Citation Nr: 21025980 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-32 952 DATE: April 29, 2021 ORDER A disability greater than 20 percent prior to November 11, 2019 and greater than 30 percent beginning February 1, 2020 for rotator cuff tendinopathy, right shoulder, with arthritis of the acromioclavicular joint and biceps tendonitis (non-dominant), exclusive of the time period from November 11, 2019 to January 31, 2020 where a temporary total rating has been assigned, is denied. A disability rating greater than 10 percent prior to October 14, 2019 and greater than 40 percent thereafter for degenerative joint disease, lumbar spine, is denied. A disability rating greater than 10 percent for patellofemoral pain syndrome, left knee, is denied. FINDINGS OF FACT 1. The Veteran is left hand dominant. 2. Prior to November 11, 2019 the Veteran’s right shoulder disability was manifested by, at worst, flexion to 50 degrees, abduction to 40 degrees, external rotation to 5 degrees, and internal rotation to 70 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups.  There was no evidence of ankylosis of the scapulohumeral articulation; malunion of the humerus, or malunion of the major clavicle or scapula or nonunion without loss movement.  3. Beginning February 1, 2020 the Veteran’s right shoulder disability has been manifested by, at worst, flexion to 20 degrees, abduction to 35 degrees, external rotation to 30 degrees, and internal rotation to 30 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups. There was no evidence of ankylosis of the scapulohumeral articulation; malunion of the humerus, or malunion of the major clavicle or scapula or nonunion without loss movement.  4. Prior to October 14, 2019, the Veteran’s lumbar spine disability was manifested by, at worst, forward flexion to 80 degrees, extension to 30 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 25 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups. There was no evidence of ankylosis or severe IVDS with incapacitating episodes. 5. Beginning October 14, 2019, the Veteran’s lumbar spine disability has been manifested by, at worst, forward flexion to 5 degrees, extension to 5 degrees, right lateral flexion to 5 degrees, left lateral flexion to 5 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 5 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups. There is no evidence of ankylosis or severe IVDS with incapacitating episodes. 6. Throughout the appeal period, the Veteran’s left knee disability has been manifested by, at worst, flexion to 70 degrees and extension to 0 degrees, even in contemplation of functional loss due to pain and other factors, or as a result of repetitive motion or flare-ups.  There is no demonstration of ankylosis, lateral instability or recurrent subluxation, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. Prior to November 11, 2019, the criteria for a disability rating greater than 20 percent for rotator cuff tendinopathy, right shoulder, with arthritis of the acromioclavicular joint and biceps tendonitis (non-dominant) were not met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.25, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5010-5201.  2. Beginning February 1, 2020, the criteria for a disability rating greater than 30 percent for rotator cuff tendinopathy, right shoulder, with arthritis of the acromioclavicular joint and biceps tendonitis (non-dominant) are not met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.25, 4.40, 4.45, 4.71a, DCs 5010-5201. 3. Prior to October 14, 2019, the criteria for a disability rating greater than 10 percent for degenerative joint disease, lumbar spine were not met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.25, 4.40, 4.45, 4.71a, DC 5242. 4. Beginning October 14, 2019, the criteria for a disability rating greater than 40 percent for degenerative joint disease, lumbar spine are not met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.25, 4.40, 4.45, 4.71a, DC 5242. 5. The criteria for a disability rating greater than 10 percent for patellofemoral pain syndrome, left knee are not met.  38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260.  REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1989 to August 2000. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) which continued a 20 percent disability rating for the Veteran’s right shoulder disability, continued a 10 percent disability rating for the Veteran’s lumbar spine disability, and continued a 10 percent disability rating for the Veteran’s left knee disability. The Veteran testified before the undersigned at a Travel Board hearing in June 2015. A transcript of the hearing is of record. This case was previously before the Board in February 2019 at which time it was remanded for additional development. Notably, in a May 2016 rating decision the RO reduced the disability rating for the Veteran’s service-connected right shoulder disability from 20 to 10 percent disabling, effective August 1, 2016. Subsequently, in a March 2020 rating decision the RO granted a temporary total rating for the Veteran’s right shoulder disability effective November 11, 2019 pursuant to 38 C.F.R. § 4.30 based on convalescence following surgery and continued the previously assigned 10 percent disability rating effective February 2, 2020. Most recently, by rating decision dated in July 2020, the RO reinstated the 20 percent disability rating for the Veteran’s right shoulder effective August 18, 2000 and increased the disability rating for the shoulder to 30 percent effective February 1, 2020. The RO also increased the disability rating for the Veteran’s lumbar spine from 10 to 40 percent effective October 14, 2019 and also granted service connection for right lower radiculopathy due to the Veteran’s lumbar spine disability, also effective October 14, 2019. As these increases did not represent a full grant of the benefits sought, the Veteran’s appeal has not been abrogated and the matters regarding the right shoulder and lumbar spine remain in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). General Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability.  Separate diagnostic codes identify the various disabilities.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.   If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria for the higher rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran.  38 C.F.R. § 4.3.   A veteran’s entire history is to be considered when assigning disability ratings.  38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).  The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal.  Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007).   38 C.F.R. § 4.40 notes that disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance.  Functional loss may be due to the 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 the visible behavior of the claimant undertaking the motion.  38 C.F.R. § 4.40.   38 C.F.R. § 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly).  38 C.F.R. § 4.45.   The United States Court of Appeals for Veterans Claims (Court) has held that when a diagnostic code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain “on use or due to flare-ups.”  DeLuca v. Brown, 8 Vet. App. 202, 206 (1995).   Also, the Court has held that “to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of” 38 C.F.R. § 4.59.  See Correia v. McDonald, 28 Vet. App. 158 (2016).  38 C.F.R. § 4.59 states that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” As such, pursuant to Correia, an adequate VA joints examination must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and nonweight-bearing conditions. Effective February 7, 2021, several changes to the diagnostic codes used for rating musculoskeletal disabilities were made.  See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020).  When a law or regulation changes after a claim has been filed or reopened, but before the administrative or judicial appeals process has been concluded, the version of the law or regulation most favorable to the appellant generally applies.  