Citation Nr: 21029781 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 09-42 199 DATE: May 17, 2021 ORDER Entitlement to an initial disability rating greater than 10 percent for arthritis of the left knee, rated as limitation of flexion, is denied. Entitlement to an initial disability rating greater than 10 percent for arthritis of the right knee, rated as limitation of flexion, is denied. Entitlement to an initial disability rating greater than 10 percent for limitation of extension in the left knee from January 24, 2018 is denied. Entitlement to an initial disability rating greater than 10 percent for limitation of extension in the right knee from January 24, 2018 is denied. Entitlement to an initial disability rating greater than 20 percent for instability of the left knee from January 12, 2021 is denied. Entitlement to an initial disability rating greater than 10 percent for instability of the right knee from January 12, 2021 is denied. REMANDED Entitlement to a temporary total disability rating for convalescence under 38 C.F.R. § 4.30 following a February 2019 surgery on the appellant's left knee is remanded. Entitlement to a temporary total disability rating for convalescence under 38 C.F.R. § 4.30 following an April 2019 surgery on the appellant's right knee is remanded. FINDINGS OF FACT 1. Even during periods of flare-ups or after repeated use over time, the appellant's left and right knee disabilities do not at least as likely as not manifest with symptoms of limitation of flexion to 30 degrees or less, or extension limited to 15 degrees or greater. 2. From January 12, 2021, the Veteran's service-connected degenerative arthritis of the left knee has been manifested by no more than moderate lateral instability. 3. From January 12, 2021, the Veteran's service-connected degenerative arthritis of the right knee has been manifested by no more than slight lateral instability. CONCLUSIONS OF LAW 1. From the date of service connection, September 22, 2011, the criteria for an initial rating in excess of 10 percent for arthritis of the left knee, rated as limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260. 2. From the date of service connection, September 22, 2011, the criteria for an initial rating in excess of 10 percent for arthritis of the right knee, rated as limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260. 3. From January 24, 2018, the criteria for an initial rating in excess of 10 percent for limitation of extension in the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5261. 4. From January 24, 2018, the criteria for an initial rating in excess of 10 percent for limitation of extension in the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5261. 5. From January 12, 2021, the criteria for an initial rating in excess of 20 percent for service-connected degenerative arthritis of the left knee with instability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 6. From January 12, 2021, the criteria for an initial rating in excess of 10 percent for service-connected degenerative arthritis of the right knee with instability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the United States Army from February 1981 to November 1992. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, granted service connection for arthritis of the left and right knees and assigned an initial 10 percent rating for each knee based on painful motion pursuant to Diagnostic Code 5003. The appellant was notified of that decision in an April 2, 2012 letter. This assigned ratings for the appellant's left and right knee disabilities were appealed in a notice of disagreement (NOD) received by VA on April 1, 2013. A Statement of the Case (SOC) was issued by VA in December 2014. VA received the appellant's Substantive Appeal (VA Form 9) in January 2015, perfecting the appeal and requesting a hearing before the Board. The request for a hearing was later withdrawn in April 2017. These claims were previously remanded by the Board for further development in December 2015, December 2017, April 2019, March 2020, and July 2020. The most recent remand in July 2020 was to order substantial compliance with the March 2020 remand instructions. Supplemental Statements of the Case were issued in September 2018, September 2019, April 2020, and January 2021. In a September 2019 rating decision, the RO granted separate ratings for limitation of extension of the right and left knees; 10 percent ratings were assigned to each knee, effective from January 24, 2018. In a January 2021 rating decision, the RO granted a separate 20 percent rating for instability in the left knee under Diagnostic Code 5257, effective from January 12, 2021, a separate 10 percent rating for instability in the right knee under Diagnostic Code 5257, effective from January 12, 2021. The Veteran has not expressed satisfaction with the increased disability ratings; this case thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). Initial Ratings 1. Entitlement to an initial disability rating greater than 10 percent for arthritis of the left knee, rated as painful limitation of motion. 2. Entitlement to an initial disability rating greater than 10 percent for arthritis of the right knee, rated as painful limitation of motion. 3. Entitlement to an initial disability rating greater than 10 percent for limitation of extension in the left knee from January 24, 2018. 4. Entitlement to an initial disability rating greater than 10 percent for limitation of extension in the right knee from January 24, 2018. 5. Entitlement to an initial disability rating greater than 20 percent for instability of the left knee from January 12, 2021. 