Citation Nr: 21026311 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 08-26 138A DATE: April 30, 2021 ORDER Entitlement to an increased evaluation greater than 10 percent for right knee patellofemoral syndrome with degenerative changes prior to January 7, 2014 is denied. Entitlement to an increased evaluation greater than 10 percent for left knee patellofemoral syndrome with degenerative changes prior to January 7, 2014 is denied. Entitlement to a compensable evaluation for limitation of flexion of the right knee from January 7, 2014 is denied. Entitlement to a compensable evaluation for limitation of flexion of the left knee from January 7, 2014 is denied. FINDINGS OF FACT 1. During the period prior to January 7, 2014, the Veteran's right knee patellofemoral syndrome with degenerative changes was manifested by arthritis, pain, crepitus, and limitation of motion no worse than from 0 to 100 degrees, without recurrent subluxation or lateral instability. 2. During the period prior to January 7, 2014, the Veteran’s left knee patellofemoral syndrome with degenerative changes was manifested by arthritis, pain, crepitus, and limitation of motion no worse than from 0 to 100 degrees, without recurrent subluxation or lateral instability. 3. During the period from January 7, 2014, the Veteran's limitation of flexion of the right knee is no worse than 60 degrees. 4. During the period from January 7, 2014, the Veteran’s limitation of flexion of the left knee is no worse than 60 degrees. CONCLUSIONS OF LAW 1. During the period prior to January 7, 2014, the criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome with degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2020). 2. During the period prior to January 7, 2014, the criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome with degenerative changes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2020). 3. During the period from January 7, 2014, the criteria for a compensable rating for right knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260 (2020); 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). 4. During the period from January 7, 2014, the criteria for a compensable rating for left knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260 (2020); 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1988 to February 1992. This case came to the Board of Veterans’ Appeals (Board) on appeal from an Agency of Original Jurisdiction (AOJ) decision dated in September 2006, that in pertinent part, denied an increase in 10 percent ratings for service-connected patellofemoral syndrome with degenerative changes of the right and left knees. The Veteran testified before the undersigned Veterans Law Judge at a January 2014 hearing; a transcript of the hearing is of record. In April 2014, the Board remanded this case for additional development. In a September 2014 rating decision, the AOJ granted increased 50 percent ratings for patellofemoral syndrome of the right and left knees with degenerative changes and limitation of extension, each effective January 7, 2014. The AOJ also granted separate noncompensable ratings for limitation of flexion of each knee, effective January 7, 2014. In August 2015, the Board denied an evaluation greater than 10 percent for right knee patellofemoral syndrome with degenerative changes prior to January 7, 2014 and greater than 50 percent thereafter; denied an evaluation greater than 10 percent for left knee patellofemoral syndrome with degenerative changes prior to January 7, 2014 and greater than 50 percent thereafter; and denied initial compensable evaluations for limitation of flexion of the right and left knees. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2016 memorandum decision, the Court vacated the Board’s decision only as to the following issues: entitlement to increased ratings greater than 10 percent prior to January 7, 2014 for left and right knee patellofemoral syndrome with degenerative changes, and entitlement to initial compensable disability ratings for limitation of flexion of the left and right knees. The Court remanded these issues to the Board. The Court also determined that the Veteran had abandoned his appeal of disability ratings in excess of 50 percent for the period after January 7, 2014 for his left and right knee patellofemoral syndrome, and dismissed the appeal as to the abandoned issues. In July 2017 and October 2019, the Board remanded the case to the AOJ for additional development consistent with the Court's memorandum decision, and it was subsequently returned to the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). In general, the degree of impairment resulting from a disability is a factual determination and the Board’s primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any initial rating/increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). As noted above, the issues of entitlement to ratings greater than 50 percent from January 7, 2014 for patellofemoral syndrome of the left and right knees with degenerative changes, based on limitation of extension, are no longer in appellate status. The issues remaining on appeal are entitlement to ratings greater than 10 percent during the period prior to January 7, 2014 for right and left knee patellofemoral syndrome with degenerative changes, and entitlement to