Only the former criteria can be applied for the period prior to the effective date of the new criteria.  However, both the old and new criteria can be applied as of that date.  See VAOPGCPREC 7-2003 (Nov. 19, 2003); see also 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114.  While the Veteran has not yet been notified of all applicable regulatory changes and considered his claim under such regulations, the Board notes that the rating criteria prior to February 7, 2021 pertaining to the shoulders, lumbar spine, and knees are significantly more favorable to the Veteran.  As such, there is no prejudice to the Veteran in the Board considering the claims at this time. 1. A disability greater than 20 percent prior to November 11, 2019 and greater than 30 percent beginning February 1, 2020 for rotator cuff tendinopathy, right shoulder, with arthritis of the acromioclavicular joint and biceps tendonitis (non-dominant), exclusive of the time period where a temporary total rating has been assigned, is denied. The Veteran seeks a higher disability rating for his service-connected rotator cuff tendinopathy, right shoulder, with arthritis of the acromioclavicular joint and biceps tendonitis (non-dominant).  By way of history, the Veteran’s service treatment records show that he was involved in a motorcycle accident and injured his right shoulder in 1995. He submitted an initial claim for service connection for a right shoulder disability in August 2000 and, by rating decision dated in September 2001, the RO granted service connection for right shoulder rotator cuff tear with impingement, assigning a 10 percent disability rating effective August 18, 2000. Subsequently, by rating decision dated in June 2003, the RO increased the Veteran’s disability rating for the right shoulder from 10 to 20 percent disabling, also effective August 18, 2000. The Veteran submitted the current claim for an increased for the right shoulder in September 2012 and, as above, by rating decision dated in November 2012, the RO continued a 20 percent disability rating for the Veteran’s right shoulder disability. The Veteran disagreed with this decision and perfected this appeal. Subsequently, in a May 2016 rating decision the RO reduced the disability rating for the Veteran’s right shoulder from 20 percent to 10 percent disabling, effective August 1, 2016. Thereafter, in a March 2020 rating decision the RO granted a temporary total rating for the Veteran’s right shoulder disability effective November 11, 2019 pursuant to 38 C.F.R. § 4.30 based on convalescence following a November 11, 2019 right shoulder surgery and continued the previously assigned 10 percent disability rating effective February 2, 2020. Most recently, by rating decision dated in July 2020, the RO reinstated the 20 percent disability rating for the Veteran’s right shoulder effective August 18, 2000 and increased the disability rating for the shoulder to 30 percent effective February 1, 2020.   The Veteran’s rotator cuff tendinopathy, right shoulder, with arthritis of the acromioclavicular joint and biceps tendonitis (non-dominant) is currently rated under 38 C.F.R. § 4.71a, DCs 5010-5201. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned.  38 C.F.R. § 4.27.  Prior to February 7, 2021, DC 5010 pertained to traumatic arthritis which was rated as degenerative arthritis under DC 5003. Pursuant to DC 5003, degenerative or traumatic 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. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a , DCs 5003, 5010. Beginning February 7, 2021, under DC 5010 provides that post-traumatic arthritis is rated under limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Prior to February 7, 2021, under DC 5201 (pertaining to limitation of motion of the arm), limitation of motion at shoulder level warrants a 20 percent rating for both the major and minor arms.  With limitation of the arm midway between side and shoulder level, a 30 percent rating is warranted for the major arm and a 20 percent rating is warranted for the minor arm.  With limitation of the arm to 25 degrees from the side a 40 percent rating is warranted for the major arm and a 30 percent rating is warranted for the minor arm.   Beginning February 7, 2021, under DC 5201, limitation of motion at shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent for both the major and minor arms.  With limitation of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) a 30 percent rating is warranted for the major arm and a 20 percent rating is warranted for the minor arm.  With limitation of the arm to 25 degrees from the side a 40 percent rating is warranted for the major arm and a 30 percent rating is warranted for the minor arm. For VA purposes, normal range of shoulder motion is: forward elevation (flexion) 0 to 180 degrees; shoulder abduction 0 to 180 degrees; internal rotation 0 to 90 degrees; and external rotation 0 to 90 degrees.  Lifting the arm to shoulder level is lifting it to 90 degrees.  See 38 C.F.R. § 4.71, Plate I.  Evidence relevant to the current level of severity of the Veteran’s right shoulder disability includes VA shoulder examinations dated in October 2012, March 2015, and January 2020.  During the October 2012 VA examination, the examiner diagnosed right rotator cuff tendinopathy, bilateral acromioclavicular arthritis, and right biceps tendonitis. At that time, the Veteran reported injuring his right shoulder in a motorcycle accident in 1996 and reinjuring it again in 1999. Since then, the Veteran experienced sharp pain in the right shoulder with raising his arm over his head or out to the side. He had tried to do push-ups but experienced increased pain. It was noted that the Veteran was left hand dominant. The Veteran denied experiencing flare-ups. On range of motion testing of the right shoulder, the Veteran had flexion to 130 degrees and abduction to 120 degrees. The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. There was functional loss/impairment of the right shoulder, described as less movement than normal and pain on movement. There was localized tenderness or pain to palpation as well as guarding of the right shoulder. Muscle strength testing was slightly abnormal (4/5) for right shoulder abduction and normal for right shoulder forward flexion. There was no ankylosis. Testing for rotator cuff conditions revealed positive Hawkins’ Impingement and Lift-off subscapularis tests for the right shoulder. There was a history of mechanical symptoms for the right shoulder but no history of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint. Crank apprehension and relocation test was negative. There was no acromioclavicular (AC) joint condition or any other impairment of the clavicle or scapula but there was tenderness on palpation of the AC joint and cross-body adduction test was positive for both shoulders. There was no history of total shoulder joint replacement. There were no scars but it was noted that the right shoulder was tender over the biceps an tendon insertion. There was no functional impairment of an extremity such that no effective function remained, other than that which would be equally well served by an amputation with prosthesis. Diagnostic imaging revealed arthritis. The examiner noted that the Veteran’s bilateral shoulder disabilities impacted his ability to work in that the Veteran had difficulty with physical activities but had switched to a desk job which did not both him so much. During the March 2015 VA examination, the examiner noted diagnoses of right bicipital tendonitis, bilateral rotator cuff tear, bilateral glenohumeral joint osteoarthritis, and bilateral acromioclavicular joint osteoarthritis.  At that time, the Veteran reported that his right shoulder pain “comes and goes” but that he performed daily stretches. The Veteran reported that he could not go past 100 degrees of flexion and that he experienced sharp pain with raising his arm over his head or out to the side. He noted that “there are good days and bad days.” The Veteran denied any further therapy, workup or surgical repair/debridement. He reiterated that he was left hand dominant and, again, denied experiencing flare-ups of shoulder pain. The Veteran did experience functional loss/impairment of the shoulders, described as decreased range of motion due to pain.    