Citation Nr: 21027118 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 06-05 775 DATE: May 4, 2021 ORDER A 20 percent rating, for degenerative joint disease of the thoracolumbar spine, is granted prior to November 1, 2010, and a rating higher than 20 percent is denied. A rating in excess of 20 percent for a left shoulder strain is denied. A rating in excess of 10 percent for a right knee strain based on limitation of motion is denied. A rating in excess of 10 percent for a left knee strain based on limitation of motion is denied. A rating of 20 percent, but no higher for right knee instability is granted. A rating of 20 percent, but no higher, for left knee instability is granted. FINDINGS OF FACT 1. The Veteran had active duty from March 1977 to June 1994, with an earlier period of unverified service. 2. Resolving all reasonable doubt in his favor, his low back disability manifested by pain, flareups, limited range of motion, including forward flexion limited between 30 and 60 degrees for the entirety of the appeal period. 3. The Veteran's left (minor) shoulder disability is manifested by painful, limited motion but not to 25 degrees of either flexion or abduction from his side, with flareups causing additional pain and weakness when lifting his arm over his head. 4. The Veteran's left and right knee disabilities manifest with pain, limitation of motion with flexion to 30 degrees and 15 degrees, weakness, and giving away. Resolving all reasonable doubt in his favor, both knees exhibited moderate instability throughout the appeal period. CONCLUSIONS OF LAW 1. The criteria for a rating of 20 percent for degenerative joint disease of the lumbar spine is met prior to November 1, 2010; the criteria for a rating in excess of 20 percent have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5003, 5235-5243 (2020); 38 C.F.R. § 4.71a DCs 5003, 5235-5243 (2021). 2. The criteria for a rating in excess of 20 percent for a left shoulder disability is not warranted. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, DCs 5200-5203 (2020); 38 C.F.R. § 4.71a, DCs 5200-5203 (2021). 3. The criteria for a rating in excess of 10 percent for a left knee strain for limitation of motion is not met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.71a, DCs 5003, 5257-5260 (2020); 38 C.F.R. §§ 4.71a, DCs 5003, 5257-5260 (2021). 4. The criteria for a rating in excess of 10 percent for a right knee strain for limitation of motion is not met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.71a, DCs 5003, 5257-5260 (2020); 38 C.F.R. §§ 4.71a, DCs 5003, 5257-5260 (2021). 5. The criteria for a rating of 20 percent, but no higher, for a left knee strain for instability is met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.71a, DC 5257 (2020); 38 C.F.R. §§ 4.71a, DC 5257 (2021). 6. The criteria for a rating of 20 percent, but no higher, for a right knee strain for instability is met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.71a, DC 5257 (2020); 38 C.F.R. §§ 4.71a, DC 5257 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appeal returns from a November 2020 Joint Motion for Partial Remand (JMPR) from the Court of Appeals for Veterans Claims (the Court). The Court determined that the prior October 2019 Board decision provided inadequate reasons and bases for the claims listed above. However, the issues of awarding separate 10 percent ratings for right and left knee instability, and the award of 20 percent for right lower extremity radiculopathy, were not disturbed and as such are not currently before the Board. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Lumbar Spine While this appeal was pending, the rating criteria for musculoskeletal disabilities was amended effective February 7, 2021. See 85 Fed. Reg. 230 (Nov. 30, 2020). If the amended criteria are more favorable, the implementation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of the change. If the pre-amended criteria are more favorable, VA can apply the pre-amended criteria for the period prior to and from the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's appeals under the pre-amended criteria prior to February 7, 2021, and both the pre-amended and amended criteria since February 7, 2021. The criteria that is more favorable will be applied. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Lumbosacral spine disabilities are rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (Spine Formula). 38 C.F.R. § 4.71a, DCs 5237-5243. Intervertebral disc syndrome (IVDS) is rated under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula), whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The amended regulations clarify that DC 5243 is to be assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign DC 5242 for all other disc diagnoses. No other changes were made to the rating criteria for the spine. The amended regulations clarify that DC 5243 is to be assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root; DC 5242 should be assigned for all other disc diagnoses. The Veteran is currently assigned DC 5242 for degenerative joint disease, but the period after February 7, 2021 will be examined to see if the new regulations apply. The Veteran's low back disability has been rated at 10 