higher compensable ratings from January 7, 2014 for limitation of flexion of the right and left knees. The record reflects that the AOJ assigned the effective date of January 7, 2014 for its award of increased ratings because that was the date of the Board hearing. See September 2014 AOJ decision. In its November 2016 memorandum decision, the Court remanded the issues of higher initial compensable ratings for limitation of flexion of the left and right knees for an adequate VA examination that expresses functional loss in terms of the degree of additional limitation of motion loss. With regard to the issue of entitlement to an earlier effective date for increased 50 percent ratings for right and left knee patellofemoral syndrome with degenerative changes, the Court stated that the transcript from the January 7, 2014 Board hearing does not support the Board’s finding that the Veteran’s increased symptoms necessarily began on the date of the hearing, and that because his testimony related to symptoms occurring before the date of the hearing, the Board should have discussed the date on which the Veteran testified that symptoms began, and such a finding was required to support an effective date of January 7, 2014. See 38 U.S.C.§ 5110(a); McGrath v. Gober, 14 Vet. App. 28, 35 (2000); 38 C.F.R. § 3.400. The Court remanded the issue of the effective date for the award of 50 percent ratings for the Board to provide adequate reasons or bases for its decision. The Board notes that although increased ratings were granted for the service-connected bilateral knee disabilities during the pendency of the appeal, since this increase did not constitute a full grant of the benefits sought throughout the rating period on appeal, the issues of entitlement to a rating higher than 10 percent for each knee prior to January 7, 2014 remain in appellate status. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The claim for an earlier effective date prior to January 7, 2014 for the 50 percent ratings for right and left knee disabilities is entirely overlapping with the appeal for increased ratings greater than 10 percent prior to January 7, 2014, and adjudication of the increased rating appeals will encompass all effective date concerns. The Board notes that the Veteran's service-connected conditions include fibromyalgia, and that VA examinations and outpatient treatment records have related some of his bilateral knee pain to fibromyalgia. See VA examinations dated in July 2009, November 2009, and July 2012, and VA outpatient treatment records dated in March 2010 and September 2010. Governing law provides that the evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See Esteban v. Brown, 6 Vet. App. 259 (1994); see also 38 C.F.R. § 4.14. Symptoms of fibromyalgia may not be considered when evaluating the service-connected knee disabilities. 1. Entitlement to an increased rating in excess of 10 percent for right knee patellofemoral syndrome with degenerative changes, prior to January 7, 2014 2. Entitlement to an increased rating in excess of 10 percent for left knee patellofemoral syndrome with degenerative changes, prior to January 7, 2014 The Veteran contends that his service-connected right and left knee disabilities are more disabling than currently evaluated and that a 50 percent rating should be assigned for each knee effective July 20, 2005 because of constant pain, difficulty walking, using stairs, driving, working, and sitting. See January 2014 Board hearing and his statements dated in September 2017 and August 2019. He previously asserted that a 40 percent rating should be assigned for each knee. See his September 2008 substantive appeal. At the Board hearing in January 2014, the Veteran testified that he had cracking, grinding, and swelling of the knees. He testified that his knees sometimes gave out, but then defined “give out” as stiffening up really badly. See hearing transcript, page 5. He indicated that he used a cane and sometimes used a knee brace, although the knee brace aggravated his knees. He previously asserted that the September 2006 VA examiner forced his knees into the degrees of flexion shown in the examination findings, and that he had constant knee pain. See his October 2006 notice of disagreement and September 2008 statements. In September 2017, he asserted that his bilateral knee flexion and extension were not evaluated prior to January 7, 2014. In March 2021, the Veteran's representative asserted that the Veteran reported marked interference with his daily activities, and said his symptoms had severely worsened and were more frequent and intense, including additional loss of range of motion, incapacitating attacks of pain, functional loss due to weakness, fatigability, incoordination or pain on movement, and limitation of motion due to pain on use, including use during flare-ups. This appeal arises from the Veteran’s July 20, 2005 claim for increased ratings. The effective date for an award of an increased rating is the date of claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). If it is factually ascertainable that an increase in disability occurred within the one-year period prior to filing the claim, the effective date will be the date the increase was shown. 