On range of motion testing of the right shoulder, the Veteran had flexion to 130 degrees, abduction to 125 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees. The examiner noted that this loss of motion did contribute to a functional loss in that the Veteran had difficulty and experienced pain doing overhead activities.  There was no evidence of pain with weight bearing but there was objective evidence of crepitus.  The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of motion.  The Veteran was examined immediately after repetitive use over time but the examiner found that neither pain, weakness, fatigability, nor incoordination significantly limited functional ability with repeated use over a period of time. There were no additional factors contributing to disability.  Muscle strength testing was slightly abnormal (4/5) for both right shoulder forward flexion and abduction and there was a reduction in muscle strength but there was no muscle atrophy.  There was no ankylosis. Rotator cuff conditions of both shoulders was suspected due to positive Hawkins’ Impingement and Empty-Can tests. However, no instability, dislocation, nor labral pathology was suspected. It was noted that the Veteran had an AC joint condition, described as bilateral arthritis. This condition affected the Veteran’s range of motion of the shoulder and resulted in tenderness on palpation of the bilateral AC joints. Cross-body adduction testing was positive, bilaterally. There were no conditions or impairments of the humerus, to include loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. There was also no malunion of the humerus with moderate or marked deformity. Other pertinent physical findings included tenderness to palpation over the AC joint and biceps tendon, crepitus at AC joint, guarding noted with PROM, and decreased strength with forward flexion and abduction against resistance. The Veteran did not use an assistive device. There was no functional impairment of an extremity such that no effective function remained, other than that which would be equally well served by an amputation with prosthesis.  Diagnostic testing revealed arthritis and some tearing of the tendons.  The examiner noted that the Veteran’s shoulder disorders did not impact his ability to work.   During the October 2019 VA examination, the examiner noted a diagnosis of rotator cuff tendinopathy, right shoulder, with arthritis of the acromioclavicular joint and biceps tendonitis.  At that time, the Veteran reported that he had previously treated his right shoulder disability with both physical therapy and steroid injections and that he was scheduled to have rotator cuff repair surgery in November 2019. He experienced constant right shoulder pain which he treated with medication as well as ice/heat. It was noted that the Veteran was left hand dominant. Significantly, the Veteran denied experiencing flare-ups of the shoulders and also denied experiencing any functional loss or functional impairment due to his shoulder disabilities. On range of motion testing of the right shoulder, the Veteran had flexion to 60 degrees, abduction to 50 degrees, external rotation to 5 degrees, and internal rotation to 80 degrees. The examiner noted that this loss of motion did not contribute to a functional loss.  There was no evidence of pain with weight bearing but there was evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the anterior deep shoulder. There was also evidence of crepitus.  The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of motion.  The Veteran was not examined immediately after repetitive use over time and the examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time.  Pain significantly limited functional ability with repeated use over a period of time.  This resulted in additional loss of motion, specifically: for the right shoulder, the Veteran had flexion to 50 degrees, abduction to 40 degrees, external rotation to 5 degrees, and internal rotation to 70 degrees. There were no additional factors contributing to disability.  Muscle strength testing was normal and there was no muscle atrophy.  There was no ankylosis. A bilateral rotator cuff condition was suspected, as Hawkins’ Impingement as well as Empty-Can testing was positive. Neither instability, dislocation, nor labral pathology were suspected. While there was an AC joint condition which resulted in tenderness on palpation of the AC joint, this did not affect the Veteran’s range of motion of the right shoulder. Cross-body adduction testing was positive. There were no impairments of the humerus. There were no other pertinent physical findings. The Veteran did not use an assistive device. There was no functional impairment of an extremity such that no effective function remained, other than that which would be equally well served by an amputation with prosthesis.  Diagnostic testing was not performed.  The examiner noted that the Veteran’s shoulder disorders impacted the Veteran’s ability to work in that he was unable to work above shoulder height due to increased right shoulder pain. With regard to Correia, the examiner wrote that there was objective evidence of pain on passive range of motion testing as well as evidence of pain when the joint is used in non-weight bearing. During the January 2020 VA examination, the examiner continued diagnoses of bilateral rotator cuff tear, bilateral degenerative arthritis, as well as rotator cuff tendinopathy of the right shoulder with arthritis of the AC joint. At that time, the Veteran reported that his symptoms had worsened since his last VA examination in October 2019 and that he had had surgery on his right shoulder in November 2019. He was currently in physical therapy a few times each week and had constant, sharp, anterior shoulder pain down to the bicep as well as the superior posterior area. He treated this condition with icing, stretching, Mobic, and physical therapy. It was noted that the Veteran was left hand dominant. The Veteran reported experiencing flare-ups of the shoulders, described as severe pain of the anterior shoulder down to the bicep as well as the superior posterior area which lasts a few days. He is careful with range of motion and how he sleeps and has activity level was “way down.” The Veteran also reported experiencing functional loss/impairment in that he was no longer able to hunt, hike, fish, or tie his shoes. On range of motion testing of the right shoulder, the Veteran had flexion to 20 degrees, abduction to 35 degrees, external rotation to 30 degrees, and internal rotation to 30 degrees. The examiner noted that this loss of motion contributed to a functional loss.  There was evidence of localized tenderness or pain on palpation of the joints or associated soft tissue, described as tenderness to palpation of the anterior shoulder of a moderate severity. There was no evidence of pain with weight bearing but there was evidence of crepitus.  The Veteran was unable to perform repetitive-use testing with at least three repetitions due to fear of pain.  The Veteran was not examined immediately after repetitive use over time and the examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time.  Pain, weakness, fatigability, and lack of endurance significantly limited functional ability with repeated use over a period of time.  This resulted in additional loss of motion, specifically: for the right shoulder, the Veteran had flexion to 20 degrees, abduction to 35 degrees, external rotation to 30 degrees, and internal rotation to 30 degrees. Similarly, the Veteran was not examined during a flare-up, but the examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss during a flare-up.  