Citation Nr: 21025164 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 13-01 074 DATE: April 27, 2021 ORDER Entitlement to service connection for memory loss, to include as an undiagnosed illness or qualifying chronic disability under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, is dismissed. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome and early degenerative changes in the right knee (hereinafter referred to as a “right knee disability”) is denied. Entitlement to a disability rating in excess of 10 percent for patellofemoral pain syndrome and early degenerative changes in the left knee (hereinafter referred to as a “left knee disability”) is denied. FINDINGS OF FACT 1. There is no longer a case or controversy as to the issue of entitlement to service connection for memory loss as service connection has been granted. 2. For the entire appeal period, the Veteran has right knee arthritis with noncompensable limitation of motion. 3. For the entire appeal period, the Veteran has left knee arthritis with noncompensable limitation of motion. CONCLUSIONS OF LAW 1. The Board lacks jurisdiction over the issue of entitlement to service connection for memory loss as service connection for memory loss was granted, and thus this claim is rendered moot. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 19.7, 20.101, 20.200, 20.202. 2. The criteria for a disability rating in excess of 10 percent for a right knee disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code (DC) 5003. 3. The criteria for a disability rating in excess of 10 percent for a left knee disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.71a, DC 5003. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1990 to December 1996. This case originally came before the Board of Veterans’ Appeals (Board) on appeal from a March 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was most recently before the Board in June 2019, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. In a September 2020 rating decision, the AOJ granted service connection for memory loss, and in a corresponding September 2020 supplemental statement of the case the AOJ continued the denial of service connection for right and left knee disabilities. The case has now been returned to the Board for further appellate consideration. The Veteran did not request a hearing before the Board. See 1/7/13 Statement in lieu of VA 646. The Veteran contended in his January 2018 brief that assignment of noncompensable initial ratings for his right and left knee disabilities was clearly and unmistakably erroneous. However, this contention never adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b). Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Dismissal of the Memory Loss Service Connection Claim The Veteran most recently filed a petition to reopen the service connection claim for Gulf War Syndrome, to include headaches, memory loss, fatigue, muscle and joint pain, and sleep disturbance, in June 2010. The RO reopened and denied the claim in a March 2011 rating decision. In his June 2011 Notice of Disagreement (NOD), the Veteran included Gulf War Syndrome to include memory loss as a specific issue of disagreement. The Board reopened and remanded the Gulf War Syndrome claim in March 2018, and then remanded specifically the memory loss claim again in June 2019. Subsequently, in September 2020, the RO granted service connection for memory loss. As the claim for service connection for memory loss has been resolved by a full grant of benefits, the Board finds that this issue is no longer on appeal. See 38 C.F.R. § 19.26(d). The Board notes that the Veteran has not appealed the initial rating or effective date assigned at this point. Therefore, the Veteran’s claim for service connection for memory loss has been rendered moot by the grant of the claim by the RO in September 2020. The Board lacks jurisdiction over the issue, and it is dismissed. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 19.7, 20.101, 20.200, 20.202. Increased Rating Claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion (ROM) testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, supra. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to disability ratings in excess of 10 percent for right and left knee disabilities The Veteran contends that increased ratings are warranted for his right and left knee disabilities as there has been a worsening. See June 2010 statement; June 2011 NOD. He also appears to assert that increased ratings are warranted based on extraschedular consideration and that separate ratings are warranted under different diagnostic codes. See March 2016 statement in lieu of a VA Form 646. As the evidence in support of the separate right and left knee disability claims is largely the same, the Board will adjudicate both issues together. Law In this case, the Veteran’s right and left knee disabilities are each evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5260 and Diagnostic Code 5260, respectively. