Citation Nr: 21026750 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 08-27 746 DATE: May 3, 2021 ORDER 1. An increased, combined staged (20 percent prior to March 30, 2010, 40 percent from March 30, 2010 to October 8, 2013, and 60 percent from that date) rating is granted for the Veteran's right knee disability, subject to regulations governing payment of monetary awards. 2. An increased, combined staged (20 percent prior to March 30, 2010, 40 percent from March 30, 2010 to October 8, 2013, and 60 percent from that date) rating is granted for the Veteran's left knee disability, subject to regulations governing payment of monetary awards. FINDINGS OF FACT 1. Prior to March 30, 2010, the Veteran's right and left knee disabilities were each reasonably shown to have been manifested by arthritis with painful limited motion and slight (but no greater) instability; but not shown to have been manifested by compensable limitations of flexion or extension, dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint, symptomatic removal of semilunar cartilage, ankylosis, nonunion or malunion of the tibia or fibula, or genu recurvatum. 2. From March 30, 2010 to October 8, 2013, the right and left knee disabilities were each reasonably shown to have been manifested by arthritis with painful limited motion, slight (but no greater) instability, and dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint; they were not shown to have been manifested by compensable limitations of flexion or extension, ankylosis, nonunion or malunion of the tibia or fibula, or genu recurvatum. 3. From October 8, 2013 to January 14, 2021, the right and left knee disabilities were reasonably shown to have been manifested by flexion limited to 15 degrees (estimated during flare-ups), severe instability, and dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint; they were not shown to have been manifested by compensable limitation of extension, ankylosis, nonunion or malunion of the tibia or fibula, or genu recurvatum. 4. From January 14, 2021, the right and left knee disabilities are reasonably shown to have been manifested by extension limited at 30 degrees (estimated during flare-ups), severe instability, and dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint; they are not shown to have been manifested by compensable limitation of flexion, ankylosis, nonunion or malunion of the tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. Prior to March 30, 2010, the Veteran's right knee disability warrants a combined 20 percent, but no higher, rating (based on formulation of 10 percent under Codes 5003-5260 and 10 percent under Code 5257). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.71a; Codes 5003, 5010, 5256-5263. 2. Prior to March 30, 2010, the Veteran's left knee disability warrants a combined 20 percent, but no higher, rating (10 percent under Codes 5003-5260 and 10 percent under Code 5257). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.71a; Codes 5003, 5010, 5256-5263. 3. From March 30, 2010 to October 8, 2013, the Veteran's right knee disability warrants a combined 40 percent, but no higher, rating (20 percent under Code 5258, 10 percent under Codes 5003-5260, and 10 percent under Code 5257). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.71a; Codes 5003, 5010, 5256-5263. 4. From March 30, 2010 to October 8, 2013, the left knee disability warrants a combined 40 percent, but no higher, rating (20 percent under Code 5258, 10 percent under Codes 5003-5260, and 10 percent under Code 5257). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.71a; Codes 5003, 5010, 5256-5263. 5. From October 8, 2013 to January 14, 2021, the Veteran's right knee disability warrants a combined 60 percent, but no higher, rating (30 percent under Code 5260, 30 percent under Code 5257, and 20 percent under Code 5258). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.71a; Codes 5003, 5010, 5256-5263. 6. From October 8, 2013 to January 14, 2021, the Veteran's left knee disability warrants a combined 60 percent, but no higher, rating (30 percent under Code 5260, 30 percent under Code 5257, and 20 percent under Code 5258). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.71a; Codes 5003, 5010, 5256-5263. 7. From January 14, 2021, the Veteran's right knee disability warrants a combined 60 percent, but no higher, rating (40 percent under Code 5261, 30 percent under Code 5257, and 20 percent under Code 5258). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.68, 4.71a; Codes 5003, 5010, 5055, 5162, 5163, 5256-5263; 85 Fed. Reg. 76457 (Feb 7, 2021). 8. From January 14, 2021, the Veteran's left knee disability warrants a combined 60 percent, but no higher, rating (40 percent under Code 5261, 30 percent under Code 5257, and 20 percent under Code 5258). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.21, 4.25, 4.59, 4.68, 4.71a; Codes 5003, 5010, 5055, 5162, 5163, 5256-5263; 85 Fed. Reg. 76457 (Feb 7, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from February 1979 to September 1979 and from February 1981 to August 1993. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision, which increased the ratings for her right and left knee disabilities (patellofemoral syndrome) from 0 to 10 percent, each, effective November 30, 2006. [A final July 2009 rating decision assigned a temporary total (100%) convalescence rating for the left knee from May 11, 2009 through July 31, 2009, and a final July 2010 rating decision assigned a temporary total convalescence rating for the right knee from January 25, 2010 through April 30, 2010. Accordingly, those periods of time are not for consideration herein.] In August 2011, a Travel Board hearing was held before the undersigned; a transcript is in the record. An October 2011 Board decision granted a 20 percent combined rating for each knee (10 percent under Code 5257 for instability and 10 percent under Code 5003 for painful range of motion) for the entire period, and remanded for additional development the matters of entitlement to further increases in the ratings. A March 2015 rating decision assigned 30 percent, each, separate ratings for left and right knee limitations of flexion and for instability (resulting in the 50 percent, each, combined ratings currently assigned for the right and left knee disabilities from October 8, 2013). In June 2017, the matters were remanded for additional development. In March 2018, the Board denied increases in the combined staged ratings (20 percent prior to October 8, 2013, and 50 percent from that date) assigned for the left and right knee disabilities, each. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (CAVC). A March 2020 Memorandum Decision set aside the Board's decision and remanded the matters for further development and readjudication. In November 2020, the case was remanded for additional development. An interim (February 2021) rating decision assigned an increased (from 30 to 40 percent) rating for limitation of extension (previously rated as limitation of flexion), effective January 14, 2021, for the right and left knee disabilities, each. The Veteran previously had an attorney representative. See May 2020 VA Form 21-22a. In December 2020 correspondence (while the appeal was being developed at the agency of original jurisdiction (AOJ), the attorney withdrew as the Veteran's representative; he copied the Veteran on such correspondence. February 4, 2021 VA correspondence notified the Veteran that she is no longer represented and provided her a list of Veterans Service Organizations that can assist her. She has not since appointed a new representative. Although an unrelated piece of VA correspondence dated January 2021 returned as undeliverable, the February 4, 2021 VA correspondence was not returned as undeliverable (and is presumed to have been received by the Veteran). Accordingly, the Board is proceeding with the understanding that she is pursuing the appeal pro se. 1., 2. Increased combined staged (20 percent prior to March 30, 2010, 40 percent from March 30, 2010 to October 8, 2013, and 60 percent from that date) ratings are granted for the Veteran's right and left knee disability, each. