Citation Nr: 21028953 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 15-18 386A DATE: May 12, 2021 ORDER Entitlement to a compensable rating from August 31, 2012, to December 11, 2014, for limitation of motion of the left knee is denied. Entitlement to a 10 percent rating from December 11, 2014, to May 16, 2015, for limitation motion of the left knee is granted. Entitlement to a disability rating greater than 10 percent from May 16, 2015, to July 14, 2015, for limitation of motion of the left knee is denied. Entitlement to a disability rating greater than 10 percent from August 31, 2012, to October 25, 2012, for instability or recurrent subluxation of the left knee is denied. Entitlement to a 10 percent rating from October 25, 2012, to May 16, 2015, for instability of the left knee is granted. Entitlement to a disability rating greater than 20 percent from May 16, 2015 to July 14, 2015, for instability or recurrent subluxation of the left knee is denied. Entitlement to a 20 percent rating from August 31, 2012 to October 25, 2012, for meniscal impairment of the left knee is granted. Entitlement to a disability rating greater than 20 percent from October 25, 2012, to May 16, 2015, for meniscal impairment of the left knee is denied. Entitlement to a 20 percent rating from May 16, 2015, to July 14, 2015, for meniscal impairment of the left knee is granted. Entitlement to a disability rating greater than 30 percent from September 1, 2016, for status post left knee arthroplasty is denied. FINDINGS OF FACT 1. The record evidence shows that, prior to December 11, 2014, the Veteran's left knee disability was manifested by meniscal impairment compatible with dislocation with frequent episodes of pain, locking and effusion into the joint and mild instability. 2. The record evidence shows that, from December 11, 2014 to May 16, 2015, the Veteran's left knee disability was manifested by meniscal impairment compatible with dislocation with frequent episodes of pain, locking and effusion into the joint, mild instability, and painful but otherwise noncompensable limitation of motion. 3. The record evidence shows that, from May 16, 2015 to July 14, 2015, the Veteran's left knee disability was manifested by meniscal impairment compatible with dislocation with frequent episodes of pain, locking and effusion into the joint, moderate instability and painful but otherwise noncompensable limitation of motion. 4. The record evidence shows that, from September 1, 2016, the Veteran's status post left knee replacement has not been manifested by intermediate degrees of residual weakness, pain or limitation of motion or severe painful motion or weakness. CONCLUSIONS OF LAW 1. The criteria for a compensable rating from August 31, 2012 to December 11, 2014, based on limitation of motion of the knee have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5003, 5260, 5261 (2019). 2. The criteria for a 10 percent rating from December 11, 2014 to July 15, 2014, for limitation motion of the left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5003, 5260, 5261 (2019). 3. The criteria for a 10 percent rating from August 31, 2012 to May 16, 2015, for instability of the left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257 (2019). 3. The criteria for a disability rating greater than 20 percent from May 16, 2015 to July 14, 2015, for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257 (2019). 4. The criteria for a 20 percent rating prior to May 16, 2015, for meniscal impairment of the left knee have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5258 (2019). 5. The criteria for a disability rating greater than 20 percent from May 16, 2015 to July 14, 2015, for left knee meniscal impairment have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5258 (2019). 6. The criteria for a disability rating greater than 30 percent from September 1, 2016, for status post left knee arthroplasty have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5055 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1970 to March 1996. This matter is on appeal before the Board of Veterans Appeals (Board) from a July 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a February 2019 decision, the Board denied the claims. The Veteran appealed. In a February 2020 order, the Court of Appeals for Veterans Claims (Court) upheld a joint motion of the parties and remanded the appeal back to the Board for action consistent with the joint motion. In August 2020, the case was remanded to the RO for further development. Increased Ratings The Veteran contends that he is entitled to higher rating(s) for his service-connected left knee disability. Left knee disability prior to July 14, 2015. Service connection for left knee disability was granted initially by a January 1997 rating decision. A 10 percent rating was assigned effective April 1, 1996 under DC 5257. In a claim received on August 31, 2012, the Veteran requested an increased rating. In July 2013 and July 2015 rating decisions, the RO continued the 10 percent rating. In a September 2015 rating decision, the RO granted a temporary total rating for surgery (i.e. total knee arthroplasty with convalescence effective July 14, 2015 and assigned a subsequent 30 percent rating for status post left knee arthroplasty effective September 1, 2016. In a February 2021 rating decision, the RO granted a separate 20 percent rating