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. As such, the Veteran’s right knee disability under DC 5003 is rated under DC 5260 based on limitation of flexion of the leg. However, given that the Veteran’s 10 percent ratings are based on noncompensable painful motion of the knee, DC 5003 is appropriate for both the right and left knee disabilities. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021, the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to February 7, 2021, Diagnostic Code 5003 provided that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. However, when there is some limitation of motion of the specific joint or joints involved that is noncompensable under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added, under DC 5003. A 20 percent rating is authorized if there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Any limitation of motion must be confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. For these purposes, VA regulations consider the knees to be major joints. 38 C.F.R. § 4.45(f). As of February 7, 2021, Diagnostic Code 5003 is only changed in that it now applies exclusively to degenerative arthritis that is not post-traumatic. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg, and remains unchanged in the amended code. Flexion of the leg limited to 15 degrees is rated 30 percent, flexion of the leg limited to 30 degrees is rated 20 percent, flexion of the leg limited to 45 degrees is rated 10 percent, and flexion of the leg limited to 60 degrees is rated as noncompensable. Diagnostic Code 5261 also remains unchanged under the amended code. Under Diagnostic Code 5261 for limitation of extension of the knee, a 50 percent rating is warranted where extension is limited to 45 degrees, a 40 percent rating is warranted where extension is limited to 30 degrees, a 30 percent rating is warranted where extension is limited to 20 degrees, a 20 percent rating is warranted where extension is limited to 15 degrees, a 10 percent rating is warranted where extension is limited to 10 degrees, and a noncompensable rating is warranted where extension is limited to 5 degrees. Separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for limitation of flexion and limitation of extension of the same knee joint. See VAOPGCPREC 9-2004 (September 17, 2004). Normal range of motion of the knee is to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Separate disability ratings are possible for limitation of knee motion and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97 (July 1, 1997). When x-ray findings of arthritis are present and a veteran’s knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98 (August 14, 1980; see also Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Prior to the regulatory change, Diagnostic Code 5257 addressed recurrent subluxation or lateral instability of the knee. Under that code, a 30 percent rating was warranted where subluxation or lateral instability was severe. A 20 percent rating was warranted where subluxation or lateral instability was moderate. A 10 percent rating was warranted where subluxation or lateral instability was slight. The Board observes that the terms “unstable” and “instability” are general and can have many meanings depending on context, including instability in the normal plane of motion of the joint (weakness, giving way). Ratings based on limitation of motion, including weakness, incoordination, fatigue, etc., reasonably contemplate this type of instability. “Lateral” instability is a specific type of instability that is demonstrated by clinical testing, such as varus and valgus stress, Lachman, Drawer, and McMurray, and which under VA law is not contemplated in a rating based on limited motion. Additionally, the Board notes that words such as “slight,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. The first is for recurrent subluxation or instability and the second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating under the amended criteria requires persistent instability. Id.; see also 38 C.F.R. § 4.31. “Persistent” is defined as “continuing or inclined to persist in a course” with “continuing” defined as “constant” and “persist” defined as “to continue to exist.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). Under the amended criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (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, or (b) 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 10 percent rating is assigned for 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. Lastly, regarding patellar instability, 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 warrants a 30 percent rating, which is the highest allowable rating for patellar instability. 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 warrants a 20 percent rating. 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 warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). 