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). "Staged" ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining, including regarding degree of disability, is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. The Board observes that the schedular criteria for evaluating disabilities of the musculoskeletal system, including the knee joint, have undergone revision during the pendency of this appeal. Specifically, and as relevant to this case, revisions to Codes 5003, 5010, and 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Prior to February 7, 2021, Code 5010 provided for rating traumatic arthritis as degenerative arthritis under Code 5003. Under the revised criteria, Code 5010 applies only to post-traumatic arthritis, which is to be 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. Under both the prior and revised rating criteria, degenerative arthritis is rated under Code 5003. Degenerative arthritis established by x-ray findings is rated on the basis of limitation of motion under the appropriate Code(s) for the specific joint(s) involved. When the limitation of motion is noncompensable under the appropriate Code(s), a 10 percent rating is for application for each such major joint affected by limitation of motion, to be combined, not added under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Code 5003. The criteria for rating knee disabilities are found at 38 C.F.R. § 4.71a, Codes 5256-5263. Code 5256 applies when the knee is ankylosed. As noted above, revisions to Code 5257 (for recurrent subluxation or instability of the knee) were made effective February 7, 2021. See 85 Fed. Reg. 76457 (Feb 7, 2021). Because these changes took effect during the pendency of the Veteran's appeal, both the former and revised criteria will be considered in evaluating the Veteran's service-connected knee disabilities. However, application of the new criteria prior to the effective date of the amended regulation is not allowed. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Green v. Brown, 10 Vet. App. 111, 116-119 (1997); see also 38 U.S.C. § 5110(g). Prior to February 7, 2021, under Code 5257, knee impairment manifested by recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent (the maximum) when severe. Effective February 7, 2021, Code 5257 provides ratings for both recurrent subluxation or instability of the knee and for patellar instability. As it pertains to recurrent subluxation or instability of the knee, Code 5257 provides a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent (maximum) rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. As it pertains to patellar instability of the knee, Code 5257 provides a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. [Note (1) explains that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) explains that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). See Code 5257 (Effective February 7, 2021).] Under Code 5258, a maximum 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under Code 5259, a 10 percent rating is assigned for symptomatic removal of semilunar cartilage. Under Code 5260, limitation of flexion of the leg warrants a 0 percent rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and a (maximum) 30 percent rating when limited to 15 degrees. Under Code 5261, limitation of extension of the leg warrants a 0 percent rating when extension is limited at 5 degrees; a 10 percent rating when limited at 10 degrees; a 20 percent rating when limited at 15 degrees; a 30 percent rating when limited at 20 degrees; a 40 percent rating when limited at 30 degrees; and a (maximum) 50 percent rating when limited at 45 degrees. Code 5262 applies when there is malunion or nonunion of the tibia and fibula. Code 5263 applies when there is acquired, traumatic genua recurvatum. Normal or full ROM of the knee is from 0 degrees of extension to 140 degrees of flexion. Plate II. 38 C.F.R. § 4.71. Separate ratings may be assigned for separate symptoms, including for [compensable] limitations of flexion and extension, instability, and dislocation of semilunar cartilage or symptomatic removal of semilunar cartilage. VAOPGCPREC 9-2004 (September 17, 2004), 69 Fed. Reg. 59990 (2004). In determining the degree of limitation of motion, the provisions of 38 U.S.C. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Ratings for extremities are also governed by 38 C.F.R. § 4.68 (the amputation rule), which provides that the combined rating for disabilities of an extremity shall not exceed the rating for amputation of the extremity at the elective level, were amputation to be performed. Under Code 5162, amputation of a leg at the middle or lower third of the thigh is rated 60 percent. The next higher (80 percent) rating (under Code 5161) requires that the elective site of amputation be at the upper third of the thigh, one-third of the distance from perineum to the knee joint measured from the perineum. 38 C.F.R. § 4.71a. An increased rating may be assigned for up to one year prior to receipt of a formal claim for increase, when it is factually ascertainable that an increase in disability had occurred during that period. 38 C.F.R. § 3.400(o)(2). Consequently, the evaluation period for consideration here is from November 2005 (a year prior to the November 30, 2006 date of claim) to the present. Factual Background In a July 2007 statement, the Veteran reported knee pain and that her "knees have started buckling" when she walks. On October 2007 VA (fee basis) examination, the Veteran reported knee symptoms including weakness, stiffness, giving way, locking up, and dislocation, with popping "from time to time." She did not report swelling, heat, redness, lack of endurance, or fatigability. She reported constant localized knee pain described as aching and sharp in nature and 8/10 in severity; the pain could be elicited by walking, sitting, or exercise, or it came on by itself; it was relieved by rest or medication and she was considering knee surgery. She reported that at the time of pain, she could function with or without medication. The pain was constant in both knees, right worse than left, and she had to change positions "constantly". Current treatment included cortisone injections. She reported difficulty sitting, walking, or standing for prolonged periods. On physical examination, the Veteran's posture and gait were within normal limits, her feet showed no signs of abnormal weight bearing, and she did not require an assistive device for ambulation. For both knees, there was weakness, tenderness, guarding of movement, crepitus, and locking pain; there was no edema, effusion, redness, heat, subluxation, or genu recurvatum. Right knee range of motion (ROM) was to 100 degrees flexion and 0 degrees extension. Left knee ROM was to 90 degrees flexion and 0 degrees extension. Joint function of both knees was additionally limited (by 0 degrees) after repetitive use by pain, fatigue, weakness, lack of endurance, and incoordination, with pain having the major functional impact. Anterior and posterior cruciate and medial and lateral-collateral ligament stability testing was within normal limits bilaterally. Medial and lateral meniscus test was within normal limits bilaterally. X-rays of the knees showed normal right knee and degenerative changes of the left knee. The diagnosis was changed, from left and right knee patellofemoral syndrome, to left knee arthritis and right knee patellofemoral syndrome. The examiner opined that the effect of the condition on the Veteran's usual occupation and daily activity was inability to stand or walk for prolonged periods. In an April 2008 statement, the Veteran reported that she has arthritis in both knees. She stated that when she bends her knees, "they lock up and pain sets in. When I go to straighten them out, they make a popping sound." A March 2008 private treatment record notes the Veteran's report of popping and grinding behind the left kneecap, and pain when traversing stairs and getting up and down from a chair. Testing showed tenderness along the court of the patella; her knees were stable to varus and valgus stress. A May 2008 private treatment record notes the Veteran's report of bilateral knee pain and locking. She denied swelling and redness. November 2008 x-rays of the knees showed bilateral degenerative joint disease (DJD). An April 2009 VA treatment record notes an assessment of bilateral lateral patellar subluxation, left more symptomatic than right. A May 6, 2009 VA treatment record notes an assessment of planned left knee arthroscopy with synovectomy, chondroplasty, and possible partial meniscectomy. On May 11, 2009, the Veteran underwent left knee arthroscopic synovectomy. The surgical report notes that the "patella was tracking nicely and the menisci were both in excellent condition." The report also notes that "Articular surfaces had good cartilage. Entering the medial joint space, the cartilage surfaces were in excellent condition, just some grade two changes on the tibial surface. The femoral condyle only just had some grade one softening." A June 2009 VA orthopedic record notes the Veteran's report of left knee bucking with ambulation. A July 2009 VA orthopedic record notes that the Veteran was 7.5 weeks status post left knee synovectomy; left knee ROM was 0 to 135 degrees. In a July 2009 statement, the Veteran reported that her left knee causes difficulty getting in and out of a car, and that it locks and makes a popping sound. An August 2009 VA