for meniscal impairment of the left knee under DC 5258 effective from October 31, 2012 to May 16, 2015 and granted a separate 20 percent rating for left knee moderate instability under DC 5257 from May 16, 2015 to July 14, 2015. The Board notes that, the Veteran's currently assigned knee ratings during the period from the date of receipt of the claim for increase, August 31, 2012, to the date of assignment of a total temporary rating for status post knee replacement, July 14, 2015, are as follows: a 10 percent rating based on apparent slight instability of the knee assigned from August 31, 2012 to October 25, 2012; a 20 percent rating for meniscal impairment of the left knee assigned from October 25, 2012 to May 19, 2015; a 10 percent rating based on limitation of motion of the left knee assigned from April 16, 2015 to July 14, 2015; and a 20 percent rating for moderate instability of the left knee assigned from May 19, 2015 to July 14, 2015. In October 2012, the Veteran was afforded a VA examination. The diagnoses were degenerative joint disease, left knee and patellofemoral syndrome, left knee. The Veteran reported flare-ups of joint stiffness while standing for prolonged periods of time and sitting for short periods of time. Upon range of motion evaluation, left knee flexion measured to 120 degrees with no pain, and full extension was found also without pain. Repetitive use testing showed no change in range of motion. Functionally, he suffered from weakened movement and excess fatigability after repetitive use. Normal joint stability was found, and he was not found to have patellar subluxation or dislocation. He was found to have a meniscal condition with meniscal dislocation and frequent episodes of joint pain. He reported popping as a residual symptom from prior arthroscopic knee surgery. The examiner noted that the Veteran used orthotics although these were noted to be for his bilateral foot pain. The examiner commented that the impact of the bilateral knee conditions on his ability to work was functional limitation due to weakness, pain, stiffness, and limitation of motion. At an April 2013 Tricare visit, the Veteran's left knee range of motion measured from five to 120 degrees, extension to flexion. In an October 2014 statement, the Veteran indicated that his left knee was painful when walking, standing, or when climbing up and down stairs. He noted that he suffered on a daily basis due to this condition. At a December 11, 2014 VA examination, the diagnosis was left knee patellofemoral syndrome with degenerative changes. He reported that, after receiving a total right knee replacement, his left knee problems had gone from bad to worse. He noted that the knee popped while walking and rising from a sitting position. He also reported that it was a challenge to walk up and down stairs. Additionally, it was very painful to do basic chores at home and while working. Upon range of motion testing, flexion measured to 120 degrees with pain, and full extension to 0 degrees without pain. Repetitive use testing showed no change in range of motion. Functional loss on repetitive use was noted to involve less movement than normal and pain on movement. There was also pain on palpation. There was normal joint stability and no patellar subluxation or dislocation was found. He had a meniscal condition with meniscal dislocation, meniscal tear, frequent episodes of joint locking and frequent episodes of joint pain. He reported residuals from earlier left knee arthroscopic surgery as pain when stooping, walking, standing, and walking up and down stairs. It was noted that the Veteran's VA provider had issued him a left knee brace. He reported regular use of a left knee brace. The examiner commented that the impact of the bilateral knee disability on his ability to work was pain aggravated by activity. The examiner also commented that the Veteran had additional limitation of functional ability of the knee joint or repeated use over time with a degree or range of motion loss during pain on use or during flare-ups of approximately 20 degrees of left flexion. At a March 2015 VA Tricare visit, it was noted that an X-ray of the left knee showed a complete loss of medial joint space. There was general loss of joint space and osteophyte formation as well. Regarding the meniscus there was +2 medial joint line tenderness and +1 lateral joint line tenderness. There was also positive patellar compression and patellar grind testing. It was noted that the Veteran had had longstanding nonoperative management for his left knee pain. He declined an injection and was noted to be a candidate for a total left knee arthroplasty. The Veteran was afforded another VA examination in May 2015. The examiner diagnosed the Veteran with left knee instability and degenerative arthritis. He reported flare-ups in the form of stiffness and pain. He indicated that the flare-ups would occur if he attempted to stand for a long period of time or if he was working on his lawn without a knee brace. The examiner commented that flare-up support (i.e. the knee brace) was not working currently because the Veteran was found by a treating physician to have bone on bone contact in the left knee with complete loss of medial joint space, osteophyte formation, loss of joint space more generally and patellofemoral osteophyte. Upon range of motion evaluation, flexion was measured to 100 