percent prior to November 1, 2010 under DC 5242 for degenerative joint disease of the lumbar spine, and 20 percent under the same DC thereafter. No other changes were made to the rating criteria for the spine. Although updates were also made for the rating for some forms of arthritis in the new regulations, a 20 percent rating for degenerative arthritis under DC 5003 remains unchanged. A rating in excess of 10 percent will be warranted when the objective medical evidence shows the following: forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees (20 percent); combined range of motion of the thoracolumbar spine not greater than 120 degrees (20 percent); forward flexion of the thoracolumbar spine 30 degrees or less (40 percent); muscle spasms or guarding that is severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis (20 percent); favorable ankylosis of the entire thoracolumbar spine (40 percent); incapacitating episodes of IVDS having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); incapacitating episodes of IVDS having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months (40 percent); or, degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations (20 percent). Under the new regulations, the next higher rating may be warranted of 40 percent for IVDS is warranted with incapacitating episodes having a total during of at least 4 weeks but less than 6 weeks during the past 12 months. Under both the old and new regulations, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Turning to the evidence, a higher rating for ankylosis is not warranted by the evidence. A February 2005 VA examiner, November 2010 VA examiner, March 2016 VA examiner, October 2017 VA examiner, and a December 2018 VA examiner all affirmatively found no ankylosis of the lumbar spine. Similarly, a review of his VA and private treatment records fails to show a diagnosis of ankylosis. Further, he has not claimed that his spine ankylosed, nor does descriptions of his flareups include evidence of his spine locking at any angle. As such, a higher rating for ankylosis is not warranted by the evidence. For the period prior to November 1, 2010, a higher rating may be warranted due to muscle spasms or guarding resulting in an abnormal gait or spinal contour. This is not supported by the medical evidence. A February 2005 VA examiner report should no muscle spasm. During a November 2010 VA examination, the Veteran reported flareups four times per week lasting three hours, which caused stiffness, spasms, decreased motion, and numbness and paresthesia. However, upon examination there was no evidence of muscle spasm, and his gait and spinal curvature were normal. VA and private medical records similarly do not show the requisite symptoms associated with muscle spasm or guarding to warrant a higher rating during this period. April 2003 VA medical records show complaints of chronic pain in his back. May 2006 VA medical records show back pain at 6 or 7 out of 10. September 2008 VA medical records show muscle spasms, but not the associated abnormal gain or spinal contour associated and required for a higher rating. July 2005 lay statements also referenced observed back pain, although did not specifically speak to guarding or muscle spasms. As such, the evidence does not support that a higher rating prior to November 1, 2010, due to muscle spasms or guarding is warranted by the evidence. Next, a higher rating is not warranted at any point in the appeal period for IVDS. The most recent December 2018 VA examination found IVDS, although it was denied in earlier examinations. Nevertheless, even if IVDS existed for the entirety of the appeal period, a February 2005 VA examiner, November 2010 VA examiner, March 2016 VA examiner, October 2017 VA examiner, and a December 2018 VA each failed to find that in any given year there were incapacitating episodes of IVDS of at least two weeks but less than four for a 20 percent rating, or more than four weeks and less than six for a 40 percent rating. Similarly, although he endorsed pain and flareups in his VA and private treatment records as noted above, and in a July 2005 lay statement it was noted he had to rest in bed for 60 percent of a vacation, he lacks the physician prescribed bedrest necessary for a higher rating of IVDS. This also applies under the new regulations. It is unclear whether he has IVDS as described under the new regulations, as it only applies when there is disc herniation with compression and/or irritation of the nerve root. However, remand to establish this is unnecessary because the requisite bed rest prescribed by a physician to treat incapacitating episodes is not shown by the record, as outline above. As such, a higher rating is not warranted by the evidence. Turning then to limitation of motion, a February 2005 VA examiner measured forward flexion as limited to 0 to 70 degrees, extension 0 to 20 degrees, right and left lateral flexion 0 to 30 degrees, right lateral rotation 0 to 15 degrees and left lateral rotation 0 to 10 degrees. There was no additional limitation based on pain, fatigue, weakness, lack of endurance, or incoordination on repetitive use. The Veteran did not report flareups during the examination. A November 2010 VA examiner