Citation Nr: 21027340 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 17-09 838 DATE: May 5, 2021 ORDER Entitlement to service connection for right ankle Charcot joint is granted. Entitlement to a higher initial rating for left lower extremity radiculopathy, rated noncompensable, from August 1, 2011 through June 12, 2017, and 40 percent disabling, from June 13, 2017, is denied. Entitlement to a higher initial rating for right lower extremity radiculopathy, rated noncompensable, from August 1, 2011 through June 12, 2017, and 40 percent disabling, from June 13, 2017, is denied. Entitlement to a rating in excess of 40 percent for residuals, fracture, L5 vertebra with degenerative joint disease, from August 1, 2011 through June 12, 2017, is denied. Entitlement to a 50 percent rating, but no higher, for residuals, fracture, L5 vertebra with degenerative joint disease, from June 13, 2017, is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an increased rating for right knee arthritis with limitation of flexion, rated 10 percent disabling, from August 1, 2011 through October 31, 2016, and noncompensable, from November 1, 2016, is denied. Entitlement to an increased rating for right knee arthritis with limitation of extension, rated noncompensable, from August 1, 2011 through October 31, 2016, and 10 percent disabling from, November 1, 2016, is denied. Entitlement to an increased rating for left knee arthritis with limitation of flexion, rated 30 percent disabling, from August 1, 2011 through October 31, 2016, and noncompensable, from November 1, 2016, is denied. Entitlement to an increased rating for left knee arthritis with limitation of extension, rated 10 percent disabling, from August 1, 2011 through October 31, 2016, and 40 percent disabling, from November 1, 2016, is denied. Entitlement to an increased rating for bilateral hearing loss, rated noncompensable, from August 1, 2011 through June 12, 2017, and 30 percent disabling, from June 13, 2017, is denied. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's current right ankle Charcot joint began during active service. 2. Since June 13, 2017, but no earlier, the Veteran's left lower extremity radiculopathy has been manifested by at most moderately severe incomplete paralysis of the sciatic nerve. 3. Since June 13, 2017, but no earlier, the Veteran's right lower extremity radiculopathy has been manifested by at most moderately severe incomplete paralysis of the sciatic nerve. 4. From August 1, 2011 through June 12, 2017, the Veteran's residuals, fracture, L5 vertebra with degenerative joint disease did not result in spinal ankylosis or the functional equivalent of spinal ankylosis, and he did not experience incapacitating episodes due to intervertebral disc syndrome (IVDS) having a total duration of at least 6 weeks during a 12-month period. 5. Since June 13, 2017, the Veteran's residuals, fracture, L5 vertebra with degenerative joint disease are manifested by limitation of forward flexion of the thoracolumbar spine to 20 degrees, with an additional 20 degree limitation of motion during flare ups and associated neurologic symptoms; there is no ankylosis of the entire spine or incapacitating episodes due to IVDS having a total duration of at least 6 weeks during a 12-month period. 6. From August 1, 2011 through October 31, 2016, the Veteran's right knee arthritis was manifested by limitation of flexion of the knee to at most 50 degrees and limitation of extension of the knee to at most 5 degrees with repeated use over time and during flare ups; there is no additional significant loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. 7. Since November 1, 2016, the Veteran's right knee arthritis is manifested by limitation of flexion of the knee to at most 70 degrees and limitation of extension of the knee to at most 10 degrees with repeated use over time and during flare ups; there is no additional significant loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. 8. From August 1, 2011 through October 31, 2016, the Veteran's left knee arthritis was manifested by limitation of flexion of the knee to 0 degrees and limitation of extension of the knee to at most 10 degrees with repeated use over time and during flare ups; there is no additional significant loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. 9. Since November 1, 2016, the Veteran's left knee arthritis is manifested by limitation of flexion of the knee to at most 80 degrees and limitation of extension of the knee to at most 30 degrees with repeated use over time and during flare ups; there is no additional significant loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. 10. From August 1, 2011 through June 12, 2017, the Veteran had at worst level I hearing in both ears. 11. Since June 13, 2017, the Veteran has had at worst level VII hearing in the right ear and level V hearing in the left ear. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for right ankle Charcot joint are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(b). 2. The criteria for an initial compensable rating, from August 1, 2011 through June 12, 2017, and a rating higher than 40 percent, from June 13, 2017, for left lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code (DC) 8620. 3. The criteria for an initial compensable rating, from August 1, 2011 through June 12, 2017, and a rating higher than 40 percent, from June 13, 2017, for right lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.123, 4.124, 4.124A, Diagnostic Code (DC) 8620. 4. The criteria for a rating in excess of 40 percent, from August 1, 2011 through June 12, 2017, for residuals, fracture, L5 vertebra with degenerative joint disease are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71A, Diagnostic Codes (DC) 5010, 5242. 5. The criteria for a 50 percent rating, but no higher, from June 13, 2017, for residuals, fracture, L5 vertebra with degenerative joint disease are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71A, Diagnostic Codes (DC) 5010, 5242. 6. The criteria for a rating in excess of 10 percent, from August 1, 2011 through October 31, 2016, and a compensable rating, from November 1, 2016, for right knee arthritis with limitation of flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71A, Diagnostic Codes (DC) 5003, 5260. 7. The criteria for a compensable rating, from August 1, 2011 through October 31, 2016, and a rating in excess of 10 percent, from November 1, 2016, for right knee arthritis with limitation of extension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71A, Diagnostic Codes (DC) 5003, 5261. 8. The criteria for a rating in excess of 30 percent, from August 1, 2011 through October 31, 2016, and a compensable rating, from November 1, 2016, for left knee arthritis with limitation of flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71A, Diagnostic Codes (DC) 5003, 5260. 9. The criteria for a rating in excess of 10 percent, from August 1, 2011 through October 31, 2016, and in excess of 40 percent, from November 1, 2016, for left knee arthritis with limitation of extension are not. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71A, Diagnostic Codes (DC) 5003, 5261. 10. The criteria for a compensable rating, from August 1, 2011 through June 12, 2017, and a rating in excess of 30 percent, from June 13, 2017, for bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.85, 4.86, Diagnostic Code (DC) 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1971 to April 1973 and from September 1976 to July 1988. These matters initially came before the Board of Veterans' Appeals (Board) from an August 2013 rating decision. In March 2014, the agency of original jurisdiction (AOJ) made the following determinations: awarded a separate 10 percent rating for left knee arthritis with limitation of extension, from August 1, 2011; awarded an increased (30 percent) rating for left knee arthritis with limitation of flexion, from August 1, 2011; and awarded a separate noncompensable disability rating for right knee arthritis with limitation of extension, from August 1, 2011. In January 2017, a Decision Review Officer (DRO) awarded an increased (40 percent) rating for left knee arthritis with limitation of extension and an increased (10 percent) rating for right knee arthritis with limitation of extension, both from November 1, 2016. In February 2019, the Board awarded a TDIU and remanded the issues of entitlement to service connection for right ankle disability and entitlement to increased ratings for the service connection back disability, right and left knee disabilities, and bilateral hearing loss for further development. The AOJ implemented the Board's award of a TDIU in a March 2019 rating decision, in which a TDIU was awarded, from October 30, 2018 (the day after the Veteran's gainful employment ended). In November 2020, the AOJ awarded an increased (30 percent) rating for bilateral hearing loss, from June 13, 2017. The AOJ also awarded service connection for left and right lower extremity radiculopathy and assigned initial 40 percent disability ratings, both from June 13, 2017. In September 2013, the Veteran requested a hearing at the AOJ (see a September 2013 "Report of General Information" form (VA Form 27-0820)). He withdrew his AOJ hearing request in October 2016 (see an October 2016 VA Form 27-0820). The Veteran testified before the undersigned Veterans Law Judge at a June 2017 hearing and a transcript of the hearing has been associated with his claims file. As for characterization of the issues on appeal, the Board has included the separate issues of entitlement to higher initial ratings for left and right lower extremity radiculopathy because these issues are being considered as part of the claim for an increased rating for the service-connected back disability. See 38 C.F.R. § 4.71A, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (providing that associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately, under an appropriate diagnostic code). Since the