degrees, and he had full extension. Pain was noted on the examination as causing functional loss. There was also evidence of pain with weightbearing and objective evidence of crepitus. Range of motion after repetitive use testing measured to 90 degrees flexion and full extension. Repetitive use was noted to result in functional loss in the form of pain, fatigue, and weakness. Flare-ups were also found to limit the Veteran's left knee limitation of flexion to 90 degrees. The examiner also found that another contributing factor to the left knee disability was more movement than normal. No ankylosis was found. After joint stability testing via the Lachman test, Grade 2+(5-10 mm) on a scale with a maximum of 3+ (10-15 mm) of anterior instability was measured. It was noted that the left knee regularly required a brace for support. The examiner indicated that the Veteran had never had a meniscal condition. Regarding the impact of the left knee disability on his ability to work, the Veteran reported that going up and down stairs was difficult and he was unable to do security work in the church anymore. In a June 2015 Form 9, the Veteran reported that due his left knee flare-ups and weakness, he used a knee brace to support walking up and down stairs. Also, he indicated that his knee would lock after sitting for a while and when attempting to stand. Additionally, he reported that his knee slipped out of joint when driving after the ligaments relaxed. A July 14, 2015 Tricare operative report shows that the Veteran underwent a left knee total arthroplasty. In October 2015, the Veteran underwent another VA examination. The examiner noted that the Veteran had left knee replacement surgery in July 2015. He reported that flare-ups resulted in residual weakness, pain, and limitation of motion while going through the recovery process. He also had difficulty when walking downstairs because the ligament rubbed against the prosthetic device. Functionally, pain and weakness in the left knee also resulted in difficulty walking or standing for more than 20 minutes. Left knee flexion measured to 95 degrees and he had full extension. Reduced range of motion contributed to his functional loss. The left knee also showed severe tenderness in the joint, crepitus, and pain with weightbearing. Pain significantly limited functional ability after repetitive use testing and during flare-ups. Additionally, less movement than normal, swelling, deformity, interference with sitting, and interference with standing contributed to the left knee disability. No joint instability, subluxation or ankylosis was found. (Notably, this examination was performed during a period where the temporary total disability rating was in place). As noted above, a temporary total rating for the left knee disability status post arthroplasty with surgery and convalescence was assigned effective July 14, 2015 and then a 30 percent rating was assigned following convalescence effective September 1, 2016. The Veteran has not appealed the length of the 100 percent rating for temporary convalescence. Accordingly, the Board's analysis of the appeal covers whether the Veteran's left knee disability warrants any higher ratings prior to July 14, 2015 and subsequent to September 1, 2016. The analysis below covers the period prior to July 14, 2015. Considering DC 5258, prior to July 14, 2015 the Board notes that the Veteran has already been assigned the highest 20 percent rating for symptomatic meniscal impairment from October 31, 2012 to May 16, 2015. The Board also notes that the RO apparently did not continue the 20 percent rating from May 16, 2015 to July 14, 2015 based on the May 2015 examiner not finding any meniscal impairment. The earlier VA examinations did show such impairment. The May 2015 examiner also was not accurate concerning the Veteran not having a history of meniscal impairment. In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that a 20 percent rating for meniscal impairment under DC 5258 will be assigned from May 16, 2015 to September 1, 2016. The Board next finds that, because the October 2012 examination clearly showed the meniscal impairment and this examination took place only two months after receipt of the Veteran's increased rating claim, the 20 percent rating will be assigned effective on the date that the Veteran's claim was received (i.e. August 31, 2012). Because a 20 percent rating has been assigned under DC 5258 from August 31, 2012 to July 14, 2015, the Board finds that there is no basis for assigning a separate rating under DC 5259 for impairment compatible with symptomatic removal of the semilunar cartilage as this would represent impermissible pyramiding. Concerning DC 5257, the RO already has assigned a separate 10 percent rating from August 31, 2012 to October 25, 2012 and a 20 percent rating for left knee moderate instability from May 16, 2015 to July 14, 2015. Considering the period prior to May 16, 2015, instability or recurrent subluxation of the left knee was not shown objectively. The October 2012 VA examiner found normal left knee joint stability along with no subluxation as did the December 2014 VA contract examiner. (Notably, the Veteran reported during the December 2014 VA examination that he was prescribed a brace for the left knee by his treating provider which arguably constitutes evidence that some instability may have been present). There