Pain, weakness, fatigability, and lack of endurance significantly limited functional ability with flare-ups that resulted in additional loss of motion, specifically: for the right shoulder, the Veteran had flexion to 20 degrees, abduction to 35 degrees, external rotation to 30 degrees, and internal rotation to 30 degrees. There were no additional factors contributing to disability.  Muscle strength testing for the right shoulder was described as active movement with gravity eliminated (2/5) and there was no muscle atrophy.  There was no ankylosis. A bilateral rotator cuff condition was suspected but the examiner was unable to perform testing to confirm this. Neither instability, dislocation, nor labral pathology were suspected. Also neither a clavicle, scapula, acromioclavicular joint, and/or sternoclavicular joint condition was suspected. The Veteran did not demonstrate impairment of the humerus. With regard to surgical history, it was noted that the Veteran underwent rotator cuff repair of the right shoulder in November 2019. There were no other pertinent physical findings other than scars, which were neither painful nor unstable and did not have a total area greater than 30 square centimeters. The Veteran did not use an assistive device. There was no functional impairment of an extremity such that no effective function remained, other than that which would be equally well served by an amputation with prosthesis.  Diagnostic testing revealed arthritis.  The examiner noted that the Veteran’s shoulder disorders impacted the Veteran’s ability to work as a fire suppression systems trainer. While the Veteran was able to work from home most days, he had lost two to four weeks of work in the last 12 months due to his right shoulder disability. He was also unable to hunt, bike, fish, or tie his shoes and was undergoing physical therapy a few days per week for his right shoulder due to his recent surgery. With regard to Correia, the examiner wrote that there was objective evidence of pain on passive range of motion testing as well as evidence of pain when the joint is used in non-weight bearing. Also, of record are VA treatment records dated through February 2020.  These records show treatment for the Veteran’s shoulders but are negative for any range of motion findings. There are two periods of time at issue here: prior to November 11, 2019, when the Veteran’s right shoulder disability was evaluated as 20 percent disabling; and beginning February 1, 2020 to the present, while the Veteran’s right shoulder disability has been evaluated as 30 percent disabling. The Board will consider the proper evaluation to be assigned for the entire period on appeal. As for the period of time prior to November 11, 2019, the Board finds that a disability rating greater than 20 percent is not warranted for the Veteran’s right shoulder disability. Significantly, the Veteran’s range of motion did not meet the criteria for a 30 percent rating under DC 5201, as the Veteran had significantly more than 25 degrees of forward flexion.  As above, the October 2012 VA examination report shows flexion to 130 degrees, the March 2015 VA examination shows flexion to 130 degrees, and the January 2020 VA examination shows flexion to 50 degrees. While these ranges of motion were not specified on active versus passive, the examinations otherwise fully address all information required to rate the disability, to include functional loss range of motion, which is a more specific description of the Veteran’s overall functional capabilities.    As for the period of time beginning February 1, 2020, the Board finds that a disability rating greater than 30 percent is not warranted for the Veteran’s right shoulder disability. Significantly, the Board notes that a 30 percent disability rating is the highest rating possible under DC 5201 for the minor/non-dominant arm. There is no evidence that the Veteran has ankylosis of the scapulohumeral articulation to warrant a higher rating under DC 5200 (ankylosis of the scapulohumeral articulation). 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 above, the Veteran had at least some motion in his right shoulder during all four VA examinations. Finally, a higher rating under DC 5202 requires recurrent dislocation of the scapulohumeral joint. However, there was no indication of such in any of the above VA examination reports. Finally, while there is evidence of arthritis in the right shoulder, pursuant to DC 5010, arthritis due to trauma and substantiated by X-ray findings is to be evaluated based on the limitation of motion of the joint. There is also no evidence of malunion of the humerus, or malunion of the major clavicle or scapula or nonunion without loss movement.  Therefore, there is no basis for a higher schedular rating under either 5201, 5202, or 5203.   The Board accepts that the Veteran has functional impairment, pain, and pain on motion (see DeLuca) and finds the Veteran’s own reports of symptomatology to be credible.  However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher rating.  The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned ratings for each shoulder are warranted and no more.   The Veteran denied experiencing flare-ups prior to the most recent examination in 2020. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court stated that flare-ups must be considered in providing an estimate of additional functional loss based on range of motion. The 2020 examiner gave an estimate of additional loss during flare-ups or after repeated use over time, and the Veteran is in receipt of the highest rating since November 2019. In sum, the evidence of record reflects that the Veteran’s symptomatology for the right shoulder disability warrants no more than the disability ratings assigned.  The Board finds that no higher rating can be assigned pursuant to any other potentially applicable diagnostic code.  As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied.  See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 49. 2. A disability rating greater than 10 percent prior to October 14, 2019 and greater than 40 percent thereafter for degenerative joint disease, lumbar spine, is denied. The Veteran seeks a higher disability rating for his service-connected lumbar spine disability.  By way of history, the Veteran’s service treatment records show incidents of low back pain in January 1993, due to heavy lifting, and again in October 1996 with physical therapy. He submitted an initial claim for service connection for a lumbar spine disability in May 2004 and, by rating decision dated in November 2008, the RO granted service connection for degenerative joint disease of the lumbar spine, assigning a 10 percent disability rating effective May 27, 2004. The Veteran submitted the current claim for an increased for the lumbar spine disability in September 2012 and, as above, by rating decision dated in November 2012, the RO continued a 10 percent disability rating for the Veteran’s lumbar spine disability. The Veteran disagreed with this decision and perfected this appeal. Subsequently, by rating decision dated in July 2020, the RO increased the disability rating for the Veteran’s lumbar spine from 10 to 40 percent effective October 14, 2019 and also granted service connection for right lower radiculopathy due to the Veteran’s lumbar spine disability, also effective October 14, 2019. Spine disabilities may be evaluated under either of two general rating formulas.  One applies to IVDS, and is based upon the duration of incapacitating episodes.  The other general rating formula involves the General Rating Formula for Diseases and Injuries of the Spine.   Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating will be assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent of more of height.   A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.   A 40 percent rating requires evidence of forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine.  A 50 percent rating will be assigned with evidence of unfavorable ankylosis of the entire thoracolumbar spine.  A 100 percent rating requires evidence of unfavorable ankylosis of the entire spine.   