claim period for the back issue dates back to August 1, 2011, the Board has characterized the radiculopathy issues as entitlement to higher initial ratings for left and right lower extremity radiculopathy, rated noncompensable, from August 1, 2011 through June 12, 2017, and 40 percent disabling, from June 13, 2017. As a final preliminary matter, in the February 2019 remand, the Board instructed the AOJ to, among other things, ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records, obtain the Veteran's outstanding VA treatment records, and afford the Veteran examinations to assess the severity of his service-connected back disability, right and left knee disabilities, and hearing loss. Pursuant to the Board's remand, the Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records by way of a June 2020 letter. Copies of the authorization forms (VA Forms 21-4142a and 21-4142) were included with the letter. Moreover, all available outstanding VA treatment records were obtained and associated with the claims file and the Veteran was afforded VA examinations in April 2019, October 2020, and November 2020 to assess the severity of his service-connected back disability, right and left knee disabilities, and hearing loss. Therefore, the AOJ substantially complied with the Board's pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). I. Service Connection Entitlement to service connection for right ankle Charcot joint Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Veteran contends that he has current right ankle disability which had its onset in service. The Board finds, for the following reasons, that the Veteran has a current diagnosis of right ankle Charcot joint and that the evidence is at least evenly balanced as to whether this disability began during active service. As an initial matter, the Board notes that the Veteran reported on a May 1971 report of medical history form completed for purposes of entrance into service that he experienced a right ankle sprain prior to service. The Board points out, however, that a veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). The term "noted," in 38 U.S.C. § 1111, refers to "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304 (b). A "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." 38 C.F.R. § 3.304 (b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). In this case, although the Veteran is competent to report a history of right ankle problems prior to service, a veteran's report of history, even when related by a medical professional, without an independent basis in the record, is insufficient to rebut the presumption of soundness. Miller v. West, 11 Vet. App. 345 (1998). There is no other evidence of any pre-existing right ankle disability prior to service and the Veteran's May 1971 entrance examination did not reflect any ankle abnormalities. Therefore, the Board finds that the evidence is not clear and unmistakable that any right ankle disability pre-existed service and was not aggravated in service and the Veteran is presumed sound at service entrance. 38 U.S.C. § 1111. Medical records, including a January 2019 VA primary care note, indicate that the Veteran has experienced right ankle Charcot joint during the claim period. Therefore, current right ankle disability has been demonstrated. There is also evidence of right ankle symptoms in service and evidence of continuous symptoms in the years following service. In this regard, the Veteran reported during the June 2017 hearing that he twisted his right ankle when he jumped out of a helicopter in service in approximately 1976 or 1977 and that he continued to experience ankle problems (including pain) during the remainder of his service. Moreover, the report of a VA examination conducted in August 1988 (only approximately two months following the Veteran's separation from service in July 1988) indicates that the Veteran reported right ankle instability and his post-service medical records and lay statements indicate that his right ankle symptoms continued in the years following service. The Veteran is competent to report right ankle symptoms in service and continuous ankle symptoms in the years following service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). There is nothing to explicitly contradict his reports and they are generally consistent with the evidence of record. Thus, the Board finds that the reports of right ankle problems in service and continuous right ankle symptoms in the years following service are credible. The nurse practitioner who conducted an October 2020 VA ankle examination opined that the Veteran's claimed right ankle disability was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. The examiner reasoned that the Veteran had a current diagnosis of a right below the knee amputation that was secondary to an infection, and that his service treatment records were silent for any chronic right ankle pain. The October 2020 opinion is of little, if any, probative value because it is solely based on the absence of clinical evidence of right ankle problems during service, and it does not take into account the Veteran's competent and credible reports of right ankle injury and symptoms in service and continuous symptoms in the years following service. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). In sum, the evidence reflects that the Veteran experienced right ankle symptoms in service and that there were continuous right ankle symptoms in the years following service. He has also experienced current right ankle Charcot joint during the claim period. There is no adequate medical opinion contrary to a conclusion that the current right ankle Charcot joint had its onset in service. Thus, the evidence is at least evenly balanced as to whether this disability had its onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for right ankle Charcot joint is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. See also Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). II. Higher Initial Ratings/Increased Ratings Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4 ) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports considering the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. § 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71A were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021 and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. 1. Entitlement to higher initial ratings for left and right lower extremity radiculopathy (rated noncompensable from August 1, 2011 through June 12, 2017 and 40 percent disabling from June 13, 2017) and entitlement to a rating in excess of 40 percent for residuals, fracture, L5 vertebra with degenerative joint disease A. Background The Veteran's claim for an increased rating for his service-connected back disability was received on August 1, 2011. The Veteran reported during an October 2013 VA back examination that he experienced moderate low back pain and occasional pain in the left buttock area. There was no numbness, tingling, or loss of sensation. He was unable to lift anything heavier than 10-15 pounds, had problems with prolonged standing, walking, and bending, and was only able to walk a mile at most. He walked with a mild limp, but did not use any walking aids. He did not experience any flare ups of back symptoms. Examination revealed that the ranges of motion of the thoracolumbar spine were flexion to 20 degrees with pain beginning at 0 degrees, extension and right lateral flexion both to 20 degrees with pain beginning at 0 degrees, and left lateral flexion and rotation both to 20 degrees with pain beginning at 20 degrees. There was pain with right lateral rotation beginning at 25 degrees. The Veteran was not able to perform repetitive-use testing with 3 repetitions because he was experiencing too much pain and muscle spasms. There was functional loss/impairment of the thoracolumbar spine in terms of less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and/or weight-bearing. There was localized tenderness or pain to palpation of the entire midline lumbar area. Moreover, lower extremity muscle strength was all normal (5/5) bilaterally, there was no muscle atrophy, lower extremity reflexes were normal (2+) bilaterally, lower extremity sensation was normal bilaterally, and straight leg raise testing was negative bilaterally. There was no radicular pain or any other signs or symptoms due to radiculopathy, and the Veteran did not have any other neurologic abnormalities or findings related to the thoracolumbar spine. He had IVDS of the thoracolumbar spine and experienced less than 1 week of incapacitating episodes due to IVDS during the previous 12 months. He did not use any assistive devices as a normal mode of locomotion and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were no scars related to the Veteran's back disability. He was diagnosed as having spondylolisthesis grade 1 degenerative L3 on 4. This disability impacted his ability to work. The examiner who conducted the October 2013 examination concluded that it was not feasible to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability during flare ups or when the joint was used repeatedly over a period of time. The report of a VA back examination dated in December 2013, the Veteran's December 2014 notice of disagreement (VA Form 21-0958), and his February 2017 substantive appeal (VA Form 9) indicate that he experienced back pain which affected his ability to stand up, walk, and climb stairs, affected the quality of his sleep, and occurred while sitting. The pain occurred on a daily basis and was 7-8/10 in intensity. Flare ups of back pain occurred 1 to 2 times per week, lasted for a day or two at a time, and additionally limited the Veteran's functioning by approximately 50 percent compared to when he was not experiencing a flare up. Examination revealed that the ranges of motion of the thoracolumbar spine were flexion to 20 degrees with pain beginning at that point, extension to 0 degrees with