the Veteran had, at worst, right knee flexion to 80 degrees and extension to 20 degrees. See e.g., September 2017 VA examination report (noting flexion to 100 degrees and extension to 20 degrees), VA records from March 2018, January 2019, and January 2020 (noting full range of motion); January 2020 VA examination report (noting that with flare-ups the Veteran would have flexion to 80 degrees and extension to zero). Such findings do not support the criteria for increased ratings under Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a. Turning to the Veteran’s left knee disability, for the period prior to September 30, 2016, the Board finds that a rating in excess of 10 percent is not warranted. At no time prior to September 30, 2016 was the Veteran’s left knee disability manifested by flexion limited to 45 degrees or extension limited to 10 degrees. See March 2010 VA examination report (noting left knee flexion to 135 degrees and extension to 5 degrees), June 2013 VA examination report (noting left knee flexion to 110 degrees and extension to zero degrees with an additional 25 degree loss in motion during flare-ups), August 2013 addendum (noting an additional 25 degrees of loss in motion during flare-ups). Accordingly, the criteria for a compensable rating under Diagnostic Codes 5260 or 5261 have not been met. 38 C.F.R. § 4.71a. The Board acknowledges the representative’s assertion that the September 2013 addendum opinion, which clarified the June 2013 VA examiner’s statements regarding functional loss during flare-ups, was inadequate. Specifically, the representative asserted that it was inadequate because the clinician did not examine the Veteran and therefore had “no idea what was actually going on.” See August 2016 Hearing Transcript at 4. While Board acknowledges that the clinician did not physically examine the Veteran, she reviewed the Veteran’s claims file and her opinion, that June 2013 examiner’s 25 degrees estimate referred to flexion and that Veteran would not have additional loss of extension with flare-ups, is consistent with the weight of the VA and private treatment records. See e.g., VA records from May 2010, August 2010, May 2012, July 2012, July 2013, May 2014; April 2011 record from Orthopedic and Fracture Clinic; Dr. Rodriguez records from January 2013 and August 2014; and December 2014 record from Dr. Takahashi (noting extension to 0 degrees and/or full range of motion). Therefore, the Board finds that the September 2013 opinion is adequate and highly probative. As such, the June 2013 VA examiner’s statements cannot reasonably be interpreted as indicating that the Veteran would have compensable limitation of extension during flare-ups. For the period from September 30, 2016 through September 13, 2017, the Board finds that the criteria for a 20 percent rating, but no higher, for limitation of extension has been met. See 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2020). Specifically, Dr. Rodriguez indicated that the Veteran’s left knee extension was limited to 15 degrees. Nevertheless, a compensable rating for limitation of flexion is not warranted as the evidence is against finding that the Veteran had flexion limited to 45 degrees. See e.g., September 2016 DBQ (noting flexion to 108 degrees); April 2017 VA record (noting full range of motion in both knees). From September 14, 2017, the Board finds that a left knee rating in excess of 10 percent has not been warranted. Although the Veteran continued to have painful range of motion, the evidence indicates that he did not have compensable limitation of flexion or extension. Accordingly, a rating in excess of 10 percent is not warranted. See VA records from March 2018, January 2019, and January 2020 (noting full range of motion); January 2020 VA examination report (noting, that even with flare-ups, he had left knee flexion to 130 degrees and extension to zero). The Board also considered whether higher or separate ratings were warranted for either knee under any other diagnostic code. However, there is no probative evidence of ankylosis, dislocated semilunar cartilage with frequent locking and effusion into the joint, symptomatic semilunar cartilage removal with symptoms other than those already contemplated in the ratings presently assigned, malunion or nonunion of the tibia or fibula, or genu recurvatum in either knee. The Board acknowledges that the September 2016 DBQ from Dr. Rodriguez indicated that the Veteran had extremely unfavorable right side ankylosis and favorable left side ankylosis. However, ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). As such, Dr. Rodriguez’s finding of ankylosis is inconsistent with the other evidence of record and his own range of motion findings. Thus, Dr. Rodriguez’s statements regarding ankylosis are not probative. Accordingly, higher or separate ratings under Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not warranted for either knee. The Board has also considered whether the Veteran is entitled to a separate left knee rating under Diagnostic Code 5257 for recurrent subluxation or lateral instability. The Board acknowledges that the September 2016 DBQ from Dr. Rodriguez noted that left side Lachman test testing was 1+. However, in the same DBQ, Dr. Rodriguez indicated that the Veteran did not have left side subluxation or lateral instability. Given the conflicting findings by Dr. Rodriguez and the other medical evidence of record, which consistently indicated that the Veteran did not have left knee subluxation or lateral instability, the Board finds that Dr. Rodriguez’s finding of left knee instability is not probative. As such, the Board finds that a separate rating under Diagnostic Code 5257 is not warranted. See VA examination reports from March 2010, June 2013, September 2017, and January 2020 (noting no recurrent subluxation or lateral instability); April 2011 Orthopedic & Fracture clinic record (noting that varus stress, valgus stress, anterior drawer, posterior drawer, and Lachman testing were all negative on the left side). The Board has also considered whether higher or separate ratings are warranted under the recently revised provisions of Diagnostic Code 5257. 85 Fed. Reg. 76453 (Nov. 30, 2020). The evidence indicates that the Veteran was prescribed a right knee brace. Nevertheless, in the absence of evidence that he was also prescribed an assistive device such as a cane, crutch, or walker, a rating in excess of the currently assigned 20 percent rating is not warranted. Id. Regarding the Veteran’s left knee, as noted above there is no probative evidence of left knee instability or use of a left knee brace. Thus, a separate left knee rating is not warranted under the revised provisions of Diagnostic Code 5257. Id. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against ratings in excess of those assigned, that doctrine is not applicable. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990).   REASONS FOR REMAND 1. Entitlement to service connection for a low back condition is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives. The January 2019 remand requested an opinion addressing whether the Veteran’s low back disability was aggravated by his service-connected knee disabilities. While an addendum opinion was obtained in October 2020, the rationale for the opinion did not address aggravation. Accordingly, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, in a December 2020 correspondence, the representative asserted that the Veteran’s knee disabilities precluded a successful exercise program and led to weight gain. As the January 2020 VA clinician stated that chronic obesity was a risk factor for the Veteran’s low back condition, this theory of entitlement is reasonably raised and must be addressed on remand. This matter is REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his low back condition. After securing any necessary releases, request any relevant records identified. In addition, obtain any available updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's low back. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any low back condition was caused by his service-connected knee disabilities, to include any gait disturbance due to the knees. (b.) Whether it is at least as likely as not (50 percent probability or greater) that any low back condition was worsened beyond the natural progress of the condition by the Veteran’s service-connected knee disabilities, to include any gait disturbance due to the knees. If it was worsened beyond the natural progress of the condition, the clinician should attempt to determine the degree of aggravation beyond baseline. (c.) Whether it is at least as likely as not (50 percent probability or greater) that the service-connected knee disabilities caused him to become obese, gain weight, or aggravated his obesity. (d.) If so, state whether the obesity was a substantial factor in causing his low back condition and whether his low back condition would not have occurred or worsened but for the weight gain caused by his service-connected disabilities. The examiner should address the September 2016 statement Dr. Rodriguez indicating that the Veteran’s bilateral knees severely limited his ability to exercise and keep weight off and that his gait has “directly affected his lower back.”   A complete rationale should be provided for all opinions and conclusions expressed. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Anderson 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.