also is no other medical finding of record indicative of recurrent instability or subluxation. Nonetheless, the Board will not reduce the 10 percent rating already assigned based on slight instability. The Board next finds that a separate compensable rating under DC 5257 is warranted from October 25, 2012 to May 16, 2015. A disability rating greater than 10 percent prior to May 16, 2015, is not warranted as moderate instability was not shown prior to that date. At the May 16, 2015 VA examination, findings compatible with moderate instability were shown; however, severe instability or recurrent subluxation was not shown. Thus, the Board finds that a disability rating greater than 20 percent is not warranted from May 16, 2015. Considering DC 5260, flexion of the left knee was not found to be 45 degrees or less prior to July 14, 2015. In this regard, review of the October 2012, December 2014 and May 2015 examinations shows that flexion was never less than 90 degrees even after repetitive use testing. There is no other evidence indicative of flexion to 45 degrees or less. Consequently, a separate rating under DC 5260 is not warranted. The Board notes that the 10 percent rating assigned for limitation of motion of the knee from April 16, 2015 to July 14, 2015 was assigned under DC 5260. As explained below, this impairment is rated appropriately under DC 5003 for painful but otherwise noncompensable limitation of motion. Thus, this 10 percent rating for limitation of motion of the left knee will be continued but will be recharacterized as impairment under DC 5003. The 10 percent rating also will be expanded to part of the portion of the appeal period prior to April 16, 2015 (i.e. from December 11, 2014 to April 16, 2015) as outlined below. The Board finds that the Veteran is not prejudiced by the change in DC as the 10 percent rating is being continued for the same underlying impairment and is being assigned for a longer time frame within the appeal period. Considering DC 5261, extension was found to be normal (i.e. to 0 degrees) at the October 2012, December 2014, and May 2015 VA examinations even after repetitive use testing. At the April 2013 VA Tricare visit, extension was to 5 degrees; however, this finding does not warrant assignment of a separate compensable rating. There is no other evidence of record prior to July 14, 2015, which provides a basis for awarding a compensable 10 percent rating for limitation of extension under DC 5261. Under Diagnostic DC 5003, VA is authorized to assign a 10 percent rating when limitation of motion is noncompensable in degree and when the limitation is objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. As explained above, the 10 percent rating under DC 5260 from May 16, 2015 to July 14, 2015, is being recharacterized as a 10 percent rating under DC 5003. As 10 percent is the maximum rating under this DC for the knee joint, the Board must consider whether the 10 percent rating is warranted for the prior period from August 31, 2012 to May 16, 2015. Notably, at the October 2012 VA examination the Veteran's motion was not objectively painful even on repetitive use. Nor were there objective findings of swelling or muscle spasm. At the December 11, 2014 VA examination, the Veteran's functional loss on repetitive use included pain on movement and he had limitation of flexion that was noncompensable in degree (i.e. to 120 degrees). There also was objective evidence of pain on motion with limitation of motion that was otherwise noncompensable during the May 2015 VA examination. Accordingly, a 10 percent rating is assigned as of December 11, 2014. With this addition, the Veteran is assigned a 10 percent rating under DC 5003 from December 11, 2014 to July 14, 2015. The Board has considered whether any other rating DCs applicable to rating disability of the knee could be applied. Ankylosis, impairment of the tibia or fibula and genu recurvatum are not shown. Consequently, there is no basis for applying any of these DCs. See 38 C.F.R. § 4.71a, DCs 5256, 5262, 5263. The Board next has considered whether an additional rating could be awarded based on functional loss. See DeLuca, 8 Vet. App. at 202. The Board notes that the existing ratings assigned specifically account for loss of function, including loss of motion on repetitive use and flare-ups. Generally, the existing ratings assigned (a 20 percent rating for meniscal impairment for the period from August 31, 2012 to July 14, 2015, a 10 percent rating under DC 5257 for left knee instability prior from August 31, 2012 to October 25, 2012, a 20 percent rating for instability from May 16, 2015 to July 14, 2015, and a 10 percent rating under DC 5003 from December 11, 2014 to July 14, 2015) provide appropriate compensation for the Veteran's functional loss. The October 2012 examiner found functional limitation was present in the form of weakness, pain and limitation of motion. The December 2014 VA examiner found that there was functional loss including less movement than normal and pain on movement. And the May 2015 examiner found functional loss in the form of pain, fatigue and weakness and more movement than normal. This level of function is compatible with the existing ratings assigned, which combine to be at least 30 percent disabling during the entire appeal period prior to July 14, 2015. Entitlement to a disability rating greater than 30 percent