38 C.F.R. § 3.400(o)(2). The date “entitlement arose” is not defined in the current statute or regulation. The Court has interpreted it as the date when the claimant met the requirements for the benefits sought; this is determined on a “facts found” basis. See 38 U.S.C. § 5110 (a); see also McGrath v. Gober, 14 Vet. App. 28, 35 (2000). During the pendency of the appeal, effective February 7, 2021, VA revised the criteria for rating certain musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020). The revised criteria apply to all applications for benefits received by VA on or after that date; however, only the old rating criteria may be applied prior to the effective date. In this case, the revisions are not applicable to this portion of the rating period on appeal because the revisions became effective after this period. Throughout the rating period prior to January 7, 2014, the AOJ has rated service-connected left and right knee patellofemoral syndrome with degenerative changes as 10 percent disabling for each knee under Diagnostic Code 5261. The AOJ previously rated the bilateral knee disabilities as 10 percent disabling under Diagnostic Codes 5299-5009, and the September 2006 rating decision indicated that this rating was assigned by analogy, since patellofemoral pain syndrome is not specifically listed in the rating schedule. See 38 C.F.R. § 4.20. The Board finds that in this case, Diagnostic Code 5003 (degenerative arthritis), is more appropriate than Diagnostic Code 5009 (other types of arthritis), as the evidence reflects that he has been diagnosed with degenerative arthritis, including on X-ray study. See VA examinations in September 2006, July 2019, and January 2020. The September 2006 VA examiner diagnosed degenerative joint disease of the bilateral knees. Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated based on 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 Diagnostic Code 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 assigned for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and a 20 percent rating is assigned for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020). The assigned Diagnostic Code 5261 suggests that the right and left knee patellofemoral syndrome with degenerative changes is rated based on compensable limitation of extension. 38 C.F.R. § 4.71a. A review of the evidence reflects that the right and left knee disabilities have manifested as osteoarthritis and been rated based on painful noncompensable limitation of motion, and that the right and left knee patellofemoral syndrome with degenerative changes have not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the rating period prior to January 7, 2014. Therefore, the Diagnostic Code assigned should have been Diagnostic Code 5003, to show that the right and left knee patellofemoral syndrome with degenerative changes (osteoarthritis) is being rated based on noncompensable limitation of motion that is painful. For this reason, the Board considers the Diagnostic Code for the right and left knee patellofemoral syndrome with degenerative changes to be more appropriately rated pursuant to Diagnostic Code 5003 to reflect the actual rating already assigned. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion of the leg limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2020). Full knee flexion is to 140 degrees. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension of the leg limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2020). Full knee extension is to zero degrees. 38 C.F.R. § 4.71, Plate II. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Board previously remanded this case to obtain medical opinions complying with the requirements in Sharp, supra, in which the Court held that VA examiners must attempt to estimate functional loss during a flare-up based on all information that can be feasibly derived, including the lay statements of the Veteran. On VA examination in September 2006, the Veteran denied a history of flare-ups, but reported that he was unable to stand for more than a few minutes, and was able to walk for one-quarter mile. On VA examination in May 2014, the Veteran did not report that flare-ups impacted the function of the lower legs, but reported pain and stiffness when sitting, pain on stairs, and said he could walk approximately one to two city blocks. The Board finds that during the period prior to January 7, 2014, the preponderance of the evidence is against a rating in excess of 10 percent for right knee patellofemoral syndrome with degenerative changes or for left knee patellofemoral syndrome with degenerative changes. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he had peripatellar pain with squatting, and discomfort especially with full flexion of the knees (see September 2017 VA examination) would not result in limitation of motion more nearly approximating extension limited to 15 degrees, or limitation of motion more nearly approximating flexion limited to 45 degrees (as required for a 10 percent rating for limitation of flexion under Diagnostic Code 5260). Rather, at worst, the Veteran exhibited flexion in the right and left knees limited to 100 degrees, and full extension of both legs throughout this portion of the rating period on appeal. Range of motion of the knees was full on examination during outpatient treatment in August 2009 and September 2010. The Board notes that range of motion during a flare-up on VA examination in September 2017 (after the rating period on appeal) was from 0 to 80 degrees in the right knee and 0 to 75 degrees in the left knee. On VA examination in September 2006, range of motion of the right knee was from 0 degrees of extension to 100 degrees of flexion, with pain at 90 degrees, range of motion of the left knee was from 0 degrees of extension to 100 degrees of flexion, with pain at 90 degrees, and there was no additional limitation of motion on repetitive use testing in either knee. The examiner opined that the right and left knee disabilities were manifested by crepitus, tendonitis, painful movement, weakness, and subpatellar tenderness. The examiner stated that the Veteran's service-connected bilateral knee disabilities and right hand disability produced decreased mobility, decreased manual dexterity, problems with lifting and carrying, lack of stamina, decreased strength in the lower extremity, and pain. VA outpatient treatment records reflect treatment for fibromyalgia and pain in multiple joints. In March 2010, he complained of diffuse constant body pain. The diagnostic assessment was fibromyalgia, and the physician indicated that the Veteran had trigger points and weakness in the extensors. The physician opined that the weakness seemed to be a result of the pain, as he did not have concurrent musculoskeletal fatigue. On VA examination in March 2014, range of motion of the right knee was as follows: extension to 0 degrees (with pain at 45 degrees), and flexion to 60 degrees (with pain at 0 degrees). Range of motion of the left knee was as follows: extension to 0 degrees (with pain at 45 degrees), and flexion to 60 degrees (with pain at 0 degrees). There was no additional limitation of motion on repetitive use testing in either knee. The examiner also indicated that the Veteran had functional loss after repetitive use testing including less movement than normal, pain on movement, and disturbance of locomotion. On VA examination in September 2017, range of motion of the right knee was as follows: flexion from 0 to 80 degrees, and extension from 75 to 0 degrees. Range of motion of the left knee was as follows: flexion from 0 to 75 degrees, and extension from 75 to 0 degrees. There was no additional functional loss or limitation of motion on repetitive use testing in either knee. The examiner stated that the examination was being performed during a flare-up and pain, weakness, fatigability, or incoordination significantly limited functional ability with a flare-up. In a July 2018 addendum, the examiner stated that there was no evidence of pain on passive range of motion testing or on weightbearing. The October 2020 VA examiner noted that range of motion of each knee was from 0 to 90 degrees on examination in July 2019, but was reduced during a flare-up on examination in January 2020 to 0 to 80 degrees in the right knee and 0 to 75 degrees in the left knee. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg during the period prior to January 7, 2014. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017). Although Diagnostic Code 5257, pertaining to knee instability, was revised effective February 7, 2021, the revisions are not applicable in this case because the revisions became effective after the rating period on appeal. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). The Veteran has reported that he has instability of both knees because his kneecaps slide and are not stable. See his September 2008 substantive appeal. He has testified that his knees sometimes give out, but then defined “give out” as stiffening up really badly. See January 2014 Board hearing transcript, page 5. On VA examinations in September 2006, March 2014, September 2017, July 2019, and January 2020, VA examiners consistently found no instability in either knee on joint stability testing. The VA examiners also found no patellar dislocation or subluxation during rating period prior to January 7, 2014. The January 2020 VA examiner indicated that there was no recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Board finds that a separate rating is not warranted under Diagnostic Code 5257 as the preponderance of the evidence, including the Veteran's lay statements and testimony, does not show that his bilateral knee disabilities were manifested by recurrent subluxation or lateral instability during the rating period prior to January 7, 2014. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020); English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). A higher rating is not warranted under Diagnostic Code 5256, as the evidence reflects that there is no ankylosis of the right knee. Diagnostic Codes 5258, 5259, 5262 and 5263 are inapplicable in this case as the evidence does not show dislocation of the semilunar cartilage with frequent episodes of locking, pain and effusion of the joint, symptomatic removal of the semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. In conclusion, the Board finds that during the period prior to January 7, 2014, the preponderance of the evidence is against the Veteran’s claims for ratings in excess of 10 percent for right knee patellofemoral syndrome with degenerative changes, and left knee patellofemoral syndrome with degenerative changes. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to a higher compensable rating for limitation of flexion of the right knee from January 7, 2014 4. Entitlement to a higher compensable rating for limitation of flexion of the left knee from January 7, 2014 During the rating period from January 7, 2014, the only issues on appeal are entitlement to initial compensable ratings for limitation of flexion of the left and right knees. The Veteran’s representative contends that a 30 percent rating should be assigned for limitation of flexion of each knee because the May 2014 VA examination showed that pain on motion resulted in functional loss at 0 degrees and the Veteran had functional limitations on standing and walking. See May 2017 written brief. As noted, during the pendency of the appeal, effective February 7, 2021, VA revised the criteria for rating certain musculoskeletal disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453 (Nov. 30, 2020). The revised criteria apply to all applications for benefits received by VA on or after that date; however, only the old rating criteria may be applied prior to the effective date. Diagnostic Code 5260 was not revised. The rating criteria of Diagnostic Code 5003, pertaining to degenerative arthritis, were not revised other than to clarify that this Code pertains to degenerative arthritis other than post-traumatic. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). Formerly, this Code applied to arthritis, degenerative (hypertrophic or osteoarthritis). Under the former criteria in effect prior to February 7, 2021, Diagnostic Code 5010 provides that arthritis due to trauma is to be rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2020). The revised version of Diagnostic Code 5010 provides that post-traumatic arthritis is rated as 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. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5010). During the period from January 7, 2014, the Veteran’s left and right knee patellofemoral syndrome with degenerative changes with limitation of flexion have each been each rated noncompensable under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Full knee flexion is to 140 degrees. 38 C.F.R. § 4.71, Plate II. During the period from January 7, 2014, the Board finds that the preponderance of the evidence is against a compensable rating for right and left knee patellofemoral syndrome with degenerative changes. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he had peripatellar pain with squatting, and discomfort especially with full flexion of the knees (see September 2017 VA examination), that he had flare-ups once weekly where his bilateral knee pain increased to 10/10 in severity (see July 2019 and January 2020 VA examinations) would not result in limitation of motion more nearly approximating flexion limited to 45 degrees. Throughout the rating period from January 7, 2014, flexion was no worse than 60 degrees in either knee. See VA examinations in March 2014, September 2017, July 2019, and January 2020. On VA examination in March 2014, right and left knee flexion was to 60 degrees (with pain at 0 degrees). There was no additional limitation of motion on repetitive use testing in either knee. The examiner also indicated that the Veteran had functional loss after repetitive use testing including less movement than normal, pain on movement, and disturbance of locomotion. On VA examination in September 2017, right knee flexion was to 80 degrees, and left knee flexion was to 75 degrees. There was no additional functional loss or limitation of motion on repetitive use testing in either knee. The examiner stated that the examination was being performed during a flare-up and pain, weakness, fatigability or incoordination significantly limited functional ability with a flare-up. In a July 2018 addendum, the examiner stated that there was no evidence of pain on passive range of motion testing or on weightbearing. On VA examination in July 2019, right and left knee flexion was to 90 degrees. Pain was noted on flexion but did not result in or cause functional loss. There was no additional functional loss or limitation of motion on repetitive use testing in either knee. The examiner stated that the examination was not being conducted during a flare-up, and pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare-ups. On VA examination in January 2020, right knee flexion was to 80 degrees, and left knee flexion was to 75 degrees. Pain was noted on examination but did not result in or cause functional loss, and the pain was noted on flexion. The knee joint was very tender to palpation. The examiner stated that the examination was being conducted during a flare-up and opined that pain and lack of endurance significantly limited functional ability with flare-ups. The examiner stated that the range of motion during a flare-up was as listed above. The October 2020 VA examiner noted that flexion of each knee was to 90 degrees on examination in July 2019, but was reduced during a flare-up on examination in January 2020 to 80 degrees in the right knee and 75 degrees in the left knee. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for compensable ratings for right and left knee limitation of flexion. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. L. Wasser, 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.