found his range of motion limited as follows: forward flexion was 0 to 60 degrees with pain at 35, extension was 0 to 15 with pain at 15 degrees, right and left lateral flexion 0 to 25 degrees with pain at 25 degrees, right lateral rotation 0 to 25 degrees with pain at 25 degrees, and left lateral rotation 0 to 25 degrees with pain at 25 degrees. Pain was noted and caused functional loss. There was no evidence of pain with weightbearing. There was no additional loss of function or range of motion after three repetitions. The Veteran reported functional loss due to pain, fatigue and weakness. The Veteran reported flareups up to four times per week. A March 2016 VA examiner measured his range of motion limited as follows: forward flexion was 0 to 45 degrees, extension 0 to 10 degrees, right and left lateral flexion each 0 to 25 degrees, and right lateral rotation 0 to 20 degrees and left lateral rotation 0 to 15 degrees. Pain was noted and caused functional loss. There was no evidence of pain with weightbearing. There was no additional loss of function or range of motion after three repetitions. The Veteran reported functional loss due to pain, fatigue and weakness. The Veteran denied flareups during the examination. An October 2017 VA examination showed the following limitations: forward flexion was 0 to 60 degrees, extension 0 to 20 degrees, right and left lateral flexion both 0 to 20 degrees, right lateral rotation 0 to 15 degrees, and left lateral rotation 0 to 20 degrees. Pain was noted and caused functional loss. There was no pain with weight bearing or tenderness on palpation. The Veteran did complain of flareups during this examination, but the examiner did not estimate the additional loss of range of motion for either repeated use over time or during flareups. Finally, a December 2018 VA examiner measured the following limitations of motion: forward flexion was 0 to 75 degrees, extension was 0 to 20 degrees, right and left lateral flexion both 0 to 30 degrees, and right and left lateral rotation both 0 to 20 degrees. The examiner found no additional loss of range of motion after repetitive testing or repetitive use over time, however did estimate that during flareups due to pain flexion was limited to 0 to 50 degrees, extension 0 to 20 degrees, with no additional limitation of motion for lateral flexion or lateral rotation. A review of his private and VA medical records shows treatment for his back disorder, but never any measured limitation of motion that would warrant a higher rating. April 2003 VA medical records show complaints of chronic pain in his back. May 2006 VA medical records show back pain at 6 or 7 out of 10. September 2008 VA medical records show muscle spasms. August 2009 private medical records list debilitating arthritis, but do not specify if this applies to the back. They also show that were no spine abnormalities and normal muscle strength and tone, however the records were focused on heart treatment. He described in October 2011 VA medical records that he had constant dull low back pain, that was made better by rest, and became sharp pain made worse by walking, standing and exercise. He again complained of constant low back pain made better by rest and worse by walking, bending over, and exercise during a March 2016 VA medical appointment. May 2017 VA medical records show he had low back pain made better by rest, worse by walking, standing, and bending over, and that the pain interfered with the activities of daily living, appetite, relationships, mood, concentration, sleep, and mobility. May 2018 VA medical records show that there was tenderness upon palpation of the lumbar spine, and he received a shot for back pain. Multiple June 2018 VA medical records showed he was treated for lumbar spine pain, which was radiating pain down his right leg. He was given a TENS unit for the pain, but it was not helpful, and he rated the pain as 10/10. July 2005 lay statements also referenced observed back pain, with his mother stating he had to stay in bed for 60 percent of a 2003 vacation. In a July 2010 statement, the Veteran reported flareups and weakness throughout the appeal period, and the VA examiners mistakenly attributed him saying there were no flareups. In December 2018, he claimed his back condition had worsened. The Veteran requested through his representative in a January 2021 brief that either an increase should be awarded, or a remand for retrospective opinions as each examiner prior to the December 2018 examination either denied that he had flareups or did not estimate the functional impairment they caused. However, as he maintained that he has credibly had flareups throughout the appeal period, resolving all reasonable doubt in his favor, the functional limitations for flareups measured in the December 2018 VA examination will be retroactively applied to the older examinations. There, as his limitation of flexion was limited to 50 degrees, a 20 percent rating for limitation of flexion is warranted prior to November 1, 2010 and thus for the entirety of the appeal period. However, for the rest of the appeal period, at no point was flexion measured as less than 30 degrees by a VA examiner, or treating VA or private medical professional. The