pain beginning at that point, and right and left lateral flexion and rotation all to 10 degrees with pain beginning at that point. The Veteran was able to perform repetitive use testing with 3 repetitions and the ranges of motion of the thoracolumbar spine following repetitive use testing were flexion to 10 degrees, extension to 0 degrees, and right and left lateral flexion and rotation all to 5 degrees. There was additional limitation in the ranges of spinal motion following repetitive use testing and there was functional loss/impairment of the thoracolumbar spine in terms of less movement than normal, weakened movement, excess fatigability, pain on movement, and interference with sitting, standing, and/or weight-bearing. Pain and fatigability significantly limited functional ability during flare ups or when the joint was used repeatedly over a period of time and the examiner specified that the Veteran would lose an additional 20 degrees of flexion from baseline during flare ups. There was pain to palpation of the lumbar spine, but there was no guarding or muscle spasms of the thoracolumbar spine. Moreover, lower extremity muscle strength was somewhat impaired (4/5) bilaterally, but there was no muscle atrophy. Knee and ankle reflexes were normal (2+) bilaterally, lower extremity sensation was normal bilaterally, and straight leg raise testing was negative bilaterally. The Veteran did not have any radicular pain, any other signs or symptoms due to radiculopathy, or any other neurologic abnormalities or findings related to a thoracolumbar spine disability. He did not have IVDS of the thoracolumbar spine, he did not use any assistive devices, and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There were scars related to the Veteran's back disability, but none of the scars were painful or unstable and the total area of all related scars was not greater than 39 square centimeters (6 square inches). There were no other pertinent physical findings, complications, conditions, signs, or symptoms. Diagnoses of residuals fracture L-5 vertebrae, laminectomy and partial discectomy with removal of bone fragments, and degenerative disc disease of the lumbar spine were provided. These disabilities impacted his ability to work in that he was only able to lift 30 to 40 pounds, walk 14 mile at a time, walk 1 mile during an 8 hour day, sit 30 minutes at a time, stand 10 to 15 minutes at a time, sit for 4 to 6 hours during an 8 hour day, and stand for 1 to 2 hours during an 8 hour day. He experienced daily back pain and it was hard to lift anything. The Veteran reported during the June 2017 Board hearing that his back disability had worsened since the December 2013 VA back examination. For instance, he was unable to carry any significant weight (e.g., nothing more than 2 gallons of milk), had to stop due to pain while only walking 15 feet from his car to his house, and the nerves in his back would pinch/grind if he turned his back the wrong way and cause him to drop things or fall to his knees. The Veteran's wife reported that she had witnessed the Veteran crawl to the bathroom and fall to his knees while walking due to severe pain. These episodes occurred up to 8 to 10 times per month. VA treatment records dated in April and May 2018 and the report of a VA back examination dated in April 2019 reflect that the Veteran experienced chronic lower back pain which was dull/deep/aching in nature, was 4-10/10 in intensity, was worsened by prolonged walking and sitting, radiated to the hips and buttocks bilaterally, and was associated with loss of sensation and decreased strength in his legs. He reported during an April 2018 VA physical therapy evaluation that the bilateral hip pain began approximately 1.5 months prior to the evaluation. He also experienced bilateral foot numbness and would fall when his legs gave out. Flare ups of back pain (10/10 in intensity) occurred randomly 2 to 4 times per month, during which he was unable to do anything. He was unable to run, play sports, or perform yard work, and had to use a walker while performing any housework. Examination revealed that the Veteran presented to the April 2019 examination in a wheelchair with his right leg casted below the knee due to treatment for right Charcot foot. He also had a left leg weight to equalize the weight. As a result, the Veteran was unable to perform ranges of motion of the thoracolumbar spine without risk of injury. There was evidence of pain with weight bearing, but no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissues of the thoracolumbar spine. The Veteran was not being examined immediately after repetitive use over time or during a flare up and the examination was neither medically consistent nor inconsistent with his statements describing functional loss with repetitive use over time. The examiner who conducted the April 2019 examination was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare ups because the Veteran was unable to perform range of motion exercises without risk of injury. There was no guarding or muscle spasms of the thoracolumbar spine. Moreover, muscle strength associated with left hip flexion and knee extension was somewhat impaired (4/5) and lower extremity sensation was absent bilaterally. The Veteran was unable to perform straight leg raise testing. He experienced mild intermittent pain in the lower extremities bilaterally, mild paresthesisas/dysesthesias in the right lower extremity, moderate paresthesisas/dysesthesias in the left lower extremity, and severe numbness in the lower extremities bilaterally. There was no constant pain in the lower extremities. Overall, there was moderate and severe radiculopathy involving the right and left femoral nerves, respectively. There was no ankylosis of the spine and the Veteran did not have any other neurologic abnormalities or findings related to the thoracolumbar spine. He experienced IVDS of the thoracolumbar spine, but he did not experience any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the previous 12 months. He occasionally used a wheelchair, but there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There was scarring associated with the Veteran's back disability, but the scarring was not painful or unstable and the total area of the scarring was not equal to or greater than 39 square centimeters. The Veteran was diagnosed as having multilevel degenerative joint disease and spondylolisthesis grade 1 degenerative L3 on 4. This disability impacted his ability to work in that he would have significant impairment for any task requiring standing, walking, or kneeling. His daily impairment could not be accurately assessed during the April 2019 examination. The report of a VA back examination dated in October 2020 indicates that the Veteran experienced worsening back pain which was treated with medication. Severe flare ups of back symptoms occurred on a monthly basis, were caused by overuse, and were alleviated by rest. There was functional loss/impairment of the thoracolumbar spine in that the Veteran was unable to stand or walk. The ranges of motion of the Veteran's thoracolumbar spine were unable to be tested because he was wheelchair bound and unable to complete the ranges of motion. There was no pain noted on examination and no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine. The Veteran was not being examined immediately after repetitive use over time or during a flare up and the examination was neither medically consistent nor inconsistent with his statements describing functional loss with repetitive use over time and during flare ups. The examiner who conducted the October 2020 examination was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time or during flare ups because the Veteran was wheelchair bound and unable to complete ranges of motion. There was no guarding or muscle spasm of the thoracolumbar spine. There were additional factors contributing to disability in terms of disturbance of locomotion, interference with sitting, and interference with standing. Moreover, muscle strength was 3/5 with bilateral hip flexion, bilateral knee extension, and left ankle plantar flexion, dorsiflexion, and great toe extension. Muscle strength associated with right ankle plantar flexion, dorsiflexion, and great toe extension was 0/5. There was no muscle atrophy. Right ankle reflexes were absent (0+), but all other reflexes were normal (2+). Lower extremity sensation was all absent bilaterally. The Veteran was unable to perform straight leg raise testing. He experienced severe constant pain, intermittent pain, and numbness in the lower extremities bilaterally. There was moderate paresthesias/dysesthesias in the lower extremities bilaterally. Overall, there was severe radiculopathy involving the sciatic nerves bilaterally. There was no ankylosis of the spine, the Veteran did not have any other neurologic abnormalities or findings related to the thoracolumbar spine, and he did not have IVDS of the thoracolumbar spine. He constantly used a wheelchair due to back, knee, and ankle disabilities, but there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There was scarring related to the Veteran's back disability, but the scarring was not painful or unstable and the total area of the scarring was not equal to or greater than 39 square centimeters. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. A diagnosis of degenerative arthritis of the spine was provided. This disability impacted the Veteran's ability to work in that he was unable to stand or walk. B. Radiculopathy The Veteran's left and right lower extremity radiculopathy is rated under 38 C.F.R. § 4.124A, DC 8620 as neuritis. This disability is rated as paralysis of the sciatic nerve under DC 8520. Under DC 8520, the following ratings apply: a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and an 80 percent rating is warranted for complete paralysis resulting in the foot dangling and dropping, no possible active movement of muscles below the knee, and weakened or (very rarely) lost flexion of the knee. 38 C.F.R. § 4.124A , DC 8520. The rating schedule provides guidance for rating neurological disabilities. With regard to rating neurological disabilities, cranial or peripheral neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. The maximum rating that can be assigned for neuritis not characterized by organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. Id. Cranial or peripheral neuralgia, usually characterized by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124A. Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested right and left lower extremity neurological symptoms of the type and extent, frequency, and/or severity, as appropriate to warrant 40 percent ratings, but no higher, since June 13, 2017, but no earlier. The above evidence reflects that during the claim period from August 1, 2011 through June 12, 2017, the Veteran experienced occasional pain in his buttocks and somewhat decreased muscle strength in the lower extremities. There were no lower extremity neurological signs or symptoms that were attributed to his service-connected back disability and the examiners who conducted the October and December 2013 VA back examinations specified that there was no radicular pain or any other signs or symptoms due to radiculopathy and that the Veteran did not have any other neurologic abnormalities or findings related to the thoracolumbar spine. The Board acknowledges that a May 2011 VA neurology initial consultation note reflects that light touch and pinprick sensation, vibration sense, position sense, and motor strength were all impaired in the lower extremities bilaterally. However, the physician who conducted the May 2011 consultation concluded that the Veteran's neurological symptoms were consistent with neuropathy, "likely of diabetic etiology." Also, as explained above, no lower extremity neurological impairment associated with the Veteran's service-connected back disability was identified during the subsequent October and December 2013 VA back examinations. Therefore, the preponderance of the evidence is against a finding that the criteria for a compensable rating for left and right lower extremity radiculopathy were met or approximated at any point during the claim period from August 1, 2011 through June 12, 2017. As for the claim period since June 13, 2017, the Veteran reported during the June 2017 Board hearing that his back disability had worsened since the December 2013 back examination. For example, the nerves in his back would pinch/grind if he turned his back the wrong way and cause him to drop things or fall to his knees. His treatment records dated during this period and the reports of the April 2019 and October 2020 VA back examinations reflect that he has experienced back pain which radiates to the hips and buttocks, decreased to absent sensation and motor strength in the lower extremities, and impaired lower extremity reflexes. There has been no muscle atrophy and the examiners who conducted the April 2019 and October 2020 examinations specified that the Veteran experienced moderate to severe lower extremity radiculopathy. In light of these findings, the absence of any marked muscle atrophy associated with the Veteran's lower extremity radiculopathy, and the fact that there has not been complete loss of lower extremity motor function, the Board finds that initial ratings higher that 40 percent under DC 8620 for left and right lower extremity radiculopathy (which contemplates moderately severe incomplete paralysis of the sciatic nerve) are not warranted at any time during the claim period. The earliest that it is factually ascertainable that the criteria for compensable ratings for left and right lower extremity radiculopathy are met is June 13, 2017, the date of the June 2017 Board hearing, during which the Veteran reported that his back disability had worsened and that he experienced neurological symptoms associated with his back disability. The Board acknowledges that there is evidence of incomplete paralysis of both the femoral (anterior crural) and sciatic nerves. Nevertheless, severe incomplete paralysis (the level below complete paralysis) also warrants a 40 percent rating under DC 8526 (the diagnostic code pertaining to paralysis of the anterior crural (femoral) nerve). The Veteran is already in receipt of a 40 percent rating for the period since June 13, 2017 on the basis of his lower extremity neurological symptoms under DC 8620. Therefore, separate ratings under both DC 8620 and DC 8526 on the basis of the same lower extremity neurological symptoms would constitute prohibited pyramiding and separate ratings are not warranted. 38 C.F.R. § 4.14. In sum, initial compensable ratings, from August 1, 2011 through June 12, 2017, and initial ratings higher than 40 percent, from June 13, 2017, for left and right lower extremity radiculopathy are not warranted. As the preponderance of the evidence is against higher ratings, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. C. Residuals, Fracture, L5 Vertebra with Degenerative Joint Disease The Veteran's service-connected back disability is rated under 38 C.F.R. § 4.71A, DCs 5010-5242. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of DCs 5010-5242 reflects that the Veteran's back disability is partially described as traumatic arthritis under DC 5010 and that the rating assigned is based on degenerative arthritis of the spine under DC 5242. Prior to the February 7, 2021 regulatory changes, traumatic arthritis was rated under the same diagnostic criteria as degenerative arthritis. 38 C.F.R. § 4.71A, DC 5010 (in effect prior to February 7, 2021). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a , DC 5003. This diagnostic code was not significantly amended by the regulatory changes. Since the regulatory changes, post-traumatic arthritis under DC 5010 is rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. 38 C.F.R. § 4.71A , DC 5010 (in effect since February 7, 2021). Limitation of motion of the thoracolumbar spine is rated under the Diseases and Injuries of the Spine (General Rating Formula). Under the General Rating Formula both prior to and since the regulatory change, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply: A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine and a 100 percent rating is warranted for ankylosis of the entire spine. Id. Note (2) provides that normal forward flexion of the thoracolumbar spine is to zero to 90 degrees and extension and left and right lateral flexion and rotation of the thoracolumbar spine are all zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. Each range of motion measurement is to be rounded to the nearest five degrees. The rating criteria provide that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71A, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Court has held that a veteran may be entitled to a rating higher than 40 percent under the General Rating Formula if he experiences the functional equivalent of ankylosis when considering the provisions of 38 C.F.R. §§ 4.40 and 4.45. Chavis v. McDonough, No. 18-2928, 2021 U.S. App. Vet. Claims LEXIS 660 (Vet. App. Apr. 16, 2021). Under DC 5243 both prior to and since the regulatory change, IVDS (preoperatively or postoperatively) is rated either under the General Rating Formula or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71A , DC 5243. Under the criteria for rating IVDS, the following ratings apply: a 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71A, DC 5243. For purposes of ratings under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a , DC 5243, Note (1). Considering the pertinent evidence in light of the applicable rating criteria and considerations delineated above, the Board finds, for the following reasons, that the Veteran has manifested thoracolumbar spine symptoms of the type and extent, frequency, and/or severity, as appropriate, to warrant no higher than a 40 percent rating during the entire claim period from August 1, 2011 through June 12, 2017, under the criteria in effect both prior to and since the regulatory change. A 50 percent rating, but no higher, is warranted since June 13, 2017. The above evidence reflects that during the claim period prior to June 13, 2017, the Veteran experienced back pain and significantly limited ranges of motion of the thoracolumbar spine. He did not report any flare ups during the October 2013 examination, but he reported during the December 2013 examination that he experienced flare ups which limited his spinal motion by an additional 50 percent. Spinal flexion was to 20 degrees during the December 2013 examination and the examiner who conducted the December 2013 examination specified that the Veteran would lose an additional 20 degrees of flexion (i.e., flexion would be to 0 degrees) during flare ups. Also, no spinal ankylosis was noted during the October and December 2013 VA back examinations and, as explained above, there is no evidence of any neurological impairment associated with the Veteran's service-connected back disability prior to June 13, 2017. Overall, despite the significantly limited ranges of spinal motion during this period, the Board finds that even considering back pain, flare ups, and other functional factors, the Veteran did not experience actual ankylosis or the functional equivalent of spinal ankylosis (as defined above) prior to June 13, 2017. In other words, a preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's back symptoms were not shown to have been so disabling to actually or effectively result in fixation of the entire thoracolumbar spine in flexion or extension with any of the additional symptoms or limitations listed in Note (5) of the General Rating Formula. Therefore, a rating in excess of 40 percent for residuals, fracture, L5 vertebra with degenerative joint disease is not warranted at any time during the claim period from August 1, 2011 through June 12, 2017. As for the period since June 13, 2017, the Veteran