Pertinent to this appeal, Note (1) of the rating schedule indicates that the agency is to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.  Also, from Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.  Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.   Alternatively, the Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted when there are incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent rating is warranted when there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; and a 40 percent rating is warranted when there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months.  A 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months.  An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.  38 C.F.R. § 4.71a, DC 5243, Note (1).  Beginning February 7, 2021, DC 5243 (pertaining to IVDS) is only used when there is disc herniation with compression and/or irritation of the adjacent nerve root. DC 5242 is used for all other disc diagnoses. Evidence relevant to the current level of severity of the Veteran’s lumbar spine disability includes VA lumbar spine examinations dated in October 2012, October 2019, and January 2020.  During the October 2012 VA examination, the examiner continued a diagnosis of degenerative joint disease of the lumbar spine. At that time, the Veteran reported that his back had “gone out” on him two to four times in the past year which was an increase from the past when this would only happen once per year. In March, he was doing laundry when his back went out. He was taken to the hospital and was off work for two weeks. He went through three to four treatments with his chiropractor and then underwent physical therapy, where he did traction three to four times. Only after all of this was he able to bend over completely. The pain was mostly on the left side of his back. When his back went out in March, he had some dull numbing sensation to his bilateral thighs for four to five days but, after physical therapy, this went away. He iced his back and stretched it daily. His previous job was physically intense but his new job was less intense. Since March, his back does not “feel right.” It does not hurt but it always seems to be on the verge of going out again. The Veteran denied experiencing flare-ups of the lumbar spine. On range of motion testing, the Veteran had flexion to 80 degrees, extension to 30 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 25 degrees. The Veteran was able to perform repetitive-use testing with three repetitions and no additional loss of motion. There was functional loss/impairment of the spine, described as less movement than normal and pain on movement. There was localized tenderness or pain to palpation, specifically the spinous process T11, L5, paraspinal muscles on the right side at T11 and L5, and swelling of the right side paraspinal muscles at around T11. There was also guarding/muscle spasm but this did not result in abnormal gait or spinal contour. Muscle strength testing was normal and there was no muscle atrophy. Reflex and sensory examination was normal and straight leg raising testing was negative. There were no signs or symptoms due to radiculopathy. There were no other neurologic abnormalities. The examiner noted that the Veteran did not have IVDS. The Veteran did not use any assistive devices to aid with locomotion. There was no functional impairment of an extremity such that no effective function remained, other than that which would be equally well served by an amputation with prosthesis. There were no other pertinent physical findings. Diagnostic imaging revealed arthritis, but there was no vertebral fracture. The examiner noted that the Veteran’s lumbar spine disability impacted his ability to work in that the Veteran had to change jobs from maintaining fire hydrants, which was physically demanding, requiring lifting, bending, reaching, and twisting, and was not working a desk job to accommodate his lumbar spine disability. During the October 2019 VA examination, the examiner diagnosed IVDS as well as lumbar radiculopathy and continued a diagnosis of degenerative joint disease of the lumbar spine.  At that time, the Veteran reported that he had constant low back pain with intermittent pain to the right posterior thigh and that he treated his condition with pain medication, ice, and heat. The Veteran denied experiencing flare-ups of lumbar spine pain and also denied experiencing functional loss/impairment of the lumbar spine.    Range of motion testing revealed forward flexion to 15 degrees, extension to 10 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 15 degrees.  The examiner noted that this loss of motion did not contribute to a functional loss.  There was evidence of pain with weight bearing as well as evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine, specifically of the midline spinal and bilateral paraspinous muscle TTP which was noted to be mild.  The Veteran was able to perform repetitive use testing with at least three repetitions with the following additional loss of motion due to pain: forward flexion to 10 degrees, extension to 10 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to 10 degrees, and left lateral rotation to 10 degrees.  The Veteran was not examined immediately after repetitive use over time and the examiner noted that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time.  Significantly, pain significantly limited functional ability with repeated use over a period of time resulting in the following additional loss of motion: forward flexion to 5 degrees, extension to 5 degrees, right lateral flexion to 5 degrees, left lateral flexion to 5 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 5 degrees. There was guarding/muscle spasm of the thoracolumbar spine but this did not result in abnormal gait or abnormal spinal contour. There were no additional factors contributing to disability.  Muscle strength testing was normal and there was no muscle atrophy.  Reflex and sensory examination were normal and a straight leg raising test was negative.  There was some radiculopathy resulting in mild intermittent pain of the right lower extremity involving the right sciatic nerve, found to be of mild severity. There was no ankylosis of the spine or any other neurologic abnormalities.  The Veteran did have IVDS but there were no episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician in the past 12 months. The Veteran did not use an assistive device to aid in locomotion.  There was no functional impairment of an extremity such that no effective function remained, other than that which would be equally well served by an amputation with prosthesis.  There were no other pertinent physical findings, to include scars.  Diagnostic testing was not performed but the examiner noted that there was no thoracic vertebral fracture with loss of 50 percent or more of height.  The examiner noted that the Veteran’s lumbar spine disorder impacted has ability to work in that the Veteran was unable to sit, stand, or walk for more than five minutes and will need to change positions and stretch. He was also unable to lift more than 10 pounds due to an increase in low back pain.   With regard to Correia, the examiner wrote that there was objective evidence of pain on passive range of motion testing as well as evidence of pain when the joint is used in non-weight bearing.  During the January 2020 VA examination, the examiner continued diagnoses of degenerative arthritis and degenerative joint disease of the lumbar spine.  