6. Entitlement to an initial disability rating greater than 10 percent for instability of the right knee from January 12, 2021. Disability evaluations are determined by the application of a schedule of ratings, which is based on the veteran's average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body to function under the ordinary conditions of daily life, including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence used to decide whether an [initial] rating on appeal was erroneous. Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of an initial rating, staged ratings may be assigned for separate periods of time based on facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria"). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In this case, the Veteran's degenerative arthritis of the right knee is assigned a 10 percent rating from September 22, 2011 pursuant to Diagnostic Code (DC) 5003-5260; a separate 10 percent rating for limitation of extension under DC 5261 is assigned from January 24, 2018 and a 10 percent rating for instability of the right knee pursuant to DC 5257 is assigned from January 12, 2021. As to the left knee, a 10 percent rating for degenerative arthritis is assigned under DC 5003-5260 from September 22, 2011; a separate 10 percent rating for limitation of extension is assigned from January 24, 2018 under DC 5261 and a 20 percent rating is assigned for left knee instability under DC 5257 from January 12, 2021. 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. 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). 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. Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021 and both the old and revised rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, Diagnostic Code 5003 was only changed to clarify that it applies specifically to degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent 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. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Additionally, Diagnostic Codes 5260 (leg, limitation of flexion) and 5261 (leg, limitation of extension) were also not changed by the revisions to the musculoskeletal system, effective February 7, 2021. The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). Prior to the regulatory change DC 5257 provided the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257. As of February 7, 2021, under the amended criteria, the DC 5257 indicated that knee, other impairment of should be rated as follows: Recurrent subluxation or instability: 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, a 30 percent disability rating is warranted For one of the following a 20 percent disability rating is warranted: (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; (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider pre-scribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation, a 10 percent disabling rating is warranted. Patellar instability: For a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker a 30 percent disabling rating is warranted. For a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker, a 20 disability rating is warranted. For a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker, a 10 percent disability rating is warranted. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Diagnostic Codes 5258 and 5259 were not changed by the revisions to the musculoskeletal code. DC 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. DC 5259 provides that a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. Turning to the evidence of record, the Veteran was afforded a VA examination in September 2011 at which time the examiner noted that the Veteran exhibited an antalgic and unsteady gait due to bilateral knee pain. The Veteran reported stiffness, giving way, tenderness, and pain. He denied weakness, swelling, heat, redness, lack of endurance, locking, fatigability, deformity, drainage, effusion, subluxation, and dislocation. The Veteran endorsed flare-ups of bilateral knee symptoms that occur once per day and last for 12 hours. Pain during flare-ups is 7/10 in severity. Flare-ups are precipitated by physical activity and alleviated with rest, Naproxen, and Hydrocodone. During flare-ups, the Veteran experiences functional impairment with bending the knees and excessive walking. He also reported difficulty standing and walking. The examiner noted that the Veteran wears bilateral knee braces. Physical examination noted weakness and tenderness of the bilateral knees. The knees showed no signs of edema, instability, abnormal movement, effusion, redness, heat, deformity, guarding of movement, malalignment, or draining. There was also no history of subluxation. Range of motion testing revealed flexion to 140 degrees, bilaterally, with pain at 100 degrees, and extension to zero degrees, bilaterally, without pain. There was no additional limitation of motion upon repetitive use testing. The examiner reported that joint function in the bilateral knees is not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Joint stability testing was within normal limits in both knees. The examiner confirmed a diagnosis of degenerative arthritis in the right and left knees. The Veteran was afforded a VA examination to assess the nature and severity of his bilateral knee disabilities in December 2012. The VA examiner confirmed continuing diagnoses of degenerative disease of the right and left knees. He described flare-ups of bilateral knee symptoms manifested by problems sitting, standing, and walking for prolonged periods. Range of motion testing revealed flexion of the right knee to 130 degrees with pain