treatment record notes the Veteran's report of left knee locking, popping, and swelling (daily). ROM was 0 to 120 degrees. An October 2009 VA treatment record notes the Veteran's continued reports of left knee pain around the patella and popping. It was noted that left knee injections did not help. Knee braces were ordered. On November 2009 VA (fee basis) examination, the Veteran reported bilateral knee symptoms including stiffness, swelling, giving way, lack of endurance, locking, fatigability, tenderness, effusion, subluxation and pain. Left knee symptoms also included weakness, and right knee symptoms also included maltracking and popping. She did not report heat, redness, deformity, drainage, or dislocation. She reported flare-ups as often as once a day and each lasting for 24 hours, with the severity level at 10/10 in the left knee and 8/10 in the right knee, precipitated by physical activity or occurring spontaneously. She reported that during the flare-ups, she experiences functional impairment with walking, climbing, exercising, sitting too long, limitation of motion of the joint, bending, kneeling, standing, or getting out of the car. She reported that the left leg gives out and pops and she has stiffness if she walks or stands, and the right knee locks, pops a lot, and gives out. She reported aching with cold air or bad weather, and difficulty walking, doing route inspections at her job, and doing any type of exercise due to her knees, as well as difficulty sleeping due to inability to lie on the left knee. She reported left knee surgery residuals of pain and arthritis. [She denied prior right knee surgery.] On physical examination, the Veteran's posture and gait were normal, and she walked with a normal tandem gait. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities, or any unusual shoe wear pattern. She required a brace on each knee "for support" for ambulation; she did not use crutches, cane, corrective shoes, a wheelchair, prosthesis, or walker. Both knees showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation, or guarding of movement. Examination of both knees revealed crepitus; there was no genu recurvatum or locking pain. There was no ankylosis of either knee. Right knee ROM was to 120 degrees flexion and 0 degrees extension; repetitive motion was possible with no additional degree of limitation. Left knee ROM was to 110 degrees flexion, with pain exhibited at 80 degrees, and 0 degrees extension; repetitive motion testing did not result in additional degree of ROM limitation. The left knee joint function was additionally limited by pain after repetitive use. The joint function bilaterally was not additionally limited by fatigue, weakness, lack of endurance, or incoordination after repetitive use. Stability tests (medial/lateral collateral ligaments, anterior/posterior cruciate ligaments, and the medial/lateral meniscus) were all within normal limits bilaterally. X-rays showed bilateral degenerative arthritic changes in both knees. The diagnoses were changed to status post left knee arthroscopic surgery with scar and DJD and right knee DJD, both of which were a result of a progression of the previous diagnoses. The examiner noted again that the knee stability tests were within normal limits for both knees, and neither knee showed signs of subluxation. The examiner opined that the effect of the conditions on the Veteran's daily activities was bilateral knee pain, worse in the left after prolonged sitting, standing, or walking. In a December 2009 statement, the Veteran reported that both of her knees "pop and give out." She also reported that she wears prosthetic braces on both knees. On January 25, 2010, the Veteran underwent right knee arthroscopy, synovectomy, and plica excision. The patella was tracking nicely with the groove. She had some grade 1 softening in the medial joint space; "the cartilage and meniscus appeared to be intact." The medical meniscus was noted to be stable; the cartilage surfaces "had just a little bit of softening." The ACL was intact. In the lateral joint space "the cartilage looked good at first, however, there was a cleft within the tibial surface where the probe could get almost down to bone, representing grade 4 chondromalacia." The synovium was debrided, and a medial plica was removed that looked chronically inflamed. Physical therapy records from February and March 2010 note that right knee ROM was from 0 to 100 degrees (or greater). In a February 2010 progress note, the physician who performed her knee surgeries noted that the Veteran is "refusing to bend [her knees], basically, since surgery." He noted her reports of knee stiffness; eventually the Veteran relaxed and showed flexion "to about 80 degrees" bilaterally. He stated that during surgery, "Both of her knees were pretty benign." The assessment was "bilateral knee pain. It's really unclear what's causing this." In a March 2, 2010 statement, the Veteran reported that her knees swell, lock, stiffen, pop, and give out without warning on a daily basis. On March 30, 2010, the Veteran underwent a private MRI on both knees. The impression was 1) intact ligaments; 2) no strict MRI criteria for medial meniscus tear; 3) subtle altered morphologic changes including blunting and truncation of the posterior horn of the lateral meniscus towards the free edge. The findings were "non-specific although given the report of previous surgery, could reflect postoperative changes should there have been previous partial lateral meniscectomy. In the absence of previous surgery to account for the findings, the findings could represent a subtle tear of the posterior horn of the lateral meniscus towards the free edge. Clinical correlation is recommended in this regard." 4) mild/small focus of osteochondral change arises along the medial femoral condyle anteriorly; 5) no evidence of patellar chondromalacia; 6) a small focus of osteochondral change of the femoral trochlea arises along the medial fact; and 7) small joint effusion without significant Baker's cyst. An April 2010 private treatment record notes the Veteran's reports of swelling and grinding in the right knee. On examination, there was effusion in the right knee; she had patellofemoral crepitance, right greater than left. MRI showed trochlear chondromalacia in the right knee and minimal trochlear chondromalacia in the left knee. An October 5, 2010 private treatment record notes the Veteran's report of ongoing knee pain. The physician (the same doctor who performed the knee surgeries) noted that he had seen her in the past and "Both times I really didn't see too much going on in her knees." He noted that the Veteran extended her knees fully but "would not let me flex her knees beyond 80 or 90 degrees...it really feels like she is fighting me." He noted that she walked with a slight, kind of awkward gait; she had no pain on McMurray's test (used to evaluate individuals for meniscus tears in the knee). An October 7, 2010 record notes decreased ROM; however, the doctor noted that the Veteran was observed walking in the office and parking lot, and had full extension during such activity. On January 2011 VA (fee basis) examination, the Veteran reported symptoms including weakness, stiffness, swelling, redness, giving way, lack of endurance, locking, fatigability, tenderness and pain; she did not experience heat, deformity, drainage, effusion, subluxation, or dislocation. She reported flare-ups as often as "multiple" times per day, with each lasting several hours, in a severity level of 9/10 and precipitated by physical activity or occurring spontaneously. She reported functional impairment during flare-ups of walking with a limp, prolonged swelling of the leg, limitation of motion with difficulty climbing stairs, bending, walking, or sitting for prolonged periods, and difficulty finding a comfortable sleeping position. She reported being unable to stand, walk, or sit for prolonged periods, being unsteady on stairs and ramps, and popping of the knees. She reported surgery residuals of pain and limping in the left knee and swelling in the right knee. She wore knee braces prescribed by orthopedics. On physical examination, the Veteran's posture was normal. She walked with an antalgic gait, but with a normal tandem gait. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities, or unusual shoe wear pattern. For ambulation, she required a brace on each knee for bilateral knee pain; she did not use crutches, cane, corrective shoes, wheelchair, prosthesis, or walker. There was guarding of movement and crepitus of both knees. There were no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, or subluxation of either knee. There was no genu recurvatum or locking pain, bilaterally, and no ankylosis of either knee. Right knee ROM was to 120 degrees flexion with pain at 120 degrees, and 5 degrees extension with pain at 5 degrees; repetitive motion was possible with flexion to 115 degrees and extension to 5 degrees, demonstrating 5 degrees of additional limitation of flexion. Left knee ROM was to 125 degrees flexion with pain at 125 degrees, and 5 degrees extension with pain at 5 degrees; repetitive motion was possible with flexion to 125 degrees and extension to 5 degrees and no additional limitation. [In an addendum, the examiner clarified a typographical error on the examination report with the correct ranges of motion: flexion was to 120 degrees and extension was to 5 degrees (rather than the originally stated 85 degrees), for both knees.] Joint function was additionally limited by pain after repetitive use bilaterally, but not by fatigue, weakness, lack of endurance, or incoordination. Stability tests (medial/lateral collateral ligaments, anterior/posterior cruciate ligaments, and the medial/lateral meniscus) were all within normal limits bilaterally. There was no subluxation of either knee. It was noted that x-rays showed mild degenerative changes symmetrically. The examiner opined that the effect of the knee conditions on the Veteran's usual occupation was that she could not walk or stand for prolonged periods of time, and her daily activities were not affected by her conditions. An April 26, 2011 left knee MRI showed mild degenerative changes, and increased signal in the body and posterior horn of the medial meniscus without definite tear seen to surface in the left knee. Right knee MRI showed a medial meniscus tear, a very small joint effusion, and very minimal degenerative changes. X-rays revealed mild medial joint space narrowing and slight lateral positioning of the patella in the femoral groove bilaterally. A July 2011 private physical therapy (PT) initial evaluation record notes that flexion was to 120-125 degrees bilaterally; extension was within normal limits. Stability tests were negative bilaterally. A July 2011 VA orthopedic surgery follow-up record (by another orthopedic surgeon) notes that, on examination, the Veteran's knees did not show effusion; the right knee looked larger due to "slight soft tissue assymetry." Both knees showed ROM of 0 to 145 degrees, and a "pop" at full extension. Both knees showed 1+ valgus laxity at 20 degrees; the other ligaments were stable. It was noted that x-rays showed mild degenerative changes, left more than right. She acknowledged that the radiologist reported a right knee medial meniscal tear, but she wrote, "the MRI is negative for meniscal tear to my reading." The assessment was bilateral knee pain due to degenerative arthritis. An August 2011 VA kinesiotherapy record notes that active ROM testing showed right knee flexion to 110 degrees and left knee flexion to 85 degrees. Both knees showed full extension. Pain was noted with all movements. A subsequent August 2011 VA treatment record notes the Veteran's reports of bilateral knee pain that increases with bending, stooping, stairs, and ambulation. She reported that wearing braces prevents buckling. Examination showed full ROM, mild crepitus, no effusion, no ligamentous instability, negative McMurray's test, and negative patellar compression test, each bilaterally. At the August 2011 Board hearing, the Veteran testified that a walker was issued for her bilateral knee disabilities that month. She testified that bed rest was prescribed for her bilateral knee disabilities from January to March 2011, and in May and June 2011 at Patient First Emergency Room. She testified that bed rest was also prescribed from January to April 2010 (a period for which a temporary total convalescence rating was assigned). In an August 2011 statement, the Veteran's husband reported that she uses a walker or knee braces. On December 2011 VA examination, the Veteran reported that she was barely able to stand, walk, or even sleep due to her knee pain, and had been unable to work for several months. She was noted to have undergone left knee arthroscopy in May 2009 (minor grade 1 articular cartilage changes) and right knee arthroscopy in January 2010 (grade 4 changes in lateral compartment), and in July 2011 knee braces and an abductor pillow were prescribed, and she was discharged from the orthopedic clinic (as no further orthopedic care was indicated; she continued to receive treatment in the mental health and chronic pain clinics). The examiner noted that the Veteran's anxiety and panic attacks were "a principal deterrent to her function." On physical examination, the examiner noted that examination was very difficult due to the Veteran's inability to relax and participate, with complaints of thigh and knee pain and spasms. She moved very stiffly, refusing to flex her knees or hips without persuasion. Overall alignment of the knees was neutral, with no effusion in either knee. Thigh circumference above the superior pole of the patella was equal bilaterally, patellar compression test was negative bilaterally, patellar mobility was normal bilaterally without subluxation or instability, and there was no localized tenderness. Ligament testing including medial/lateral, anterior/posterior, drawer, Lachman, and pivot-shift was normal bilaterally. ROM and motor testing was difficult and inconsistent due to the Veteran's inability to relax and cooperate; maximum extension was full bilaterally and maximum flexion was to 125 degrees bilaterally, and repetitive cycling movements were resisted due to pain. Sensation and circulation were normal. The diagnosis was chronic patellofemoral syndrome bilaterally and early osteoarthritis in the medial compartment of both knees, left more than right. The examiner opined that the Veteran's inability to cooperate with a complete exam seemed more related to emotional factors than to orthopedic factors, and that it is likely that her impaired functional abilities are similarly related more to emotional factors than orthopedic disease. A March 2012 VA treatment record notes the Veteran's report that the knee braces help prevent buckling. She reported increased pain with bending, stooping, stairs, and ambulation. Examination showed full ROM in each knee while wearing a brace. An April 2012 VA treatment record notes that therapy has not been successful because the Veteran could not bend her knees to ride the bike. The Veteran reported that both knees buckle forward and that she experiences "pops under the kneecap with flexion and extension." A December 2012 left knee x-ray showed mild left patellofemoral joint space narrowing. On May 2013 VA examination, the Veteran reported that she had received several series of knee injections with little to no relief, but did not have knee pain at rest. She related that she could not perform her required duties at her job and had retired on disability in September 2011. She stated that she did not have pain while sitting with her legs out and not moving, and had to adjust the way she slept due to knee pain; wearing braces helped when she had to move around. She reported daily flare-ups with prolonged standing, sitting, or walking, with pain going to 8 or 9 out of 10 in severity; when she changed position, the duration of the pain was about 45 minutes, and she had to change positions about every 45 minutes which brought the pain down to 6/10. On physical examination, right knee flexion was to 130 degrees with objective evidence of painful motion at 60 degrees; there was no limitation of extension and no objective evidence of painful motion. Left knee flexion was to 130 degrees with objective evidence of painful motion at 60 degrees; there was no limitation of extension and no objective evidence of painful motion. It was noted that the Veteran cried throughout the examination (even before the knees were examined) and "expressed pain and upset at [her former employer] with exaggerated movements and crying." Following repetitive use testing, right knee flexion was to 130 degrees and there was no limitation of extension; left knee flexion was to 120 degrees and there was no limitation of extension. Additional functional impairment after repetitive use testing included less movement than normal bilaterally, pain on movement bilaterally, disturbance of locomotion bilaterally, and interference with sitting/standing/weight-bearing bilaterally. There was tenderness or pain to palpation of both knees. Muscle strength testing was 5/5 for flexion and extension bilaterally. Anterior instability (Lachman), posterior instability (posterior drawer), and medial-lateral instability (varus/valgus) tests were normal bilaterally. There was no evidence or history of recurrent patellar subluxation or dislocation. There was no history of shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. A history of meniscal tear was noted in the left knee, with a left "meniscectomy" performed in May 2009; residual symptoms included pain and decreased ROM. A history of right knee arthroscopy in January 2010 was noted; residual symptoms included pain and decreased ROM. The examiner noted that it was difficult to examine the Veteran due to expressed pain limiting bending [of the knees] for examination. The Veteran reported regular use of braces on both knees for walking. The examiner noted that imaging studies show degenerative or traumatic arthritis in the left knee, and there was no x-ray evidence of patellar subluxation. The examiner opined that the knee conditions impacted the Veteran's ability to work because she was unable to run, jump, or jog, and had difficulty with stairs and prolonged standing/walking/sitting. An August 12, 2013 left knee MRI showed grade 3 chondromalacia of the inferior patellar apical cartilage but was otherwise unremarkable. There were no tears of the medial or lateral menisci. Right knee MRI showed "Findings equivocal for tear within the posterior horn of the lateral meniscus." [Two days later, a primary care provider wrote, "You have some damage to the patellar cartilage on [right] and a possible tear of the [left] lateral meniscus." It appears he transposed the findings to the opposite knees, based on comparison to the MRI findings he copied above his statement.] A September 2013 Social Security Administration decision granted the Veteran SSA disability benefits from September 20, 2011; her severe impairments were noted to include chronic bilateral patellofemoral syndrome, chondromalacia and osteoarthritis of both knees, insomnia, irritable bowel syndrome, adjustment disorder, anxiety not otherwise specified, depressive disorder not otherwise specified, and diabetes mellitus. On October 8, 2013, VA received a statement from the Veteran describing worsening symptoms and requesting a total disability rating based on individual unemployability (TDIU). A January 2014 VA treatment record notes the Veteran's report of bilateral knee pain rated 8/10. The examiner noted the August 2013 MRI findings, and noted that her knees showed crepitus on examination. He opined that the Veteran is "unemployable due to pain and mobility restrictions." In a September 2014 statement, the Veteran reported that she is unable to work since September 20, 2011 due to her service-connected psychiatric and physical disabilities. [A May 2013 rating decision granted service connection for depressive disorder.] On September 2014 VA (fee basis) examination, the Veteran reported that her knee conditions had worsened since the 2009 and 2010 surgeries, including with diagnoses of DJD and a right meniscal tear. She reported constant pain with intermittent worsening, and with flare-ups in cold weather. She reported that during flare-ups it was hard to walk and get around; to sleep due to the pain; and to stand, bend, and enter or exit a vehicle. On physical examination, right knee flexion was to 45 degrees with objective evidence of painful motion at 45 degrees; extension was to 0 degrees with objective evidence of painful motion at 0 degrees. Left knee flexion was to 60 degrees with objective evidence of painful motion at 60 degrees; extension was to 0 degrees with objective evidence of painful motion at 0 degrees. Following repetitive use testing, right knee flexion was to 30 degrees and extension was to 0 degrees; left knee flexion was to 30 degrees and extension was to 0 degrees. Additional functional impairment following repetitive use testing included less movement than normal bilaterally and pain on movement bilaterally. There were contributing factors of pain, weakness, fatigability, and/or incoordination and there was additional limitation of functional ability of the knee joint during flare-ups or repeated use over time; the degree of ROM loss during pain on use or flare-ups was approximately 15 degrees of flexion in the right knee and 30 degrees of flexion in the left knee. There was tenderness or pain to palpation of both knees. Muscle strength testing was 4/5 for knee flexion and extension bilaterally. Anterior instability (Lachman test), posterior instability (posterior drawer test), and medial-lateral instability (valgus/varus pressure) testing was normal bilaterally. There was evidence or history of severe recurrent patellar subluxation/dislocation bilaterally. There was no history of shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. There were no symptoms of a left knee meniscus condition; right knee symptoms included meniscal tear, frequent episodes of joint "locking", frequent episodes of joint pain, and frequent episodes of joint effusion. The examiner checked the boxes to report a history of right knee meniscectomy, with no residual signs/symptoms. He also checked the boxes to indicate that the Veteran had left knee arthroscopic surgery in 2009 and right knee arthroscopic surgery in 2010; there were no residual signs/symptoms from those arthroscopic knee surgeries. The Veteran reported constant use of braces and a walker and regular use of a cane for her knee conditions. X-rays of the right knee were normal; x-rays of the left knee showed a degenerative spur at the superior patella. The diagnoses included bilateral patellofemoral syndrome, left knee DJD, right meniscal tear status post meniscectomy, and status post right and left knee arthroscopy. The examiner opined that the Veteran's knee conditions impact her ability to work in that she cannot walk or stand for very long at all and she has a hard time getting around with a walker. On December 2014 VA treatment, there was no erythema or edema to the knees. The knees were nontender to palpation of the medial/lateral joint lines; there was tenderness to palpation on the anserine bursa bilaterally and on the hamstring tendons bilaterally. ROM was from 0 to 120 degrees with crepitus bilaterally. Patellar apprehension, patellar grind test, McMurray's test, Bounce Home test, anterior drawer test, posterior drawer test, valgus stress test, varus stress test, and pivot shift were each negative. It was noted that the Veteran wears hinged braces and neoprene sleeves "to assist with stability and pain with mild results." Based on this evidence, a March 2015 rating decision granted a 30 percent rating for right knee patellofemoral syndrome status post meniscectomy instability (under Code 5257), a 30 percent rating for left knee patellofemoral syndrome with degenerative joint disease instability (under Code 5257), a 30 percent rating for right knee limitation of flexion (under Code 5260), and a 30 percent rating for left knee limitation of flexion (under Code 5260), each effective October 8, 2013, the date of receipt of the Veteran's statement reporting worsening. A December 2015 rating decision granted an earlier effective date of November 30, 2006 for the award of service connection for right and left knee patellofemoral syndrome with DJD instability, each rated 10 percent, with the 30 percent ratings each continued from October 8, 2013. On April 2016 VA examination, the Veteran reported a history of bilateral knee pain. She reported she was status post right knee synovectomy and excision of plica in 2010 and left knee synovectomy with partial meniscectomy in 2009. She reported multiple treatments to include PT, TENS unit, steroid injections, Supartz, and Euflexa, with no improvement. She used neoprene sleeves, bilaterally, for stability. She reported that the pain was the same every day at 9/10 severity. She did not report flare-ups. With repeated use over time, she reported difficulty standing or walking for long periods, and difficulty traversing stairs. She reported no significant change or injury to her knees since the previous examination, and x-ray findings from 2014 to the time of examination showed "no significant change." The examiner noted that physical examination could not be conducted as the Veteran had "volitional pain behavior throughout the exam." She was unable to bend the knees, even slightly, during the examination; however, while getting x-rays in radiology, she was observed to be bending both knees past 90 degrees without assistance. There was evidence of pain with weight bearing bilaterally. There was pain with palpation over the anterior, lateral, and posterior knee bilaterally. There was objective evidence of crepitus bilaterally. The Veteran was able to perform repetitive use testing with no additional functional loss or ROM. Muscle strength testing was 5/5 for flexion and extension bilaterally, with no reduction in muscle strength and no muscle atrophy. There was no ankylosis of either knee. There was no history of recurrent subluxation, lateral instability, or recurrent effusion in either knee. Joint stability testing did not demonstrate joint instability; anterior instability (Lachman), posterior