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., Note (2). Diagnostic Code 5258 rates on the basis of dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. A 20 percent rating is the only rating available under that code. Diagnostic Code 5259 rates on the basis of symptomatic removal of the semilunar cartilage. A 10 percent rating is the only rating available under that code. Evidence In his June 2010 statement, the Veteran reported that it had become more difficult to continue and maintain regular daily activities. He detailed that he was regularly using a cane to assist with ambulation and was trying to get braces for his knees. A February 2011 VA examination report reflects that the Veteran was diagnosed with patellofemoral syndrome and mild degenerative joint disease (DJD) of the right knee. He reported stiffness and pain that had intensified since the last rating. Occasionally, the right knee would buckle, which was why he used a cane in the right hand. He reported swelling and flare-ups approximately twice a week. He reported increased pain, stiffness, and morning stiffness bilaterally. His right knee flared up with activity, while his left knee flared up with activity and prolonged activity. On examination, there was no swelling or tenderness bilaterally. All stability tests were negative. ROM testing for the right knee revealed flexion to 124 degrees and extension to 0 degrees with no additional limitations after repetitive use testing or due to additional fatigue, endurance, incoordination, or restriction. ROM testing for the left knee revealed flexion to 132 degrees and extension to 0 degrees; after repetitive use testing, his flexion was limited to 130 degrees. He had crepitance with palpation of the right knee and deep bending. X-rays revealed a tiny patellar spur in the right knee and no abnormalities in the left knee. He was diagnosed with patellofemoral syndrome of the bilateral knees. An April 2016 VA treatment record reflects a complaint of right knee pain and weakness. The Veteran reported knee pain “for years” that was intermittent bilaterally. However, his right knee had been troublesome in recent months with pain in the back of the knee and frequent “giving way” sensations, although he had not fallen from his knee buckling. He described pain “behind the knee cap” and reported some “grinding.” On examination, he had mild joint effusion and tenderness with palpation of the patella and joint line medially. He could actively flex and extend the knee without difficulty or discomfort, although he had mild crepitus. The Lachman’s, anterior drawer, Apley’s, and McMurray’s tests were all negative. He had no laxity with varus or valgus stress. January 2016 x-rays revealed no evidence of fracture or dislocation, mild narrowing of the bilateral medial femorotibial compartment unchanged from a prior study, and no evidence of large osteophytic spurring or right suprapatellar effusion. He was assessed with right knee femorotibial joint arthritis. June 2018 and October 2018 VA treatment records reflect knee pain for several years. The Veteran was noted to wear a right knee hinged brace and was assessed with osteoarthritis of the knees. A January 2019 VA examination report reflects that the chosen examiner reviewed the Veteran’s claims file and set forth a diagnosis of bilateral patellofemoral pain syndrome. The Veteran reported that he continued to have chronic daily knee ache that was greater on the right than the left. He also had flare-ups with increased pain when he did a lot of bending, twisting, or standing. He wore knee braces for extra support and denied that he underwent any prior knee surgeries. He had a small right anterior knee effusion and full ROM bilaterally. Specifically, ROM testing revealed flexion to 140 degrees and extension to 0 degrees bilaterally. Pain was noted with flexion and extension in the right knee that caused functional loss, and only with extension in the left knee that did not result in or cause functional loss. There was no evidence of pain on passive ROM testing or when the joint was used in nonweight-bearing. There was evidence of pain with weight-bearing and objective evidence of localized tenderness on palpation at the right anterior knee. There was objective evidence of crepitus bilaterally. Repetitive use testing did not result in additional functional loss or ROM bilaterally. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time or during flare-ups as symptoms and ROM changes could not be objectively quantitated without resorting to mere speculation. He had normal muscle strength with no muscle atrophy or ankylosis. The Veteran did not have a history of recurrent subluxation or lateral instability, and the examiner did not note a history of recurrent effusion. All joint stability tests were normal bilaterally. The Veteran did not have a meniscal condition, or any surgical procedures. He did not use any assistive devices as a normal mode of locomotion. A February 2019 VA treatment record noted that January 2019 x-rays of the knees demonstrated early degenerative changes. In September 2019, he was assessed with bilateral knee osteoarthritis. The November 2019 VA addendum opinion reflects that the examiner reviewed the electronic medical records, including but not limited to the January 2019 VA examination report. The examiner noted that, although the Veteran subjectively reported increased pain with repeated use over time and during a flare-ups, he was not measured after such repeated use over time or flare-up, and there were no entries in the medical record notifying reported