for status post replacement of left knee from September 1, 2016 As noted above, in the September 2015 rating decision, the RO granted a temporary total rating for surgery (i.e. total knee arthroplasty with convalescence) effective July 14, 2015 and assigned a subsequent 30 percent rating for status post left knee arthroplasty effective September 1, 2016. The Veteran seeks a higher rating. In a February 2018 statement, the Veteran reported that his left knee popped while walking up stairs and was painful when walking downstairs. He also indicated that it was a challenge for him to stand in line for short periods of time. He noted that he had degrees of residual weakness, pain and limitation of motion when walking up and down steep grades. In March 2018, the Veteran was afforded a VA examination. The diagnosis was total left knee arthroplasty. He reported current left knee pain. He reported an increase in weakness and pain on repetitive use and on flare-ups. However, he indicated that he did not experience any loss of motion on repetitive use or on flare-ups. Upon range of motion evaluation, the left knee measured to 140 degrees in flexion and exhibited full extension. Pain was noted on both flexion and extension. There was pain on flexion and extension. There was no additional loss of motion after 3 repetitions. The examiner found that pain and weakness significantly limited functional ability with repeated use over time and on flare-ups but did not cause additional loss of motion. Disturbance of locomotion, interference with standing, and increased knee pain with prolonged periods of standing or walking, were all found to be additional contributing factors of the left knee disability. No ankylosis, joint instability, recurrent patellar dislocation, or subluxation was found. The Veteran's gait was described as antalgic. In July 2018, the Veteran was afforded another VA examination. It was noted that he had received the total knee replacement in July 2015. Upon range of motion evaluation, flexion was measured to 130 degrees and the left knee had full extension. Pain was noted upon flexion. There was no additional loss of function or range of motion after repetitive use testing. He reported that during flare-up, the loss of range of motion was variable, depending on how strenuously the joint was being used. He indicated that at its worst, range of motion loss was minimal. There was no evidence of subluxation. Moderate 2+ anterior instability, posterior instability, medial instability, and lateral instability was found. Laxity was secondary to the total knee replacement. The examiner described the functional impact of the left knee disability as being limited in prolonged standing and ambulation. There was no objective evidence of pain on non-weight-bearing or on passive range of motion which was the same as active range of motion. At a January 2021 VA examination, the diagnosis was patellofemoral pain syndrome. The Veteran reported that it was currently painful to stand, to drive for more than one hour, to perform extended sitting, to negotiate stairs, especially going downstairs, to bend, or to squat. He indicated that he used a knee brace when he had a flare up or when working out. He noted that the knee impaired ability to walk on uneven terrain. He reported daily flare ups, which he described as severe. He indicated that the flare-ups lasted up to an hour. He reported that the flare-ups were precipitated by sharp turns, climbing, and descending stairs and carrying weights. He noted that the flare-ups were alleviated by massage, rest, and Voltaren gel. He reported that after repeated use over time, when walking, he felt as if he was going to fall and found it difficult and awkward to maneuver through airports. Range of motion testing produced findings of 110 degrees flexion and normal extension. There was evidence of pain on range of motion on weight bearing and this caused functional loss in that it impaired the ability for him to walk on uneven terrain, bend, squat, negotiate stairs, or sit or stand for extended periods. There was localized tenderness in the lateral patella that was moderately severe. On repetitive use testing, range of motion decreased flexion to 100 degrees due to pain. Pain limited functional ability with repeated use over time, estimated to be 100 degrees flexion to 5 degrees extension. The examiner found no recurrent subluxation, recurrent patellar instability or peristent instability. The Veteran did not require a prescription for a brace or other assistive device. The examiner indicated that the total knee replacement was manifested by residual pain specifically with ambulation of stairs and prolonged sedentary positions and that the Veteran regularly used a brace. The examiner described the functional impact of the disability as difficulty climbing and descending stairs and feeling like the knee was unstable in any unlevel terrain. Lawnmowing and moving in a lateral direction also caused pain and a feeling of instability. The examiner commented that range of motion was moderately affected by the knee disability and that there was pain noted with movement both passively and actively. Pain was elicited before range of motion was achieved at 80 degrees flexion on the left. Functional impairment was most marked by climbing and descending stairs, moving on uneven terrain, by bending and by squatting. Extended