functional impairment caused by his pain and weakness, including during flareups, was incorporated in the December 2018 VA examination report. There is no further reasonable doubt to be resolved, as it would require the Board making an independent medical determination regarding additional range of motion limitation and functional impairment. As such, a 20 percent rating for the entirety of the appeal period, but no higher, for limitation of flexion is warranted. As the Veteran now has a 20 percent rating for the entirety of the appeal period, a higher rating due to degenerative arthritis is not warranted as 20 percent is the maximum rating under both the old and new diagnostic codes. Left Shoulder The Veteran is rated at 20 percent for his left shoulder strain under DC 5201 for limitation of motion of the shoulder. Pertaining to limitation of motion, for the minor arm, a disability of the shoulder may be rated under DCs 5200-5203. Higher ratings require: intermediate ankylosis between favorable and unfavorable (30 percent under DC 5200); limitation of motion to no more than 25 degrees from the side (30 percent under DC 5201); or fibrous union of the humerus (40 percent under DC 5202). Under the revised criteria, a 20 percent rating is warranted when the objective medical evidence shows: flexion and/or abduction limited to 25 degrees from the side (30 percent under DC 5201). The criteria for a higher rating under DC 5200 and 5201 have not been altered. Turning to the evidence, no medical professional has found ankylosis at any angle for the Veteran's left shoulder. April 2012, March 2016 and December 2018 VA examiners each found no ankylosis upon examination. The Veteran did not report nor did either examiner find ankylosis of the left shoulder during flareups. VA and private medical records further do not reflect ankylosis. As such, a higher rating due to ankylosis is not warranted by the evidence. Similarly, the April 2012, March 2016 and December 2018 VA examiner failed to find fibrous union of the humerus. A review of all other VA and private medical records also failed to show fibrous union of the humerus. As such, a higher rating under DC 5202 for fibrous union of the humerus is not warranted by the medical evidence. As for limitation of motion, the April 2012 VA examiner found that the left shoulder had the following limitations or range of motion: flexion 0 to 170 but painful motion at 130 degrees, and left shoulder abduction 0 to 160 with painful motion at 90 degrees. After repetitive use flexion was limited to 0 to 160 degrees and abduction limited 0 to 150 degrees. The functional loss reported by the Veteran was that it caused less movement than normal in the left shoulder with pain on movement and on palpation. The Veteran reported flareups that made him unable to do any activities above his head such as changing a light bulb, and the examiner found that it would limit him from performing any work with left arm above his head or lifting or carrying more than 25-pounds, or pushing or pulling weights of more than 25-pounds with the left shoulder. The right shoulder was also measured for comparison. During a March 2016 VA examination, range of motion testing of the left shoulder showed flexion limited to 0 to 110 degrees, abduction limited 0 to 105 degrees, external rotation limited 0 to 40 degrees, and internal rotation limited 0 to 30 degrees, with pain noted and causing functional loss. There was no evidence of pain on weight bearing and no additional loss of motion after three repetitions. The examiner noted that pain, fatigue, and weakness significantly limited the functional ability of the Veteran's left shoulder with repetitive use over time, but he was unable to describe this limitation in terms of range of motion. Although he later disputed this, the Veteran did not report flareups during the examination. The right shoulder was also measured for comparison Finally, during a December 2018 VA examination, range of motion testing showed left shoulder flexion limited to 0 to 100 degrees, abduction 0 to 100 degrees, external rotation 0 to 50 degrees, internal rotation 0 to 40 degrees, with no evidence of pain, with no additional loss of motion after repetitions or repetitive uses over time. During this examination, the Veteran did claim he had flareups of the left shoulder typified by severe pain with reaching or lifting. The examiner estimated this to limited flexion to 0 to 80 degrees, abduction 0 to 85 degrees, external rotation 0 to 80 degrees, and internal rotation 0 to 30 degrees, with this additional loss of range of motion caused by pain. The right shoulder was also measured for comparison. The examiner found the functional impact of the condition to be shoulder pain with reaching and lifting. A review of his VA and private medical records show frequent complaints about right shoulder pain earlier in the appeal period. In May 2016, VA medical records show complaints of neck pain radiating to his shoulder, and that he had pain lifting his arm above shoulder height. In January 2018 VA medical records show he complained of shoulder pain as well as other musculoskeletal issues. At no point has the medical evidence shown either the Veteran's flexion or abduction