ROM after repeated use over time or during a flare-up. Therefore, de facto speculation was required for estimating ROM after repeated use over time or during a flare-up. Given that there was unlikely to be loss of ROM after repeated use or during a flare-up of patellofemoral pain syndrome, it was reasonable to speculatively posit that there was no actual loss of functional ROM after repeated use or during a flare-up despite the increased pain. The examiner noted that the information given was based solely on a review of the records and knowledge of the natural history and behavior of patellofemoral pain syndrome. In a March 2021 brief, the Veteran contended that the January 2019 VA examination report and the February 2020 were inadequate as the examiner stated that he was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time during flare-ups or with repeated use over time. The Veteran asserted that the addendum opinion was insufficient and failed to comply with the remand instructions to provide rationale if he was unable to provide an opinion without resorting to speculation with specific consideration of the VA Clinicians Guide instructions to estimate per the Veteran to what extent, if any, flare-ups affect functional impairment. Analysis Based on all of the evidence of record, the Board finds that the severity of the Veteran’s right and left knee disabilities most closely approximates the currently assigned 10 percent ratings under Diagnostic Code 5003 as the evidence of record demonstrates noncompensable limitation of motion due to arthritis with no incapacitating exacerbations. Additionally, the evidence does not demonstrate that ratings in excess of 10 percent are warranted under Diagnostic Code 5260 as flexion is not limited to 30 degrees. In fact, the evidence reflects noncompensable limitation in flexion from 124 degrees to 140 degrees in the right knee, and from 130 degrees to 140 degrees in the left knee. Therefore, although the Veteran had limitation in motion, especially after considering pain and repeated use, the Veteran’s flexion and extension were not so limited so as to warrant even compensable ratings under Diagnostic Code 5260. The Board does acknowledge that not all range of motion testing during this period complied with Correia v. McDonald, 28 Vet. App. 158 (2016). Specifically, the January 2019 VA examiner noted pain with flexion that caused functional loss in the right knee but failed to state at what point it began. Regardless, there is no indication that the Veteran’s limitation in flexion was so severe so as to approximate a limitation to only 30 degrees and thus warrant disability ratings in excess of 10 percent. Therefore, higher ratings are not warranted under Diagnostic Code 5260 for limitation in flexion. The evidence also does not demonstrate that increased ratings or separate compensable ratings are warranted under Diagnostic Code 5261 as extension is not limited in either knee. In fact, the evidence reflects normal extension bilaterally. As stated above, despite not all range of motion testing complying with Correia, there is no indication that the any limitation in extension was so severe as to approximate even 10 degrees. In fact, the Veteran exhibited normal extension bilaterally during the February 2011 VA examination and normal extension with pain bilaterally on the January 2019 VA examination. However, the examiner who provided the November 2019 VA addendum opined that the Veteran was unlikely to exhibit any additional loss of range of motion after repeated use or during flare-ups based on the natural history and behavior of patellofemoral pain syndrome. Therefore, the remaining evidence does not demonstrate extension that is so limited as to warrant separate compensable ratings under Diagnostic Code 5261. The Board has considered whether there is functional loss caused by pain, weakness, and other factors, in evaluating the Veteran’s right and left knee disabilities. 38 C.F.R. §§ 4.40, 4.45; see DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Despite the inadequate VA examination reports discussed above, the evidence does not reflect that flexion or extension is so limited as to warrant increased ratings or separate ratings under Diagnostic Code 5260 or 5261. The Board acknowledges the Veteran’s contentions in his March 2021 brief that the January 2019 VA examination report was inadequate and that the November 2019 VA addendum opinion was insufficient and failed to comply with the Board’s prior remand instructions. While the January 2019 VA examiner failed to consider the Veteran’s statements in describing any functional impairment and limitation in motion due to pain, weakness, fatigability, or incoordination, the Veteran had full range of motion on examination, despite pain with flexion and extension of the right knee and pain with weight-bearing. The remaining evidence does not reflect such additional limitation in flexion or extension in order to warrant disability ratings in excess of 10 percent or separate ratings. In fact, the February 2011 VA examiner found that the Veteran had no additional limitations due to additional fatigue, endurance, incoordination, or restriction; and the April 2016 VA treatment record reflects active flexion and extension of the right knee without difficulty or discomfort. Additionally, as discussed above, the VA examiner who provided the November 2019 VA addendum explained that, based on the history and behavior of patellofemoral pain syndrome, it was unlikely to be loss of ROM after repeated use or during flare-up of patellofemoral pain syndrome. Therefore, it was reasonable to speculatively posit that there was no actual loss of functional ROM after repeated use or during a flare-up despite the increased pain. Additionally, the Board finds that the November 2019 VA examiner substantially complied with the Board’s prior remand. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999)). Although the examiner only noted to have reviewed the Veteran’s electronic medical records, there was no other document that provided additional evidence of limitation in motion or functional impairment after repeated use or during flare-ups. Moreover, the examiner explained that there were no entries in treatment records reflecting the Veteran’s reported ROM after repeated use over time or during a flare-up. The examiner also discussed that, based on the natural history and behavior of patellofemoral pain syndrome, it was “reasonable to speculatively posit that there was no actual loss of functional ROM after repeated use or during a flare-up despite the increased pain.” In summary, the Board finds that the weight of the evidence is against disability ratings in excess of 10 percent for the Veteran’s right and left knee disabilities. Other Considerations Furthermore, the April 2016 VA treatment record reflects a complaint of weakness and frequent sensations of “giving way.” The Board acknowledges the Veteran’s reports of “giving way” and instability. However, despite his subjective complaints, the objective medical evidence demonstrates that he had normal joint stability tests. As stated above, “lateral” instability considered under the old version of Diagnostic Code 5257 is a specific type of instability that is demonstrated by clinical testing. Regarding the version of Diagnostic Code 5257 in effect since February 7, 2021, a separate rating for recurrent subluxation or instability is not warranted because the evidence does not reflect that the Veteran had a sprain, incomplete ligament tear, or complete ligament tear causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation. Rather, the evidence does not reflect a sprain or ligament tear of any severity. A separate rating based on patellar instability is also not warranted as the evidence does not reflect a diagnosed condition involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon) with recurrent instability that does not require a prescription from a medical provider for a brace, cane, or walker. Only the April 2016 VA treatment record reflects a report of “giving way” and weakness. The remaining evidence as of February 7, 2021, does not reflect recurrent complaints of any similar symptoms. The Board has considered the applicability of other diagnostic codes pertaining to knee disabilities but finds that there are none which would provide higher or separate ratings for which the appropriate symptomatology is shown. In other words, there is no evidence of record of knee ankylosis (Diagnostic Code 5256), dislocation or removal of the semilunar cartilages (Diagnostic Codes 5258 and 5259), impairment of the tibias and fibulas (Diagnostic Code 5262), or genu recurvatum (Diagnostic Code 5263). Additionally, in his March 2016 statement in lieu of a VA Form 646, the Veteran asserted that increased ratings, including in the form of extraschedular ratings, were warranted. Therefore, the Board has considered whether the Veteran’s service-connected right and left knee disabilities present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant’s disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. All three criteria must be met. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (“[R]ating schedule will apply unless there are ‘exceptional or unusual’ factors which render application of the schedule impractical.”). The Board compared carefully the level of severity and symptomatology of the Veteran’s service-connected right and left knee disabilities with the established criteria found in the rating schedule. The Board finds that the symptoms associated with the service-connected right and left knee disabilities addressed in this decision are fully addressed by the rating criteria under which such disabilities are rated. Indeed, the ratings currently assigned for the disabilities contemplate the overall functional loss from the symptomatology attributable to the Veteran’s right and left knee disabilities, as detailed above. There are no other symptoms that are not considered or fully addressed by the rating criteria. Therefore, based on evidence of record, the Board determines that referral for consideration of an extraschedular rating is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). C. M. Collins Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Lee, Associate 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.