sitting or standing were also impacted by recurrent knee pain. There was no instability of the joint found on exam. The Veteran's gait was somewhat stiff and slow to rise to standing position due to stiffness of both knees. The evidence does not show that the Veteran's left knee disability has been manifested by severe painful motion or weakness. In this regard, at the March 2018 VA examination, the left knee range of motion was essentially normal and, while there was pain on motion, it was not found to be severe. Similarly, while the Veteran was shown to have increased knee pain with prolonged periods of walking, this increased pain was not shown to be severe. Additionally, while both pain and weakness were noted to significantly limit functional ability with repeated use over time and on flare-ups, this impairment was not characterized as severe and was found not to cause additional limitation of motion. Also, at the July 2018 VA examination, range of motion was again nearly normal. Also, while pain was noted on motion, it was not found to be severe. The Veteran reported that on flare-up, at its worse, his range of motion loss was minimal. Moreover, while he had functional loss, including being limited on prolonged standing or ambulation, this impairment was not found to entail severe painful motion or weakness, nor is it compatible with such severe impairment. Additionally, at the January 2021 VA contract examination, the Veteran's knee was found to involve painful motion and to impair his ability to walk on uneven terrain. The examiner also found that the range of motion was moderately affected by the knee disability and that there was pain noted with movement both passively and actively. Additionally, the examiner noted functional impairment was most marked by climbing and descending stairs, moving on uneven terrain, by bending and by squatting and that extended sitting or standing were also impacted by recurrent knee pain. While this examination indicates significant functional impairment, it does not show a level of impairment compatible with severe painful motion or weakness. In this regard, the range of motion was still 100 degrees flexion on repetitive use testing and the tenderness in the lateral patella was found to be moderately severe rather than severe. Also, the examiner did not find any recurrent subluxation, recurrent patellar instability, or persistent instability. The Veteran reported that he used a knee brace when experiencing flare-ups and that, after repeated use over time, he felt like he was going to fall and that he found it difficult and awkward to maneuver through airports. This does not indicate severe painful motion or weakness. In this regard, he did not demonstrate severe pain on motion. Although the limitation on repeated use indicates some weakness, it is not severe in degree given that it is only manifested after repetitive or prolonged use (e.g. covering the significant walking distance involved in maneuvering through an airport). He did not report regularly requiring a brace but only needing one on flare-up. Considering the overall level of impairment shown during the January 2021 examination and the earlier examinations and the Veteran's reporting, the weight of the evidence is against a finding that there has been chronic left knee residuals consisting of severe painful motion or weakness. In other words, the Board finds that a 60 percent rating for the left knee is not warranted. DC 5055 also calls for consideration of whether an intermediate rating (i.e. higher than 30 percent but lower than 60 percent) is warranted) by rating by analogy to DCs 5256, 5261, or 5262. The Board notes that the Veteran does not meet any criteria for DC 5256 or DC 5262, as there is no evidence of ankylosis or impairment of tibia and fibula, respectively. Further, the Veteran generally had full extension of the knee; hence, DC 5261 does not warrant a higher rating for the left knee during this period on appeal. The Veteran's functional impairment due to pain and other factors set forth in 38 C.F.R. §§ 4.40 and 4.45, as well as DeLuca, has been considered in assigning the existing 30 percent rating. The Board finds that, on these facts, no higher rating is assignable on such basis. The Veteran was able to accomplish the levels of range of motion noted above in the examination findings even with pain after repetitive use testing and during flare-ups. Even after repetitive use testing, the loss of motion and the severity of other loss of function as discussed above is not compatible with a disability rating greater than 30 percent. The Board acknowledges the Veteran's reports of right knee instability and giving way during the appeal period and the July 2018 examiner's findings of instability. The Board finds that this symptom is contemplated in the rating assigned under DC 5055, as this evaluation includes weakness and is intended to compensate for all residuals of a knee replacement. Thus, to assign a separate rating under 38 C.F.R. § 4.71a DC 5257, either the initial or revised criteria (effective February 7, 2021) constitutes improper pyramiding. In conclusion, the Board finds that the evidence does not support assigning a disability rating greater than 30 percent from September 1, 2016. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dan Brook, 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.