At that time, the Veteran reported that his symptoms had increased since his last VA examination. His symptoms were worse in winter with bitter cold. He experienced right posterior leg pain down to the knee but denied urinary/bowel complaints, saddle anesthesia, or foot drop. He treated his condition with yoga two to three times per week as well as daily stretching, Mobic, icing, and hot tub. He would also lay on the floor to help with the pain and to put on his clothes daily. The Veteran reported experiencing flare-ups of the low back described as a sharp pain down the mid-back to the lower back which occur once or twice per week, are of mild severity, and last two to three days. The Veteran experienced functional loss in that the disability prevented him from hunting, hiking, fishing, or tying his shoes. He had to lay on his back to put on his shorts/pants. Range of motion testing revealed forward flexion to 20 degrees, extension to 15 degrees, right lateral flexion to 15 degrees, left lateral flexion to 15 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 10 degrees.  The examiner noted that this loss of motion contributed to a functional loss in that the Veteran was unable to hunt, hike, fish, or tie his shoes. He also had to lay on his back to put on his shorts/pants.  There was evidence of pain with weight bearing, as well as evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine along the thoracic to lumbar spine and adjacent paraspinal muscles with guarding and spasms of a moderate severity. The Veteran was able to perform repetitive use testing with at least three repetitions. This resulted in additional loss of motion, specifically: forward flexion to 15 degrees, extension to 10 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 10 degrees. Pain, weakness, and lack of endurance significantly limited functional ability with repeated use. The Veteran was not examined immediately after repetitive use over time, and the examiner noted that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time.  Pain, weakness, and lack of endurance significantly limited functional ability with repeated use over a period of time.  This resulted in additional loss of motion, specifically: forward flexion to 10 degrees, extension to 5 degrees, right lateral flexion to 5 degrees, left lateral flexion to 5 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 5 degrees.  Significantly, it was noted that the Veteran was examined during a flare-up and that pain, weakness, and lack of endurance significantly limited functional ability with flare-ups that resulted in additional loss of motion, specifically: forward flexion to 5 degrees, extension to 5 degrees, right lateral flexion to 5 degrees, left lateral flexion to 5 degrees, right lateral rotation to 5 degrees, and left lateral rotation to 5 degrees.  There was guarding/muscle spasm of the thoracolumbar spine but this did not result in abnormal gait or abnormal spinal contour. There were no additional factors contributing to disability.  Muscle strength testing was normal and there was no muscle atrophy.  Reflex and sensory examination was normal. Straight leg raising test was negative.  There was radiculopathy of the right leg resulting in mild intermittent pain, paresthesias and/or dysesthesias, and numbness. This affected the sciatic nerves and was found to be of a mild severity. There was no ankylosis of the spine or any other neurologic abnormalities.  The Veteran did have IVDS but did not require bed rest prescribed by a physician. The Veteran did not use an assistive device to aid in locomotion.  There was no functional impairment of an extremity such that no effective function remained, other than that which would be equally well served by an amputation with prosthesis.  There were no other pertinent physical findings, to include scars.  Diagnostic testing revealed arthritis but was negative for thoracic vertebral fracture with loss of 50 percent or more of height.  The examiner noted that the Veteran’s lumbar spine disorder impacted the ability to work.  Specifically, it was noted that the Veteran worked from home most days but had lost one to two weeks from work in the past 12 months and will miss “10 days per year of work due to lower back pain.” With regard to Correia, the examiner wrote that there was objective evidence of pain on passive range of motion testing, as well as evidence of pain when the joint was used in non-weight bearing. Also, of record are VA treatment records dated through February 2020.  These records show treatment for the Veteran’s lumbar spine but are negative for any incapacitating episodes requiring bedrest by a physician, or any range of motion findings.   There are two periods of time at issue here: prior to October 14, 2019, when the Veteran’s lumbar spine disability was evaluated as 10 percent disabling; and beginning October 14, 2019 to the present, while the Veteran’s lumbar spine disability has been evaluated as 40 percent disabling. The Board will consider the proper evaluation to be assigned for the entire period on appeal. As for the period of time prior to October 14, 2019, the Board finds that a disability rating greater than 10 percent is not warranted for the Veteran’s lumbar spine disability. As above, under the General Rating, the next higher 20 percent rating is assignable where forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees. Significantly, range of motion testing for the thoracolumbar spine during the October 2012 VA examinations shows lumbar flexion to 80 degrees, even with pain and on repetition. As such, the Board finds that there is no additional functional deficit of the lumbar spine due to pain. There are no other range of motion findings pertinent to thhe time period prior to October 14, 2019. As the Veteran’s thoracolumbar flexion was greater than 60 degrees prior to October 14, 2019, a higher rating for the lumbar spine is not warranted prior to that date. With regard to the possibility that the Veteran exhibited additional loss of motion of the lumbar spine prior to October 14, 2019 due to flare-ups of the back pursuant to Sharp, the Board notes that, prior to October 14, 2019, there is no evidence of flare-ups. Significantly, during the October 2012 VA examination, the Veteran specifically denied experiencing flare-ups. Furthermore, even if the Veteran had experienced flare-ups prior to October 14, 2019, the guidance on how to evaluate flare-ups has not been particularly clear and, pursuant to Mitchell, flare-ups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated.  The statements made in this case, prior to October 14, 2019, do not show that any flare-ups or repeated use over time additionally limited function in a quantifiable way, nor did they show that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings.  In particular, the October 2012 VA examiner attempted to elicit information from the Veteran in this regard, and the Veteran specifically denied experiencing flare-ups.  As for the period of time beginning October 14, 2019, the Board concludes that a disability rating greater than 40 percent for the Veteran’s lumbar spine disability is not warranted.  As above, a rating higher than 40 percent based on orthopedic impairment requires a finding of ankylosis.  Ankylosis is defined in general as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.”  Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland’s Illustrated Medical Dictionary (28th ed. 1994) at 86).  For VA compensation purposes, unfavorable ankylosis is a condition in which the thoracolumbar spine, or the entire spine, is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.  38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5).  There is no evidence that the Veteran’s spine is fixed in position, or ankylosed.  Significantly, the Veteran had flexion to 5 degrees (with flare-ups) during the January 2020 VA examination. The Board has also considered whether any other diagnostic codes might serve as a basis for an increased rating.  In this regard, DC 5003 addresses degenerative arthritis.  However, in this case, the maximum evaluation possible under DC 5003 is 10 percent, as only one major joint or group of minor joints is involved in this claim.  Therefore, it does not allow for a higher evaluation.  Also, while the Veteran was diagnosed with IVDS during the October 2019 and January 2020 VA examinations, the evidence is negative for any incapacitating episodes requiring bedrest by a physician.  There are no other applicable codes available for consideration.   