of the shoulder should be limited to 25 degrees from the side. Even when resolving all reasonable doubt in his favor and applying the flareup estimations used in the December 2018 VA examination to the prior examinations that failed to contemporaneously estimate the functional impact of flareups, the resulting limitation of motion is insufficient to warrant a higher rating. The Veteran has requested that a higher rating be given based on the functional impairment that his pain, fatiguability, weakness, and flareups cause, specifically that lifting above his head or reaching up with the left shoulder causes his symptoms to be worse. However, the next highest rating for limitation of motion requires lack of left shoulder mobility that to warrant it, he would not be able to reach above his head at all, with flexion and abduction limited to only 25 degrees from the side. Currently, the estimated loss of range of motion is significantly less than what is required for the next highest rating. It would not be equitable to give a higher rating for pain and weakness caused by lifting his left arm above his head, given that the next highest rating does not contemplate the ability to do so. Additionally, the Veteran has asked through his attorney that if a higher rating cannot be assigned, he would like the claim to be remanded for retroactive opinions regarding flareups. However, resolving all reasonable doubt in his favor, the estimated functional impairment and loss of range of motion found by the December 2018 VA examiner is retroactively applied to the older VA examiners. Still, as discussed above, this would not warrant a higher rating. As such, a rating in excess of 20 percent due to range of motion is not supported by the evidence. Knee Disabilities As the evidence for the Veteran's four knee disabilities on appeal is similar, they will be analyzed together. He is currently service connected for chronic right and left knee strains under DC 5260 for limitation of flexion at 10 percent, as well as at 10 percent each under DC 5257 for recurrent subluxation or lateral instability. The amended regulations apply may apply from the date of implementation, February 7, 2021. From there forward, whichever is most favorable will be used to assess the Veteran's current level of functional impairment. Under the pre-amended regulations, a 20 percent rating is warranted when the objective medical evidence shows: moderate recurrent subluxation or lateral instability; dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint; flexion of the leg limited to 30 degrees; extension of the leg limited to 15 degrees; malunion of the tibia or fibula with moderate knee or ankle disability; or, degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. Under the revised criteria, a 20 percent rating is warranted when the objective medical evidence shows: 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 dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint; one of the following: - sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or - unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation flexion of the leg limited to 30 degrees; extension of the leg limited to 15 degrees; medial tibial stress syndrome (MTSS), or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity; or, degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations Under the pre-amended regulations, a 30 percent rating is warranted when the objective medical evidence shows: ankylosis of the knee with favorable angle in full extension, or in slight flexion between 0 and 10 degrees; severe recurrent subluxation or lateral instability; flexion of the leg limited to 15 degrees; extension of the leg limited to 20 degrees; or, malunion of the tibia or fibula with marked knee or ankle disability. Under the revised criteria, a 30 percent rating is warranted when the objective medical evidence shows: ankylosis of the knee with favorable angle in full extension, or in slight flexion between 0 and 10 degrees; unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation; flexion of the leg limited to 15 degrees; extension of the leg limited to 20 degrees; or, MTSS or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. Turning to the evidence, an increased rating due to degenerative arthritis is not supported by the evidence. An October 2001 VA examiner interpreted X-rays that were deemed to show bilateral knees within normal limits as bilateral degenerative joint disease, however every subsequent X-ray and VA examiner did not find a diagnosis of arthritis. February 2008 VA X-rays showed no degenerative changes were appreciated. As such, a higher rating due to arthritis is not warranted by the evidence. In January 2018, VA medical records show a diagnosis of osteoarthritis of the knees but with no recent X-ray. He was referred for X-rays, and February 2018 VA X-ray reports do note degenerative joint disease in both knees. However, the December 2018 VA examiner did not find that they resulted in any incapacitating exacerbations, of either knee with involvement of two major or minor joint groups. Similarly, a review of his VA and private treatment records since his diagnosis supported by X-ray evidence fails to show incapacitating