instability (posterior drawer), medial instability, and lateral instability tests were all normal bilaterally. The Veteran had no history of recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There were no current symptoms due to a meniscus condition in either knee. The Veteran reported regular, daily use of braces for knee pain. Imaging studies documented bilateral mild degenerative arthritis. The diagnoses were bilateral patellofemoral pain syndrome and bilateral knee degenerative arthritis. The examiner opined that the knee conditions impact the Veteran's ability to perform occupational tasks in that she has difficulty walking for prolonged periods, driving, or climbing stairs. In an addendum, the examiner noted that there was no diagnosis of instability because there was no objective evidence of diagnosable disease or pathology related to instability. On February 2017 VA treatment, there was no swelling or effusion in the knees. There was crepitus and moderate tenderness to palpation on the undersurface of the bilateral patellae in the patellofemoral spaces. There was moderate tenderness over the medial joint line. The knees were stable with anterior, posterior, valgus, and varus stress testing; McMurray's test was negative. Right knee active ROM was 0 to 100 degrees; left knee active ROM was 0 to 95 degrees. On August 2017 VA examination (pursuant to the Board's June 2017 remand), the Veteran reported that she never recovered from the 2009 and 2010 knee surgeries. She reported that several cortisone and viscosupplementation injections had been administered without relief of pain. The Veteran did not report flare-ups. She stated she was totally disabled because of her knees. Upon review of the medical evidence, the examiner opined that, based on the documented ROM obtained on treatment in December 2014 and February 2017, and the progress notes from 2013 through 2017 documenting normal gait, the diagnoses for limitation in flexion of the knees were made in error. On physical examination, the examiner noted that ranges of motion were not documented because the Veteran reported experiencing severe pain in her knees; she cried when asked to perform a straight leg raise to assess her extensor mechanism, and indicated that she would not be able to complete the examination. The examiner opined that the Veteran's subjective complaints of severe pain and limited ROM due to pain "are incompatible with the mild degenerative changes in her knees." The examiner noted that during a previous VA examination, the Veteran was observed and documented to have demonstrated volitional pain behavior throughout the examination (but was evaluated on February 2017 treatment and demonstrated active ROM of 0 to 100 degrees in the right knee and 0 to 95 degrees in the left knee). The examiner noted that, on the current examination, the Veteran "reported and displayed an inability to move her knees due [to] complaint of disabling knee pain." The examiner opined that the Veteran's subjective complaints do not correlate with objective findings to include imaging studies of the knees. Although attempts were made to assess her knee strength, she demonstrated non-physiologic break away weakness of the knees, feigning significant weakness and inability to bend the knees. The examiner opined that this was not consistent with the clinical presentation during the remainder of the examination. The examiner observed that the Veteran was able to stand and walk without difficulty or impairment, sit on the exam table without discomfort with her knees briefly bent at 85 to 90 degrees, was observed taking off and putting on her shoes without difficulty, and that her sit-to-stand and stand-to-sit transitions were unimpaired. The examiner opined that this was "concerning for non-physiologic pain behaviors" and, as a result, ROM testing was invalid. There was no evidence of pain when the joint was used in non-weight bearing, and there was no evidence of pain with weight bearing; pain was not noted on examination. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was indicated but not performed. There was no history of recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment. There were no current symptoms of a left knee meniscus condition. The Veteran reported residual pain from previous arthroscopic surgeries. She reported constant use of a cane in the house and braces and a walker when she leaves the house. November 2016 x-rays were noted to show mild degenerative changes of both knees with trace right suprapatellar joint effusion. The Veteran reported that she could not work because of her knees. A March 2018 Board decision denied increases in the combined staged (20 percent prior to October 8, 2013, and 50 percent from that date) ratings assigned for the Veteran's right and left knee disabilities, each. The Veteran appealed that decision, resulting in the March 2020 Memorandum Decision, wherein the CAVC concluded that the Board erred in relying on inadequate examinations to deny the claims for increase. The CAVC found that "None of the VA examinations in this case are fully adequate," and found that "Remand is therefore warranted to obtain a medical opinion" that complies with Mitchell v. Shinseki, 25 Vet. App. 32 (2011), DeLuca v. Brown, 8 Vet. App. 202 (1995), and Correia v. McDonald, 28 Vet. App. 158 (2016). [The Memorandum Decision also discussed the applicability of Sharp v. Shulkin, 29 Vet. App. 26 (2017), regarding the requirement of examiners, in situations when direct observation is not possible, to opine on and quantify the effect of pain on functioning based on other evidence (applicable here as the Veteran has (on some examinations) reported flare-ups and elected not to fully participate/cooperate with examiners).] The CAVC also found that because "the evidence of record in this case reflects meniscus tears of both knees, the issue of entitlement to separate evaluations under [Codes] 5258 or 5259 was reasonably raised by the record and the Board was obligated to address it...The Board's failure to do so therefore renders inadequate its reasons or bases for denying additional separate compensable evaluations, necessitating remand." [Notably, the Memorandum Decision, "the law of the case," explained that the Secretary is not qualified to conclude that meniscus tears are not synonymous with semilunar cartilage dislocation and he is not correct that the only evidence of a tear is a possible right knee meniscus tear. The CAVC cited to the March 2010 MRIs (showed effusion and possible meniscus tear in each knee); the April 2011 MRI (showed right knee medial meniscal tear); July 2011 private treatment record (showed right meniscus tear); May 2013 VA examiner (noted a left meniscus tear); August 2013 MRI (showed equivocal evidence of right knee meniscus tear); and September 2014 VA examiner (noted right knee meniscus tear with frequent locking, joint pain, and effusion).] In November 2020, the Board remanded the case for additional development. On January 2021 VA (fee basis) knee examination, the diagnoses were left knee patellofemoral syndrome with DJD instability and right knee patellofemoral syndrome status post meniscectomy instability. The Veteran reported chronic pain, rated 5/10, and treatment with hinged braces, cane, non-steroidal anti-inflammatory drugs, and injections providing minimal relief. She reported flare-ups manifested by pain that limits walking. Initial ROM was noted to as 30 to 90 degrees, bilaterally, with pain on flexion and extension. There was pain with weight-bearing; there was no objective evidence of crepitus. Repetitive use testing resulted in no additional functional loss or ROM limitation. With repeated use over time, the examiner estimated that ROM would be 30 to 90 degrees, bilaterally, due to pain. During flare-ups, the examiner estimated that ROM would be 40 to 80 degrees, bilaterally, due to pain. No other factors were found to contribute to either knee disability. Muscle strength testing was 5/5 bilaterally. There was no muscle atrophy. Neither knee was ankylosed. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Anterior and posterior stability tests were normal bilaterally; medial and lateral stability tests were 2+ (5-10 mm) bilaterally. There were not shin splints, stress fractures, chronic exertional compartment syndrome, or other tibial/fibular impairment. The examiner noted the Veteran has a right knee meniscal tear with symptoms of pain and frequent episodes of joint pain; the Veteran did not have left knee meniscus (semilunar cartilage) symptoms. The examiner noted the prior (2009 left knee and 2010 right knee) debridement surgeries. The Veteran constantly used braces and regularly used a cane, both "due to knee pathology." The examiner opined that the knee disabilities limit the Veteran's ambulation to 10 minutes at a time. The examiner concluded by again noting that moderate bilateral instability was found. He reiterated that bilateral ROM was 30 to 90 degrees in weight-bearing and non-weight-bearing. He specified that the knees were not ankylosed, and again repeated that the Veteran's knee pain limits ambulation. In a separate addendum report, the January 2021 examiner explained that the Veteran's "Bilateral medial and lateral instability is noted to be moderate and treated with hinged braces to prevent instability." He also wrote that the Veteran "has substantial knee pathology limiting ambulation to 10 minutes at a time." Throughout the appeal period, the Veteran submitted numerous lay statements from her husband, former coworkers and supervisors, and herself, describing the severity of her symptoms. Her husband stated that she has used different pain medications, cortisone injections, PT, and undergone surgery to her knees. He stated that her knee disabilities impact her sleep and are aggravated by bad weather and cold air. Her former coworkers described how her knee disabilities affected her ability to do her job. Analysis The Veteran's right and left knee disabilities have each been assigned combined staged ratings of 20 percent prior to October 8, 2013, 50 percent from October 8, 2013 to January 14, 2021, and 60 percent from that date. [Notably, a 100 percent combined schedular rating has been assigned from October 8, 2013.] Initially, the Board notes the applicability of Codes 5256, 5262, and 5263 has been considered throughout the appeal period. However, as the evidence of record does not show that pathology or separate and distinct symptoms required for ratings under such codes (ankylosis, nonunion or malunion of the tibia or fibula, or genu recurvatum of the knee) was present during the evaluation period, those Codes do not have applicability in these matters (and will not be further discussed). As discussed in greater detail below, the Board finds that the Veteran's right and left knee disabilities each warrant increased, combined staged ratings of 20 percent prior to March 30, 2010 (based on a formulation of 10 percent under Codes 5003-5260 and 10 percent under Code 5257); 40 percent from March 30, 2010 to October 8, 2013 (based on a formulation of 20 percent under Code 5258, 10 percent under Codes 5003-5260, and 10 percent under Code 5257); and 60 percent from October 8, 2013 (based on a formulation of 30 percent under Code 5260, 30 percent under Code 5257, and 20 percent under Code 5258 prior to January 14, 2021, and a formulation of 40 percent under Code 5261, 30 percent under Code 5257, and 20 percent under Code 5258 from January 14, 2021). 38 C.F.R. §§ 4.68, 4.71a. Prior to March 30, 2010 The combined 20 percent ratings assigned for each knee prior to March 30, 2010 are based on a 10 percent rating for limitation of motion/flexion or painful motion due to x-ray confirmed degenerative arthritis or patellofemoral syndrome (under Code 5260 or under Codes 5003-5260), combined with a 10 percent rating for slight instability of each knee (under Code 5257 or under Codes 5003-5257). To warrant increase in the combined rating, the evidence would have to show limitation of knee flexion to 30 degrees, compensable limitation of extension (at 10 degrees), moderate instability, dislocated semilunar cartilage, or symptomatic removal of semilunar cartilage. The evidence of record does not show any such criteria were met for either knee prior to October 8, 2013. At no time prior to March 30, 2010 is the Veteran's left or right knee flexion shown to have been limited to 30 degrees, or her left or right knee extension limited to 10 degrees. On October 2007 examination, right knee ROM was 0 to 100 degrees, and left knee ROM was 0 to 90 degrees, including after repetitive use testing. On November 2009 examination, right knee ROM was 0 to 120 degrees, and left knee ROM was 0 to 110 degrees (with pain exhibited at 80 degrees); there was no additional ROM limitation following repetitive use testing. PT and treatment records during the period consistently note that bilateral flexion was to 80 degrees or greater, and that extension was full (0 degrees). Accordingly, a rating in excess of 10 percent was not warranted based on limitation of ROM. Prior to March 30, 2010, no more than slight instability was shown. The Board notes that the Veteran reported that her knees were buckling and giving way, and that she used knee braces during a portion of this period. See November 2009 VA knee examination report. The Board acknowledges the CAVC's holdings in English v. Wilkie, 30 Vet. App. 347 (2018), and Tedesco v. Wilkie, 31 Vet. App. 360 (2019). However, as objective stability testing was within normal limits on October 2007 and November 2009 knee examinations, the Board finds that more than slight instability was not shown prior to March 30, 2010, and a rating in excess of 10 percent under Code 5257 was not warranted. Finally, the Board turns to Codes 5258 and 5259, and finds that prior to March 30, 2010 a separate rating is not warranted under either Code. Although the Veteran reported locking, griding, and pain during this period, the evidence does not show dislocated semilunar cartilage (or symptomatic removal of semilunar cartilage). Significantly, for analysis purposes, the Veteran underwent left knee synovectomy in May 2009 and right knee arthroscopy, synovectomy, and plica excision in January 2010. Neither surgery was a meniscectomy, despite the Veteran's later reports to examiners (and notations of such on some subsequent examinations). The May 2009 left knee surgical report notes that the "menisci were both in excellent condition." The January 2010 right knee surgery report notes that the medial meniscus was stable and that the lateral showed grade 4 chondromalacia; a lateral meniscus tear was not diagnosed. In February 2010, the surgeon who performed both surgeries stated that "Both of her knees were pretty benign." In October 2010, he stated, "I really didn't see too much going on in her knees." Based on the contemporaneous surgical reports and the performing surgeon's statements thereafter, the evidence does not show dislocated semilunar cartilage, or that the arthroscopic surgeries in 2009 and 2010 involved removal of semilunar cartilage that became symptomatic thereafter. Accordingly, separate ratings under Codes 5258 or 5259 are not warranted prior to March 30, 2010. Consequently, the Board finds that prior to March 30, 2010 a combined rating in excess of 20 percent is not warranted for either knee. March 30, 2010 to October 8, 2013 Upon review of the record, increased (to 40 percent, combined) ratings are granted from March 30, 2010 to October 8, 2013, for each knee. The combined schedular ratings are based on a formulation of 20 percent under Code 5258, 10 percent under Codes 5003-5260, and 10 percent under Codes 5003-5257. Considering the March 2020 CAVC Memorandum Decision (the law of the case), upon re-review of the evidence, and affording the Veteran the benefit of the doubt, the Board finds that 20 percent ratings are warranted for each knee under Code 5258 from March 30, 2010, for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. The March 30, 2010 MRIs of both knees are the first objective evidence of record which suggests a finding of dislocated semilunar cartilage. Notably, the MRI report states that, "In the absence of previous surgery to account for the findings, the findings could represent a subtle tear of the posterior horn of the lateral meniscus towards the free edge." [An April 2011 MRI of the right knee confirmed a right medial meniscus tear; MRI of the left knee showed increased signal in the body and posterior horn of the medial meniscus without definite tear.] As outlined above, the May 2009 (left) and January 2010 (right) knee surgeries did not find dislocated semilunar cartilage and did not involve the removal of semilunar cartilage. The surgeon described the knees as "pretty benign," in February 2010, one month prior to the March 30, 2010 MRIs. [Although subsequently, an orthopedic surgeon disagreed with the diagnosis of a right knee meniscal tear, and MRI findings were merely "equivocal" for right knee lateral meniscus tear, the assignment of the 20 percent rating herein under Code 5258 affords the benefit of the doubt to the Veteran.] Accordingly, a rating under Code 5258 is not warranted prior to March 30, 2010. The Board has considered the applicability of Code 5259, as advised in the Memorandum Decision, but finds it does not apply. As discussed above, the May 2009 and January 2010 surgeries did not involve removal of semilunar cartilage. [Although the Veteran has reported that she may need total knee replacements in the future, there is no indication she underwent