The Board has also contemplated whether any separate evaluations are applicable here for additional disability associated with the service-connected lumbar spine disability.  Significantly, the Veteran is already in receipt of a separate disability rating for radiculopathy of the right lower extremity.   The Board accepts that the Veteran has functional impairment, pain, and pain on motion (see DeLuca) and finds the Veteran’s own reports of symptomatology to be credible.  However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher rating.  The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned ratings are warranted, and no more.  The evidence of record reflects that the Veteran’s symptomatology for the lumbar spine warrants no more than a 10 percent disability rating prior to October 14, 2019 and a 40 percent disability rating thereafter.  The Board finds that no higher rating can be assigned pursuant to any other potentially applicable diagnostic code.  As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied.  See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. at 490. 3. A disability rating greater than 10 percent for patellofemoral pain syndrome, left knee, is denied. The Veteran seeks a higher disability rating for his service-connected left knee disability.  By way of history, the Veteran’s service treatment records show treatment for left knee strains in November 1989 and October 1991. He submitted an initial claim for service connection for a left knee disability in May 2004 and, by rating decision dated in November 2008, the RO granted service connection for patellofemoral pain syndrome of the left knee, assigning a 10 percent disability rating effective May 27, 2004. The Veteran submitted the current claim for an increased for the left knee disability in September 2012 and, as above, by rating decision dated in November 2012, the RO continued a 10 percent disability rating for the Veteran’s left knee disability. The Veteran disagreed with this decision and perfected this appeal.   The Veteran’s patellofemoral pain syndrome of the left knee is currently rated under 38 C.F.R. § 4.71a, DC 5260. Pursuant to DC 5260, a noncompensable rating is warranted when there is limitation of flexion of a leg to 60 degrees.  A 10 percent disability rating is warranted if flexion is limited to 45 degrees.  A 20 percent disability rating is warranted if flexion is limited to 30 degrees.  A 30 percent disability rating is warranted if flexion is limited to 15 degrees.  38 C.F.R. § 4.71a, DC 5260.  Also, pursuant to DC 5261, a noncompensable rating is warranted when there is limitation of extension of a leg to 5 degrees.  A 10 percent disability rating is warranted if extension is limited to 10 degrees.  A 20 percent disability rating is warranted if extension is limited to 15 degrees.  A 30 percent disability rating is warranted if extension is limited to 20 degrees.  A 40 percent disability rating is warranted if extension is limited to 30 degrees.  A 50 percent disability rating is warranted if extension is limited to 45 degrees.  38 C.F.R. § 4.71a, DC 5261.  Where a claimant has both limitation of flexion and limitation of extension of the same leg, he must be rated separately under DC’s 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg.  VAOPGCPREC 9-2004 (September 17, 2004).  Under certain circumstances, a separate disability evaluation may be assigned for arthritis of the knee under DC 5003 in addition to the rating for instability under DC 5257.  VAOPGCPREC 9-98 and VAOPGCPREC 23-97. A number of other diagnostic codes also potentially apply to knee ratings. Under DC 5256, a 30 percent rating is warranted for ankylosis of the knee with favorable angle in full extension or slight flexion between 0 degrees and 10 degrees. Under DC 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. Under DC 5258, dislocated semilunar cartilage, with frequent episodes of “locking,” pain, and effusion into the joint, is rated as 20 percent disabling. Under DC 5259, a 10 percent disability rating is warranted for symptomatic removal of the semilunar cartilage. Under DC 5262, a malunion of the tibia and fibula of either lower extremity warrants a 20 percent evaluation if there is a marked knee or ankle disability. Notably, beginning February 7, 2021 DC 5257 clarifies the meaning of slight, moderate, and severe instability and requires that the condition be diagnosed based on objective medical findings. Evidence relevant to the current level of severity of the Veteran’s left knee disability includes VA knee examinations dated in October 2012, October 2019, and January 2020.  During the October 2012 VA knee examination, the examiner continued a diagnosis of patellofemoral pain syndrome of the left knee. The Veteran reported that running, bending at the knee, and high impact activities/exercises cause knee pain. He also reported that his knee “grinds” and that he experiences inflammation once a year. He treated the disability with pain medication and ice. He noted that temperature changes to coll weather increased the pain. He also noted stiffness with sitting for a while. He had pain more in the morning when he was getting out of bed but it felt pretty good by the time he got out of the shower. The Veteran denied experiencing flare-ups of the knees. Range of motion testing of the left knee revealed flexion to 120 degrees and extension to zero degrees. The Veteran was able to perform repetitive use testing with three repetitions. Flexion remained to 120 degrees and extension remained to zero degrees after repetitive testing. The examiner noted that there was no additional limitation of motion of the knees following repetitive use testing but there was functional loss and/or functional impairment of the left knee, specifically pain on movement. The examiner also noted tenderness or pain to palpation of the joint line or soft tissues of the left knee. Range of motion testing of the right knee was also performed but will not be discussed. Muscle strength testing was normal for knee flexion and extension. Joint stability testing, specifically anterior instability (Lachmann test), posterior instability (posterior drawer test), and medial-lateral instability) was also normal. There was no evidence or history of recurrent patellar subluxation or dislocation. There was also no history of “shin splints” (medial tibial stress syndrome), stress fracture, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There were no meniscal conditions or surgical procedures for a meniscal condition. There was also no history of total knee joint replacement or any other knee surgery. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms, to include scars. The Veteran denied using an assistive device and the examiner noted that the Veteran’s left knee disorder did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis.  Imaging studies were negative for both arthritis and patellar subluxation. The examiner found that the Veteran’s left knee disability did not impact his ability to work. During the October 2019 VA knee examination, the examiner diagnosed left knee joint osteoarthritis and also noted a diagnosis of patellofemoral pain syndrome. At that time, the Veteran reported experiencing constant left knee pain which he treated with pain medication, ice, and heat. The Veteran denied flare-ups of the knees and also denied functional loss or functional impairment. Range of motion testing of the left knee revealed flexion to 80 degrees and extension to 0 degrees. There was evidence of pain with weight bearing, objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, specifically the diffuse joint TTP of a mild severity, as well as objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional loss or range of motion after three repetitions. The Veteran’s left knee was not examined immediately after repetitive use over time and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain significantly limited functional ability with repeated use over a period of time and resulted in the following additional loss of motion: flexion to 70 degrees and extension to 0 degrees. Range of motion testing of the right knee was also performed but will not be discussed. There were no additional factors contributing to disability. Muscle strength testing was normal and there was no muscle atrophy. There was also no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed and was negative for any instability. There was no indication of recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There was also no indication that the Veteran had or had ever had a meniscus condition or had ever undergone surgery on his left knee. There were no other pertinent findings, to include scars. The Veteran denied using an assistive device and the examiner noted that the Veteran’s left knee disorder did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis.  