exacerbations caused by two major of minor joint groups. As such, a higher rating for degenerative joint disease is not warranted by the evidence. Next, the Veteran has not claimed nor does the medical evidence show that he has ankylosis of either knee. VA examiners in July 2008, November 2010, March 2016, October 2017, and December 2018 found that he did not have ankylosis of either knee. This includes in their description of his knee flareups. Similarly, neither private, department of defense, nor VA medical records note that he had ankylosis of either knee. As such, a separate or higher rating for ankylosis under both the old and new regulations is not supported by evidence. With respect to the semilunar cartilage, the Veteran does not have a meniscal injury. VA examiners in July 2008, November 2010, March 2016, October 2017, and December 2018 did not note a meniscal condition. Additionally, he has not claimed nor have any private, governmental, or VA medical records show any meniscal injury or surgery. As such, a separate or higher rating for a meniscal condition is not supported by the evidence. Next, the evidence does not support higher ratings based on limitation of flexion or extension. To that end, the Veteran is currently assigned a 10 percent rating for both knees for limitation of flexion for pain rather than measured limitation of flexion, in the right knee. A July 2008 VA examiner measured showed flexion from 0 to 140 degrees and extension to 0 degrees, with pain at 135 degrees, bilaterally. Repetitive use testing did not result in additional limitation of range. The examiner reported there were no flareups. A November 2010 VA examiner measured flexion at 0 to 130 degrees with pain at 130 degrees, and normal extension. The Veteran reported flareups that his knees were frequently stiff and locked up, and also were weak; more activity made it more likely to gives away; flareups occurred 5 times per month usually precipitated by increased weight bearing and improved by rest. A March 2016 VA examiner measured right knee range of motion testing showed flexion from 0 to 125 degrees with pain at 120 degrees, and extension 125 to 0 degrees, bilaterally. Pain resulting in functional loss was noted. There was no additional loss of motion after three repetitions. The Veteran reported functional loss due to pain with repeated use over a period of time. The examiner stated that the Veteran again denied flareups. The October 2017 VA examiner found flexion limited from 0 to 120 degrees and extension to 0 degrees, bilaterally. Pain not resulting in functional loss was noted. There was no additional loss of motion after three repetitions. The Veteran reported functional loss due to pain with repeated use over a period of time. The examiner noted reported flareups, described as increased pain with prolonged standing, but did not estimate additional range of motion lost for repeated use over time or flareups. Finally, the December 2018 VA examiner measured right knee range of motion flexion limited to 0 to 110 degrees and extension to 0 degrees. Left knee range of motion testing showed flexion from 0 to 105 degrees and extension to 0 degrees. There was no pain noted on examination and no additional loss of motion after three repetitions. The Veteran reported limited functional ability with flare ups due to pain. The examiner estimated, taking into account the Veteran's pain, weakness, and fatiguability during flareups, that his range of motion during those flareups of the right knee would be flexion limited from 0 to 80 degrees and extension 80 to 0 degrees, and the left knee limited to flexion of 0 to 90 degrees and extension 90 to 0. After several remands, the December 2018 VA examiner was the first to actually provide an estimation of loss of range of motion and functional impairment during flareups. A few of the earlier examinations show the Veteran stated he did not complain of any flareups, although this is in contrast to correspondence submitted. In most recent correspondences, the Veteran has continually stated that flareups existed throughout the whole of the appeal period. Additionally, he has asked through his attorney in a January 2021 brief that retroactive medical opinions be issued to determine the degree of impairment caused by flareups at the time of those prior examinations. The Board finds that the flareup estimations from the December 2018 VA examinations will be applied to each of the prior examinations. However, even when doing so, limitation of flexion to 30 degrees or limitation of extension to 15 degrees is not shown. Similarly, VA medical records show complaints of pain and limitation of motion, although do not contain range or motion measurements sufficient to warrant a higher rating. In February 2004, VA medical records show he complained of right knee throbbing, mostly at night or after sitting. October 2011 VA medical records, he described that he has constant dull knee pain, sometimes sharp and made worse by walking, standing, or exercise. March 2016 VA medical records show constant pain in his knee, worsened by walking, bending over, or exercise. January 2018 VA treatment records show pain with range of motion of the knees, but do not specify