has experienced lower extremity neurological impairment associated with his service-connected back disability during this period. Also, as noted above, forward flexion was to 20 degrees during the December 2013 VA examination, the Veteran reported flare ups of his back symptoms, and the examiner specified that flexion would be limited by an additional 20 degrees during flare ups. The ranges of spinal motion were unable to be obtained during the April 2019 and October 2020 VA examinations because the Veteran was either in a lower extremity cast and weight or was in a wheelchair. In light of the limitation of spinal flexion to 0 degrees during flare ups noted during the October 2013 examination and the fact that the Veteran has experienced neurologic symptoms associated with his back disability during the period since June 13, 2017, the Board finds that the Veteran has experienced the functional equivalent of ankylosis of the thoracolumbar spine during this period. Therefore, a 50 percent rating under the General Rating Formula for residuals, fracture, L5 vertebra with degenerative joint disease, from June 13, 2017, is warranted. Moreover, the Board acknowledges that the Veteran has been diagnosed as having IVDS during the claim period. However, he has not experienced incapacitating episodes of IVDS having a total duration of at least 6 weeks during any 12-month period at any time during the claim period. Therefore, a higher rating is not warranted on the basis of IVDS at any time during the claim period. In sum, a rating in excess of 40 percent for residuals, fracture, L5 vertebra with degenerative joint disease, from August 1, 2011 through June 12, 2017, is not warranted. A 50 percent rating, but no higher, is warranted from June 13, 2017. 2. Entitlement to increased ratings for right and left knee arthritis with limitation of flexion and extension The Veteran's service-connected right and left knee arthritis with limitation of flexion are rated under 38 C.F.R. § 4.71A, DCs 5003-5260. His service-connected right and left knee arthritis with limitation of extension are rated under 38 C.F.R. § 4.71A, DCs 5003-5261. These diagnostic codes reflect that the Veteran's knee disabilities are partially described degenerative arthritis under DC 5003 and that the ratings assigned are based on limitation of knee flexion and extension under DCs 5260 and 5261, respectively. Under DC 5260, limitation of knee flexion is rated as follows: a 10 percent rating is warranted when it is limited to 45 degrees; a 20 percent rating is warranted when it is limited to 30 degrees; and a 30 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71A, DC 5260. VA's General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Under DC 5261, limitation of knee extension is rated as follows: a 10 percent rating is warranted when it is limited to 10 degrees; a 20 percent rating is warranted when it is limited to 15 degrees; a 30 percent rating is warranted when it is limited to 20 degrees; a 40 percent rating is warranted when it is limited to 30 degrees; and a 50 percent rating is warranted when it is limited to 45 degrees. 38 C.F.R. § 4.71A, DC 5261. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, as explained above, these diagnostic codes were not changed. A. Background The Veteran's claim for increased ratings for his service-connected left and right knee disabilities was received on August 1, 2011. The Veteran reported during a December 2013 VA knee examination that he was unable to run or pedal a bike because he experienced worsening bilateral knee pain. Flare ups of knee pain and swelling occurred on a frequent basis for a few days at a time and limited the Veteran by an additional 50 percent compared to when he did not have a flare up. The ranges of right knee flexion and extension were to 90 degrees and 5 degrees, respectively, with pain at 70 degrees of flexion and 5 degrees of extension. The ranges of left knee flexion and extension were to 70 degrees and 10 degrees, respectively, with pain at 30 degrees of flexion and 10 degrees of extension. The Veteran was able to perform repetitive-use testing with 3 repetitions. The ranges of right knee motion following repetitive-use testing were flexion to 90 degrees and extension to 5 degrees and the ranges of left knee motion following repetitive-use testing were flexion to 70 degrees and extension to 10 degrees. There was additional limitation in the ranges of motion of the knee and lower leg following repetitive-use testing and there was functional loss/impairment of the knees and lower legs in terms of bilateral less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing, and left knee swelling. Pain significantly limited functional ability during flare ups or when the joint was used repeatedly over a period of time and would result in a loss of up to 70 degrees of flexion on the left and 40 degrees of flexion on the right. There was pain with passive ranges of motion bilaterally, which was worse at the superior and medial knee to the patella. Moreover, muscle strength associated with knee flexion and extension was 4/5 bilaterally and right knee stability testing was all normal. Left knee stability testing was not conducted because the Veteran was in too much discomfort. There was no evidence or history of recurrent patellar subluxation/dislocation and the Veteran did not have any shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He did not have any meniscal conditions or surgical procedures for a meniscal condition and had not undergone any total knee joint replacement. He had an unknown left knee surgery as a child, but there were no residual signs or symptoms due to arthroscopic or other knee surgery. There were scars related to the Veteran's knee disabilities, but none of the scars were painful or unstable and the total area of all related scars was not greater than 39 square centimeters (6 square inches). There were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran did not use any assistive devices and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. The Veteran was diagnosed as having bilateral degenerative arthritis of the knees. This disability impacted his ability to work in that he was only able to lift 30 to 40 pounds, walk 14 mile at a time, walk 1 mile during an 8 hour workday, sit for 30 minutes and stand for 10 to 15 minutes at a time, and sit for 4 to 6 hours and stand for 1 to 2 hours during an 8 hour workday. A November 2016 VA knee examination report indicates that the Veteran experienced constant left knee pain which was aggravated by standing, walking, climbing steps, and cutting grass. There was frequent left knee swelling after prolonged walking, occasional giving out/buckling of the knee, and popping and cracking with movement of the knee. There was no left knee locking and no left knee surgeries were performed other than the surgery performed when the Veteran was age 12. He regularly used a left knee brace and took pain medications as needed. Significant flare ups of left knee symptoms occurred approximately 3 to 4 times each week, were triggered by standing, walking, and climbing steps, and usually lasted for several hours at a time. The Veteran was employed as a manager at a hotel and experienced difficulty walking up and down the steps at work, walking around the grocery store, and cutting the grass. Examination revealed that the ranges of right knee flexion and extension were to 115 degrees and 5 degrees, respectively. The ranges of left knee flexion and extension were to 100 degrees and 30 degrees, respectively. The ranges of right and left knee motions themselves contributed to functional loss in that the Veteran would have trouble kneeling/squatting. There was pain associated with knee flexion and extension bilaterally and there was mild tenderness at the medial and lateral aspect of the knees bilaterally. There was evidence of pain with weight bearing and objective evidence of crepitus bilaterally. The Veteran was able to perform repetitive-use testing with at least 3 repetitions and there was additional loss of function or range of motion of the right knee after 3 repetitions due to pain. Specifically, right knee flexion and extension were to 100 degrees and 10 degrees, respectively, following 3 repetitions. There was no additional loss of function or range of motion of the left knee after 3 repetitions. The Veteran was not being examined immediately after repetitive use over time or during a flare up and the examination was neither medically consistent nor inconsistent with his statements describing functional loss with repetitive use over time and during flare ups. Pain significantly limited functional ability with repeated use over a period of time and during flare ups and the examiner specified that the ranges of right knee motion would be flexion to 100 degrees and extension to 10 degrees with repeated use over time. The ranges of left knee motion would be flexion to 100 degrees and extension to 30 degrees with repeated use over time. The examiner was unable to describe the additional functional loss of the knees during flare ups in terms of range of motion because the Veteran was not having a flare up at the time of the examination. There were no additional contributing factors of disability on the right, but there were additional contributing factors of disability on the left in terms of disturbance of locomotion and interference with standing. Moreover, muscle strength associated with knee flexion and extension was 4/5 bilaterally, but there was no muscle atrophy. There was no knee ankylosis, history of recurrent subluxation, history of lateral instability, or recurrent effusion, and knee stability testing was all normal bilaterally. The Veteran did not have any recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He did not have any meniscus (semilunar cartilage) condition. There was scarring associated with the Veteran's left knee disability, but the scarring was not painful or unstable and did