Imaging studies revealed left knee arthritis. The examiner found that the Veteran’s left knee disability impacted his ability to perform occupational tasks, specifically, he was unable to squat or kneel with the left knee due to increased pain.  With regard to Correia, the examiner noted that there was objective evidence of pain on passive range of motion testing and non-weight bearing testing of the left knee.   During the January 2020 VA knee examination, the examiner diagnosed bilateral shin splints and continued diagnoses of bilateral knee degenerative and left knee patellofemoral pain syndrome. At that time, the Veteran reported experiencing worsened left knee pain, described as achiness/tightness, which he treated with stretching, ice, and Mobic daily. The Veteran reported experiencing flare-ups of the left knee, described as anterior pain radiating to the shin which was constant, nagging, irritating, and felt like bone on bone. This occurred once per week depending on standing, was of a moderate severity, and lasted one week. The Veteran also reported experiencing functional loss/impairment of the left knee, described as an inability to hunt, hike, fish, squat, pick up objects, and run for fitness. Range of motion testing of the left knee revealed flexion to 120 degrees and extension to 0 degrees. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, evidence of pain with weight bearing, or objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions resulting in the following additional loss of motion: flexion to 100 degrees and extension to 0 degrees. The Veteran’s left knee was not examined immediately after repetitive use over time and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain significantly limited functional ability with repeated use over a period of time and resulted in the following additional loss of motion: flexion to 90 degrees and extension to 0 degrees. The Veteran’s left knee was not examined during a flare-up and the examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss during a flare-up. Pain significantly limited functional ability during a flare-up and resulted in the following additional loss of motion: flexion to 85 degrees and extension to 0 degrees. Range of motion testing of the right knee was also performed but will not be discussed. There were no additional factors contributing to disability. Muscle strength testing was normal and there was no muscle atrophy. There was also no ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was performed and was negative for any instability. There was evidence of “shin splints” (medial tibial stress syndrome) but no evidence of recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There was also no indication that the Veteran had or had ever had a meniscus condition or had ever undergone surgery on his left knee. There were no other pertinent findings, to include scars. The Veteran denied using an assistive device and the examiner noted that the Veteran’s left knee disorder did not result in functional impairment of an extremity such that no effective function remained other than that which would be equally well served by an amputation with prosthesis.  Imaging studies revealed bilateral knee arthritis. The examiner found that the Veteran’s left knee disability did not impact his ability to perform occupational tasks.  With regard to Correia, the examiner noted that there was no objective evidence of pain on passive range of motion testing and/or objective evidence of pain with non-weight bearing testing of the left knee.   Also, of record are VA treatment records dated through February 2020.  These records show treatment for the Veteran’s left knee but are negative for any range of motion findings. Given the evidence of record, the Board finds that a disability rating greater than 10 percent is not warranted for loss of flexion pursuant to DC 5260.  As above, the Veteran had flexion to 120 degrees during the October 2012 VA examination, flexion to 70 degrees during the October 2019 VA examination, and flexion to 85 degrees during the January 2020 VA examination.  Pursuant to DC 5260, a 20 percent evaluation is only warranted if flexion is limited to 30 degrees or less.  As such a disability rating greater than 10 percent is not warranted for the Veteran’s loss of right knee flexion pursuant to DC 5260. Furthermore, a separate compensable rating is not warranted under DC 5261 as the Veteran had extension to 0 degrees during the February 2019 VA examination. With regard to the potential for a higher rating for the left knee based additional loss of motion due to flare-ups of the left knee pursuant to Sharp, the Board notes that, even considering the Veteran’s flare-ups during the January 2020 VA examination, the Veteran still had flexion to 85 degrees. As for the period of time prior to January 2020, there is no evidence of flare-ups. Significantly, during the October 2012 and October 2019 VA examinations, the Veteran specifically denied experiencing flare-ups. Furthermore, even if the Veteran had experienced flare-ups prior to January 2020, the guidance on how to evaluate flare-ups has not been particularly clear and, pursuant to Mitchell, flare-ups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated.  The statements made in this case do not show that any flare-ups or repeated use over time additionally limited function in a quantifiable way, nor did they show that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings.  In particular, the October 2012 and October 2019 VA examiners attempted to elicit information from the Veteran in this regard, and the Veteran specifically denied experiencing flare-ups.  The Board accepts that the Veteran has functional impairment, pain, and pain on motion (see DeLuca) and finds the Veteran’s own reports of symptomatology to be credible.  However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher rating.  The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned 10 percent rating is warranted and no more. With regard to DC 5257, while the Veteran suggested possible instability during the June 2015 Board hearing, the October 2012, October 2019, and January 2020 VA examination reports are negative for a history of instability and testing was also negative for instability.  Also, while pursuant to English v. Wilkie, 30 Vet. App. 347, 349 (2019), objective evidence of lateral instability is not required to assign a rating under DC 5257, the Board finds no other subjective complaints of instability in the claims file – to include to medical professionals in the course of describing symptoms and seeking treatment. As such, the Board finds the statements made in the hearing to be of less probative value than those made throughout the appeal. A separate rating is not warranted under DC 5257.  Moreover, as there is no evidence of ankylosis, dislocated semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5258, 5262, and 5263 are not for application.  As such, an initial disability rating greater than 10 percent the left knee is not warranted.  Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board April Maddox, 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.