at what specific level of flexion or extension, and records the next month show he had increased stiffness and pain in his knees. An increased rating is warranted when there is a permanent increase in severity of symptoms but not for temporary decreases in functionality. As such, the medical evidence does not support higher ratings under DCs 5260-5261 for limitation of motion. Next, the Veteran has not claimed, and the evidence does not show, impairment of the tibia or fibula. VA examiners in VA examiners in July 2008, November 2010, March 2016, October 2017, and December 2018 did not find any impairment of the tibia or fibula in the right leg. Further, private and VA medical records did not show a left or right tibia or fibula impairment. Therefore, a higher rating is not warranted under these criteria. Additionally, the same VA examiners did not diagnose the Veteran with MTSS, nor do his private or VA medical records show treatment for MTSS. As such, a higher or separate rating for MTSS under the new rating criteria is not supported by the medical evidence. Finally, the Veteran is currently awarded a 10 percent rating for each knee for lateral instability. This has been awarded despite no VA examiner finding objective evidence of instability during the July 2008, November 2010, March 2016, October 2017, and December 2018 examinations. However, the Veteran has consistently alleged during flareups he has extreme weakness and that his knees will give way. This has been encapsulated in VA medical records, as well as lay statements from the Veteran and others, throughout the appeal period. In February 2004 VA medical records he complained that his right knee often gave out, but that he was ble to catch himself. October 2004 VA medical records showed bilateral patellar laxity and painful crepitus of the right knee. In April 2005, he was prescribed medication for tight muscles but was warned might make his knees give way. May 2006 VA medical records show his knees hurt and swell if he exerted himself and give way. March 2016 VA medical records show constant pain in his knee, worsened by walking, bending over, or exercise. May 2017 VA medical records show he reported pain in his knees, among other parts of his body, which was constant, throbbing, and stabbing, made better by rest and worse by walking, standing, and bending over, and interfered with activities of daily living, appetite, mood, concentration, sleep and mobility. July 2005 lay statements submitted from multiple parties documented that the Veteran had knee pain and fell frequently. His accounts have been consistent and credible, and the Board finds them as having particular probative value. The Veteran has argued that his flareups are not adequately encapsulated by the additional range of motion limitation shown in the December 2018 VA examination, resolving all reasonable doubt in his favor, a 20 percent rating for moderate bilateral knee instability for the entirety of the appeal period is warranted by the evidence. A rating for 30 percent is not warranted because upon examination there is no objective medical evidence of recurrent subluxation or lateral instability, and that it is tied to flareups rather than consistent, which makes the moderate designation associated with a 20 percent rather than the severe designation associated with a 30 percent the most fitting. As such, a higher rating under this diagnostic code, but no other, is warranted by the medical evidence. For the period in which the new diagnostic code applied, a rating of 30 percent under DC 5257 is not warranted by the evidence. A 30 percent rating for patellar instability requires a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair. Here, the Veteran has not claimed, nor does the medical evidence, to include VA examination show, that he had a surgical procedure of one ot the patellofemoral components that contributed to the instability. As such, a higher rating from February 7, 2021 under the new diagnostic code for patellar instability is not supported by the evidence. Similarly, a 30 percent rating for recurrent subluxation or instability, also under DC 5257, requires an unrepaired or complete ligament tear. Here, the Veteran has not claimed, nor does the medical evidence, to include VA examination show either a failed repair or complete ligament tear. As such, the increase to 20 percent under the old diagnostic code applies for this period, and a higher rating is not supported by the evidence. The Board has also considered the Veteran's lay statements that his disabilities are worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiners had the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disabilities and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran's subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, other than the increase of rating from 10 to 20 percent for bilateral knee instability, and from 10 to 20 percent for the lumbar spine disability prior to November 1, 2010, the benefit of the doubt rule is not applicable and the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Saudiee Brown Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Brendan A. Evans, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.