subsequent surgeries (to remove semilunar cartilage).] Furthermore, assignment of separate ratings under Codes 5258 and 5259 is prohibited by the rule against pyramiding, as the two ratings contemplate overlapping cartilage symptoms. See 38 C.F.R. § 4.14. As the maximum rating under Code 5259 is 10 percent, the Veteran is better served by the 20 percent rating assigned herein under Code 5258. During this period, each knee has also been assigned a 10 percent rating for limitation of motion/flexion or painful motion due to x-ray confirmed degenerative arthritis or patellofemoral syndrome (under Code 5260 or under Codes 5003-5260). The evidence does not show limitation of knee flexion to 30 degrees or compensable limitation of extension (at 10 degrees) necessary for an increased rating based on limitation of ROM. Notably, bilateral flexion was to 60 degrees (on May 2013 examination) or greater, and extension was noted to be full (0 degrees) or limited to 5 degrees (on January 2011 examination), taking into consideration reported painful motion and on repetitive use testing. Accordingly, a rating in excess of 10 percent was not warranted based on limitation of ROM (flexion or extension). Finally, during this period, a 10 percent rating has been assigned for slight instability of each knee (under Code 5257 or under Codes 5003-5257). The Board acknowledges that a July 2011 treatment record notes bilateral 1+ valgus laxity at 20 degrees (and not 2+ or 3+ laxity). However, objective stability testing was normal on January 2011, December 2011, and May 2013 knee examinations. Accordingly, the Board finds that more than slight instability was not shown from March 30, 2010 to October 8, 2013, and a rating in excess of 10 percent under Code 5257 was not warranted. From October 8, 2013 to present Upon review of the record, increased (to 60 percent combined) ratings are granted from October 8, 2013 for each knee. The combined schedular ratings are based on a formulation of 20 percent under Code 5258, 30 percent under Code 5257, and 30 percent under Code 5260 (for limitation of flexion) from October 8, 2013 to January 14, 2021, and 40 percent under Codes 5003-5261 (for limitation of extension) from January 14, 2021. 38 C.F.R. §§ 4.68, 4.71a. As explained above, a 20 percent rating (assigned herein) is warranted during this period for each knee under Code 5258. [Assignment of separate ratings under Codes 5258 and 5259 is prohibited by the rule against pyramiding, as the two ratings contemplate overlapping cartilage symptoms. See 38 C.F.R. § 4.14. As the maximum rating under Code 5259 is 10, the Veteran is better served by the 20 percent rating assigned herein under Code 5258.] From October 8, 2013 (the date when VA received her claim for a TDIU rating (the AOJ accepted the allegation of worsening as a claim for increase)), each knee has been assigned a 30 percent (maximum schedular) rating for instability under Codes 5003-5257. Neither the old criteria (in place prior to Prior to February 7, 2021) nor the new criteria (in place since February 7, 2021) provide for a rating in excess of 30 percent for instability. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Furthermore, the instability of the Veteran's knees is not shown (or alleged) to have manifestations or to cause impairment not encompassed by the schedular criteria. Although the September 2014 examiner checked the box to report a history of severe recurrent patellar subluxation, objective stability testing was normal on September 2014, December 2014, and April 2016 examinations, and "moderate" on January 2021 examination. Accordingly, a rating in excess of 30 percent under Code 5257 is not warranted for either knee from October 8, 2013. The analysis turns to consideration of limitation of motion under Codes 5260 (for limitation of flexion), 5261 (for limitation of extension), and 5003 (for painful motion, but less than compensable limitations of flexion and extension). Limitation of motion from October 8, 2013 to January 14, 2021 During this period, each knee has been assigned a 30 percent (maximum schedular) rating for limitation of flexion under Code 5260. Consequently, to warrant a higher combined rating the evidence must show compensable limitation of extension (to 10 degrees or greater) of a knee. Compensable limitation of extension is not shown, however. Extension was consistently full (to 0 degrees), including on September 2014 examination, December 2014 treatment, and February 2017 treatment. The Board notes that the Veteran refused to participate in ROM testing on August 2017 examination. However, the examiner explained that the subjective complaints of severe and disabling pain, and non-physiologic break away weakness ("feigning significant weakness") were incompatible with mild degenerative changes of the knees and inconsistent with the clinical presentation during the remainder of the examination (where she was able to stand and walk without difficulty or impairment, and sit on the exam table to bend her knees to 85-90 degrees). Accordingly, the evidence shows that from October 8, 2013 to January 14, 2021, compensable limitation of extension was not shown, and a rating in excess of 30 percent for limitation of motion was not warranted. Limitation of motion from January 14, 2021 During this period, each knee has been assigned a 40 percent rating for limitation of extension under Code 5261. Notably, the February 2021 rating decision (which increased the rating for limitation of motion from 30 to 40 percent, effective January 14, 2021) changed the applicable Code from 5260 (for flexion) to 5261 (for extension). Consequently, to warrant a higher combined rating the evidence must show limitation of extension of a knee to 45 degrees or compensable limitation of flexion (to 45 degrees). On January 2021 examination, initial bilateral ROM testing showed flexion was to 90 degrees and extension was to 30 degrees (including after repetitive use testing and as estimated with repeated use over time). During flare-ups, the examiner estimated that bilateral ROM would be 40 to 80 degrees due to pain. Accordingly, even with consideration of limiting factors (such as pain) during flare-ups and with repeated use over time, neither compensable limitation of flexion nor extension limited to 45 degrees (in order to warrant the next higher, 50 percent rating) is shown. In summary, the Veteran's service connected left and right knee disabilities, each, warrant increased, combined staged ratings of 20 percent prior to March 30, 2010 (10 percent under Codes 5003-5260 and 10 percent under Code 5257); 40 percent from March 30, 2010 to October 8, 2013 (20 percent under Code 5258, 10 percent under Codes 5003-5260, and 10 percent under Code 5257); and 60 percent from October 8, 2013 (30 percent under Code 5260, 30 percent under Code 5257, and 20 percent under Code 5258 prior to January 14, 2021, and a formulation of 40 percent under Code 5261, 30 percent under Code 5257, and 20 percent under Code 5258 from January 14, 2021). 38 C.F.R. §§ 4.68, 4.71a. The Board notes that the matter of entitlement to a total disability rating based upon individual unemployability (TDIU) was raised during the period on appeal. Notably, the Veteran reported that she last worked on September 19, 2011. See November 2014 VA Form 21-8940. A TDIU rating has been assigned from the following day, September 20, 2011, based on the impairment caused by her service-connected bilateral knee disabilities and her service-connected psychiatric disability. See December 2015 rating decision. The Board has considered the matter of entitlement to a TDIU rating prior to September 20, 2011, pursuant to Harper v. Wilkie, 30 Vet. App. 356 (2018). However, the evidence shows (and the Veteran self-reported), that she worked during such period, and that she last worked full-time on September 19, 2011. Accordingly, prior to September 20, 2011 a TDIU wass not warranted. Although not explicitly raised, the Board has considered entitlement to special monthly compensation (SMC) at the "S-1" (housebound) rate pursuant to 38 U.S.C. § 1114(s)(1). However, the criteria for such have not been met, as the Veteran does not have a single service-connected disability rated 100 percent, and she is not shown to be permanently housebound by reason of service-connected disability. Her TDIU rating was granted based on the impairment from both her service-connected bilateral knee disabilities and her service-connected psychiatric disability (and not based solely on a single disability). Consequently, the Veteran does not meet the criteria for entitlement to SMC at the housebound rate. See Bradley v. Peake, 22 Vet. App. 280, 293 (2008). GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dupont, 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.