not involve a total area equal to or greater than 39 square centimeters (6 square inches). He regularly used a left knee brace, but there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. A diagnosis of left knee degenerative arthritis was provided. This disability impacted the Veteran's ability to work in that he would have trouble kneeling/squatting, climbing steps, and standing and walking for long periods. The examiner who conducted the November 2016 examination noted that passive ranges of knee motion were attempted, but were too painful. The Veteran reported on his February 2017 VA Form 9, during the June 2017 Board hearing, and during an August 2017 examination with physician M.L. Caldwell (see August 2017 "Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ)" (VA Form 21-0960M-9)) that he was unable to climb steps due to his knee and that walking, stepping up on a sidewalk or doorway, and cold and rainy weather caused knee discomfort. Flare ups of knee pain and swelling occurred approximately once a week in the winter and following prolonged standing/walking, and he occasionally experienced giving way of his knees which caused him to fall. He was only able to walk a few feet and stand for approximately 20 minutes due to knee pain. Examination by Dr. Caldwell revealed that right knee flexion was to 70 degrees and extension was to 180 degrees. The ranges of motion contributed to functional loss in that pain and stiffness limited bending and walking. The Veteran was not able to perform repetitive use testing, but Dr. Caldwell noted that there was additional limitation in the ranges of right knee motion following repetitive-use testing and that the ranges of right knee flexion and extension following repetitive-use testing were 50 degrees and 180 degrees, respectively. There was severe right knee pain with knee flexion that contributed to functional loss and there was pain when the knee was used in weight-bearing and/or non weight-bearing which contributed to functional loss and limited the Veteran's ability to walk and stand. There was diffuse tenderness and pain with both active and passive motion of the right knee and there were additional contributing factors of disability on the right in terms of less movement than normal, weakened movement, incoordination, swelling, deformity, atrophy of disuse, instability of station, disturbance of locomotion, interference with sitting, and interference with standing. Pain, weakness, fatigability, and/or incoordination significantly limited functional ability of the right knee during flare ups or when the knee was used repeatedly over a period of time and right knee flexion and extension would be to 55 degrees and 180 degrees, respectively, during flare ups and following repeated use. Moreover, muscle strength associated with right knee flexion and extension was 4/5 and there was right lower extremity muscle atrophy (47 centimeter circumference on the right compared to 51 centimeter circumference on the left). There was no right knee ankylosis, joint stability testing did not reveal any right knee instability, and the Veteran did not have any recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He had a meniscus (semilunar cartilage) condition on the right with frequent episodes of joint pain and effusion. There were no scars related to the Veteran's right knee disability and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. He used a cane and walls/furniture to assist with ambulation, but there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. There was objective evidence of right knee crepitus. A diagnosis of right knee osteoarthritis was provided. This disability prevented the Veteran from performing work of any kind and would not improve. An April 2019 VA knee examination report reflects that the Veteran experienced daily bilateral knee pain which was 7/10 in intensity. Flare ups of bilateral knee pain (10/10 in intensity and aching/throbbing in nature) and swelling occurred 1 or 2 times per week, during which the Veteran could hardly sit or walk. The Veteran experienced functional loss/impairment of the knees in that he was unable to perform a lot of activities, such as prolonged walking, standing, and sitting. Examination revealed that the Veteran was wearing a right leg cast and a left leg weight to equalize weight. Therefore, he was unable to perform range of knee motion exercises (to include repetitive use testing) without risk of injury. There was evidence of pain with weight-bearing with both knees. The Veteran was not being examined immediately after repetitive use over time and during a flare up and the examination was neither medically consistent nor inconsistent with his statements describing functional loss with repetitive use over time and during flare ups. The examiner who conducted the April 2019 examination was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or during flare ups because the Veteran was unable to perform range of motion exercises due to his right leg cast and left leg weight. There were additional factors contributing to disability in terms of knee swelling bilaterally. Moreover, muscle strength associated with left knee flexion and extension was 4/5. The examiner was unable to perform knee stability testing due to the Veteran's right leg cast and left leg weight. There was scarring associated with his knee disability, but the scarring was not painful or unstable and the total area of the scarring was not equal to or greater than 39 square centimeters (6 square inches). There were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran constantly used a wheelchair and walker due to foot and knee disabilities, but there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. The Veteran was diagnosed as having bilateral tricompartment arthritis. This disability impacted his ability to work in that he would have significant impairment for any task requiring standing, walking, or kneeling. His daily impairment could not be assessed at the time of the April 2019 examination. A January 2020 VA physical medicine rehabilitation consultation note and the report of an October 2020 VA knee examination indicate that the Veteran experienced bilateral knee pain and swelling. Severe flare ups of bilateral knee symptoms occurred on a daily basis, lasted for hours at a time, were precipitated by overuse, and were alleviated by rest. The Veteran experienced functional loss/impairment due to his knee disabilities in that he was unable to stand or walk. Examinations revealed that the ranges of right knee motion were flexion to between 90 degrees and 100 degrees and extension to between 2 degrees and 0 degrees. The ranges of left knee motion were flexion to between 90 degrees and 100 degrees and extension to 0 degrees. There was pain associated with bilateral knee flexion and extension, the pain caused functional loss, and there was objective evidence of bilateral knee crepitus. There was no evidence of pain with weight-bearing or objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissues, and the ranges of knee motion themselves did not contribute to functional loss. The Veteran was able to perform repetitive-use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. He was not being examined immediately after repetitive use over time or during a flare up and the examination was medically consistent with his statements describing functional loss with repetitive use over time and during flare ups. Pain significantly limited functional ability of the knees with repeated use over a period of time and during flare ups. The examiner who conducted the October 2020 examination specified that the ranges of right and left knee motions with repeated use over time would be flexion to 80 degrees and extension to 0 degrees, bilaterally. The ranges of right and left knee motions during flare ups would be flexion to 70 degrees and extension to 0 degrees, bilaterally. There were additional factors contributing to disability in terms of disturbance of locomotion and interference with standing, bilaterally. Moreover, muscle strength associated with knee flexion and extension was 3/5 bilaterally, there was no muscle atrophy, and there was no knee ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion and joint stability testing was all normal bilaterally. The Veteran did not have recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He did not have a meniscus (semilunar cartilage) condition, there was no scarring related to his knee disability, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. He constantly used a wheelchair due to back, knee, and ankle disabilities, but there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. The Veteran was diagnosed as having bilateral knee joint osteoarthritis and a right below the knee amputation. These disabilities impacted his ability to work in that he was unable to walk or stand. Also, the examiner noted that there was objective evidence of pain on passive range of motion testing and on non weight-bearing testing bilaterally. B. Right Knee Arthritis I. Period from August 1, 2011 through October 31, 2016 The above evidence reflects that during the claim period from August 1, 2011 through October 31, 2016, right knee flexion was limited to at most 90 degrees and extension was limited to at most 5 degrees during the December 2013 VA examination. These findings, by themselves and without consideration of potential functional impairment, are contemplated by no more than a single 10 percent rating for painful limitation of knee flexion under DC 5260. As for functional impairment, there was pain, swelling, weakness, and excess fatigability associated with the Veteran's right knee and he reported flare ups of knee symptoms that limited his functioning by an additional 50 percent. The ranges of right knee motion remained the same following repetitive use testing and the examiner who conducted the December 2013 examination specified that pain significantly limited functional ability during flare ups or when the joint was used repeatedly over a period of time and would result in a loss of up to 40 degrees of flexion on the right (i.e., flexion to 50 degrees). The Veteran is competent to report the symptoms associated with his service-connected right knee disability and the extent of his impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of his contentions. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion was documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's right knee symptoms most closely approximated the criteria for at most a single 10 percent rating for painful limitation of knee flexion under DC 5260 during the entire claim period from August 1, 2011 through October 31, 2016. Specifically, the above evidence reflects that the flare ups and other functional impairments were not so severe, frequent and/or prolonged to warrant the next higher percent ratings. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's knee symptoms were not shown to have been so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 30 degrees or limitation of knee extension more nearly approximating 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating for limitation of knee extension under DC 5261, respectively. Overall, the Veteran's right knee disability resulted in limitation of knee flexion that is no more than 10 percent disabling during the entire claim period prior to November 1, 2016. Accordingly, a rating in excess of 10 percent for limitation of knee flexion and a compensable rating for limitation of knee extension, from August 1, 2011 through October 31, 2016, are not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71A, DCs 5260-5261. II. Period Since November 1, 2016 As an initial matter, the Board acknowledges the August 2017 DBQ completed by Dr. Caldwell. However, the Board finds, for the following reasons, that this DBQ is of minimal probative value. Specifically, Dr. Caldwell noted that the Veteran's right knee extension was to 180 degrees. However, this is beyond the normal range of motion for the knee, which is from 0 degrees to 140 degrees. See 38 C.F.R. § 4.71, Plate II. In this regard, Dr. Caldwell did not confirm whether a goniometer was used, and VA regulations provide that the use of a goniometer in the measurement of limitation of motion is "indispensable" in VA examinations. 38 C.F.R. § 4.46. Also, Dr. Caldwell initially noted that the Veteran was not able to perform repetitive use testing, but he also noted that there was additional limitation in the ranges of right knee motion following repetitive-use testing and that the ranges of right knee flexion and extension following repetitive-use testing were 50 degrees and 180 degrees, respectively. Therefore, in light of the above, the Board finds that the August 2017 DBQ from Dr. Caldwell lacks probative value as to the severity of the Veteran's service-connected right knee disability. During the claim period since November 1, 2016, the evidence other than the August 2017 DBQ from Dr. Caldwell indicates that right knee flexion has been limited to at most 90 degrees and extension has been limited to at most 10 degrees. These findings, by themselves and without consideration of potential functional impairment, are contemplated by no more than a single 10 percent rating for limitation of knee extension under DC 5261. As for functional impairment, there is pain and swelling associated with the Veteran's right knee and he has reported flare ups of knee symptoms. The examiner who conducted the November 2016 VA examination specified that right knee flexion and extension would be to 100 degrees and 10 degrees, respectively, with repeated use over time. Also, the examiner who conducted the October 2020 examination specified that right knee flexion and extension would be to 80 degrees and 0 degrees, respectively, with repeated use over time, and would be to 70 degrees and 0 degrees, respectively, during flare ups. Overall, regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion has been documented, the preponderance of the evidence supports the conclusion that the Veteran's right knee symptoms have most closely approximated the criteria for at most a single 10 percent rating for painful limitation of knee extension under DC 5261 during the entire claim period since November 1, 2016. Specifically, the above evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent ratings at any time during the claim period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's knee symptoms have not been shown to be so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 45 degrees or limitation of knee extension more nearly approximating 15 degrees, which are the requirements for a 10 percent rating for limitation of knee flexion under DC 5260 and a 20 percent rating for limitation of knee extension under DC 5261, respectively. In sum, the Veteran's right knee disability has resulted in noncompensable limitation of knee flexion and limitation of knee extension that is no more than 10 percent disabling during the entire claim period since November 1, 2016. Accordingly, higher ratings during this period are not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71A, DCs 5260-5261. C. Left Knee Arthritis I. Period from August 1, 2011 through October 31, 2016 The above evidence reflects that during the claim period from August 1, 2011 through October 31, 2016, left knee flexion was limited to at most 70 degrees and extension was limited to at most 10 degrees during the December 2013 VA examination. As for functional impairment, there was pain, swelling, weakness, and excess fatigability associated with the Veteran's left knee and he reported flare ups of knee symptoms that limited his functioning by an additional 50 percent. The ranges of left knee motion remained the same following repetitive use testing and the examiner who conducted the December 2013 examination specified that pain significantly limited functional ability during flare ups or when the joint was used repeatedly over a period of time and would result in a loss of up to 70 degrees of flexion on the left (i.e., flexion to 0 degrees). The Veteran is competent to report the symptoms associated with his service-connected left knee disability and the extent of his impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of his contentions. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. He is already in receipt of a 30 percent rating for limitation of knee flexion under DC 5260 during the claim period prior to November 1, 2016, and this is the maximum schedular rating for limitation of knee flexion. He is also in receipt of a 10 percent rating for limitation of knee extension under DC 5261 during this period. Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion was documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's left knee symptoms most closely approximated the criteria for at most the maximum 30 percent rating for limitation of knee flexion under DC 5260 and at most a 10 percent rating for limitation of knee extension under DC 5261 during the entire claim period from August 1, 2011 through October 31, 2016. With respect to knee extension, the above evidence reflects that the flare ups and other functional impairments were not so severe, frequent and/or prolonged to warrant the next higher percent rating for limitation of knee extension at any time during this period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's knee symptoms were not shown to have been so disabling to actually or effectively result in limitation of knee extension more nearly approximating 15 degrees, which is the requirement for a 20 percent rating for limitation of knee extension under DC 5261. Overall, the Veteran's left knee disability resulted in limitation of knee flexion that is 30 percent disabling and limitation of extension that is no more than 10 percent disabling during the entire claim period prior to November 1, 2016. Accordingly, a rating in excess of 30 percent for limitation of knee flexion and a rating in excess of 10 percent for limitation of knee extension, from August 1, 2011 through October 31, 2016, are not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71A, DCs 5260-5261. II. Period Since November 1, 2016 During the claim period since November 1, 2016, the evidence indicates that left knee flexion has been limited to at most 90 degrees and extension has been limited to at most 30 degrees. These findings, by themselves and without consideration of potential functional impairment, are contemplated by no more than a single 40 percent rating for limitation of knee extension under DC 5261. As for functional impairment, there is pain and swelling associated with the Veteran's left knee and he has reported flare ups of knee symptoms. The examiner who conducted the November 2016 VA examination specified that left knee flexion and extension would be to 100 degrees and 30 degrees, respectively, with repeated use over time. Also, the examiner who conducted the October 2020 examination specified that left knee flexion and extension would be to 80 degrees and 0 degrees, respectively, with repeated use over time, and would be to 70 degrees and 0 degrees, respectively, during flare ups. Overall, regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion has been documented, the preponderance of the evidence supports the conclusion that the Veteran's left knee symptoms have most closely approximated the criteria for at most a single 40 percent rating for painful limitation of knee extension under DC 5261 during the entire claim period since November 1, 2016. Specifically, the above evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent ratings. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's knee symptoms have not been shown to be so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 45 degrees or limitation of knee extension more nearly approximating 45 degrees, which are the requirements for a 10 percent rating for limitation of knee flexion under DC 5260 and a 50 percent rating limitation of knee extension under DC 5261, respectively. In sum, the Veteran's left knee disability has resulted in noncompensable limitation of knee flexion and limitation of knee extension that is no more than 40 percent disabling during the entire claim period since November 1, 2016. Accordingly, higher ratings during this period are not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71A, DCs 5260-5261. D. Additional Diagnostic Codes The Veteran has reported bilateral knee instability/buckling at various times during the claim period, including during the November 2016 VA examination and the June 2017 Board hearing. The rating criteria for knee instability were amended, effective February 7, 2021. Prior to the regulatory change, a 10 percent rating was warranted for slight recurrent subluxation or lateral instability, a 20 percent rating was warranted for moderate recurrent subluxation or lateral instability, and a maximum 30 percent rating was warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71A, DC 5257 (in effect prior to February 7, 2021). As of February 7, 2021, under the amended criteria, a 10 percent rating is warranted for recurrent subluxation or lateral instability with 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(s), walker) or bracing for ambulation. A 20 percent rating is warranted for recurrent subluxation or lateral instability with either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) 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. A maximum 30 percent rating is warranted for 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. 38 C.F.R. § 4.71A, DC 5257 (in effect from February 7, 2021). Under the amended criteria, a 10 percent rating is also warranted for patellar instability if there is 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 also warranted for patellar instability if there is 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 maximum 30 percent rating is also warranted for patellar instability if there is 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. Id. In this case, the above evidence reflects that the Veteran has reported occasional knee instability/buckling that has caused falls during the claim period and that he has used a cane, brace, walker, and wheelchair due, at least in part, to his knee disabilities. The Board acknowledges that DC 5257 does not necessarily require medical evidence of lateral instability for a rating to be assigned. Instead, the Board must address any relevant lay evidence and compare it to the medical evidence to determine which is more probative, keeping in mind that objective medical evidence is not automatically more probative than lay evidence. English v. Wilkie, 30 Vet. App. 347, 349 (2018). The Veteran is competent to report observable symptoms of his knee disabilities, such as instability, and the Board has no reason to challenge the credibility of his contentions. See Jandreau, 492 F.3d at 1372; Buchanan, 451 F.3d at 1331. Nevertheless, the Board points out that the Veteran denied a history of any recurrent subluxation, lateral instability, and/or recurrent patellar dislocation of either knee during the December 2013, November 2016, and October 2020 examinations. Moreover, stability testing of the knees has consistently been normal throughout the entire claim period. In light of these facts, the Board finds that any knee instability has not been so severe or frequent as to more nearly approximate recurrent subluxation or lateral instability under the pre-amended version of DC 5257, or persistent instability due to sprain, incomplete ligament tear, or complete ligament tear, or recurrent patellar instability under the revised version of DC 5257. Therefore, a separate compensable rating is not warranted under DC 5257 for either the left or the right knee at any time during the claim period. Also, although Dr. Caldwell noted that the Veteran had a meniscus (semilunar cartilage) condition on the right, the only symptoms associated with this condition were frequent episodes of joint pain and effusion. There is no evidence of any knee locking. Moreover, the knee pain and effusion (swelling) that Dr. Caldwell reported are already contemplated by the ratings assigned under DCs 5260 and 5261, and a separate rating under DC 5259 on the basis of these symptoms alone would constitute prohibited pyramiding. 38 C.F.R. § 4.14. There is no other evidence during the claim period of any symptoms related to cartilage dislocation or removal. Therefore, separate ratings are not warranted under DCs 5258 or 5259 at any time during the claim period. Lastly, there is no evidence of any knee ankylosis, impairment of the tibia or fibula, or genu recurvatum at any time during the claim period. Therefore, separate/higher ratings are not warranted under DCs 5256, 5262, or 5263 at any time during the claim period. 3. Entitlement to an increased rating for bilateral hearing loss, rated noncompensable from August 1, 2011 through June 12, 2017 and 30 percent disabling from June 13, 2017 Hearing loss is rated on the basis of examination results including a controlled speech discrimination test (Maryland CNC), and a pure tone audiometric test of pure tone decibel thresholds at 1000, 2000, 3000, and 4000 Hz with an average pure tone threshold obtained by dividing these thresholds by four. 38 C.F.R. § 4.85. Once these test results have been obtained, employing Table VI, a Roman numeral designation of hearing impairment is ascertained based on a combination of the percent of speech discrimination and pure tone threshold average. Once a Roman numeral designation of auditory acuity level for each ear has been determined, Table VII is used to determine the percentage evaluation for bilateral hearing loss by combining the Roman numeral designations of auditory acuity level for hearing impairment of each ear. Id. There is an alternative method of rating hearing loss in defined instances of exceptional hearing loss. In such exceptional cases, the Roman numeral designation for hearing loss of an ear may be based only on pure tone threshold average, using Table VIA, or from Table VI, whichever results in the higher Roman numeral. Exceptional hearing loss exists when the pure tone threshold at the frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more; or where the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz. In the latter situation, the higher Roman numeral, determined from Table VI or VIA, will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. Considering the pertinent evidence in light of the applicable rating criteria and considerations, the Board finds, for the following reasons, that a compensable rating, from August 1, 2011 through June 12, 2017, and a rating in excess of 30 percent, from June 13, 2017, for bilateral hearing loss are not warranted. The Veteran's claim for an increased rating for his service-connected hearing loss was received on August 1, 2011. During a November 2013 VA audiological examination, the Veteran reported that as a result of his hearing loss, he experienced difficulty hearing in conversations. Examination revealed that his pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 25 30 70 75 50 LEFT 25 25 65 75 48 Speech audiometry revealed speech recognition ability of 94 percent in both ears. Using Table VI, the November 2013 VA examination revealed level I hearing in both ears. Combining level I hearing for both ears according to Table VII yields a rating of 0 percent. During a November 2020 VA audiological examination, the Veteran reported that as a result of his hearing loss, he experienced difficulty following conversations, especially if the speaker is at a distance of 6 feet or more away from the Veteran. As a result, he had to ask for repetition on a regular basis. Examination revealed that his pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 35 45 60 90 58 LEFT 40 45 80 90 64 Speech audiometry revealed speech recognition ability of 56 percent in the right ear and 68 percent in the left ear. Using Table VI, the November 2020 VA examination revealed level VII hearing in the right ear and level V hearing in the left ear. Combining level VII hearing for the right ear and level V hearing for the left ear according to Table VII yields a rating of 30 percent. The Veteran has expressed his belief that the severity of his hearing loss warrants a higher rating. He is competent to report the symptoms of his hearing disability and the Board has no legitimate basis to challenge the credibility of his contentions. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. However, ratings for hearing loss are determined by a mechanical application of the VA rating schedule to the numeric designations assigned based on audiometric test results. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The lay statements of record do not show that the Veteran has met the specific pure tone thresholds and/or speech discrimination percentages required for a higher rating for bilateral hearing loss at any time during the claim period. In sum, the record neither shows that the evidence is so evenly balanced as to warrant a compensable rating, from August 1, 2011 through June 12, 2017, or a rating in excess of 30 percent, from June 13, 2017, for bilateral hearing loss, nor does the evidence show that the Veteran's hearing disability has more closely approximated the criteria for a higher rating at any time during the claim period. Therefore, a compensable rating, from August 1, 2011 through June 12, 2017, and a rating in excess of 30 percent, from June 13, 2017, for bilateral hearing loss is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Additional Considerations As a final matter, the Board finds that, in conjunction with the higher rating matters discussed herein, no other related issues have been raised by the Veteran or his representative, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.