and extension to zero degrees with no objective evidence of painful motion. Flexion of the left knee was also shown to 130 degrees with pain and extension to zero degrees with no objective evidence of painful motion. There was no additional limitation of motion in either knee with repetitive use testing. Additional contributing factors to functional impairment of the knees includes less movement than normal and pain on movement. There was tenderness/pain to palpation bilaterally. Muscle strength was intact. Joint stability testing was normal in both knees. Further, there was no history of recurrent patellar subluxation/dislocation. The Veteran does not have a meniscal condition in either knee. The examiner reported that the Veteran relies upon the regular use of a cane for ambulation. The VA examiner stated that the Veteran's right and left knee disabilities do impact his ability to work. Specifically, the examiner explained that the Veteran "is unable to participate in physical employment requiring prolonged standing, walking, or kneeling. The knee conditions do not inhibit his participation in sedentary employment." The Veteran was afforded a VA examination of his knees in January 2013, at which time he reported flare-ups that caused difficulty with activities such as sitting, standing, and walking for prolonged periods. Flexion in the left knee and in the right knee was measured from 0 to 130 degrees. Repetitive use testing did not reveal any additional range of motion loss. The appellant reported subjective symptoms of painful motion, although no objective indicators were noted during the examination. Muscle strength was normal with no signs of muscle atrophy or ankylosis. Joint stability testing was normal and there were no signs of patellar subluxation or dislocation. No injuries to the meniscus were noted. The examiner opined the appellant's knee disabilities did not inhibit his ability to work sedentary types of employment. Magnetic resonance imaging (MRI) of the left and right knees conducted in April 2005 revealed "[s]mall focus of meniscal transverse degenerative signal. Articular cartilage intact" in both knees. All ligaments of the knees were intact. VA treatment records dated in November 2015 and October 2017 noted the Veteran's report of continuing knee pain. Physical examination, including joint stability testing, was unremarkable. At a January 2018 VA examination, the appellant reported experiencing flare-ups wherein he felt as if his knee was going to "come unhinged" with sharp pain and swelling that caused difficulty doing any tasks. Flare-ups were reported to occur one or two times per week. The appellant did not indicate how often these flare-ups occurred. He reported typical symptoms to include stiffness, aching in the joints, difficulty walking long distances, climbing stairs, and standing for long periods of time, and decreased range of motion. Flexion in the left knee was measured at 0 to 85 degrees with full extension, and flexion in the right knee was measured at 0 to 110 degrees with full extension. Repetitive use testing showed decreases in both flexion and extension in both knees, with range of motion in the left knee being limited from 5 to 75 degrees and range of motion in the right knee being limited from 5 to 95 degrees. Muscle strength testing was normal, with no signs of ankylosis or muscle atrophy. Joint stability testing was normal and there were no signs of patellar subluxation or dislocation. No injuries to the meniscus were noted. The appellant was noted to regularly use a brace and a cane. The examiner opined that the appellant's functional limitation included standing for more than 10 minutes, walking more than one quarter mile, kneeling or squatting, running, playing basketball, doing most types of exercise. The Veteran underwent surgical repair of bilateral quadriceps tendon tears in February 2019 (left) and April 2019 (right). He subsequently attended physical therapy and reported that his knee symptoms had significantly improved. See the private treatment records dated November 2019. He reported that he still experienced stiffness, and reported difficulty with prolonged standing and walking. An addendum medical opinion issued in July 2019 found that the appellant's range of motion during flare-ups, based on the observations, testing, and medical history taken at the January 2018 VA examination, was reduced. Flexion in the left knee during flare-ups was limited to 65 degrees, and flexion in the right knee during flare-ups was limited to 85 degrees. During flare-ups extension in the left knee was limited to 10 degrees and extension in the right knee was limited to 10 degrees. Pursuant to the April 2020 Board Remand, a VA addendum opinion was obtained in April 2020 to address bilateral knee instability. The examiner reviewed the record and provided the following medical opinion: The above opinion is based on review of e-VBMS file, DBQ knee condition performed by Amy Lockett, PA-C dated January 24, 2018, diagnostic tests and review of the medical literature. Review of DBQ knee condition performed by Amy Lockett, PA-C did not reveal any evidence of knee instability on physical examination. Review of his treatment records did not reveal any evidence of knee stability. At his primary care visit at the VA on 08/30/2019, it was noted that he was still receiving physical therapy for both knees. He did not require pain medications and "walks without assistance." She added that he has "occasional use" of a cane. His physical therapy at the VA noted on November 18, 2019 that the "Veteran demonstrates restored knee AROM bilaterally as well as normalized strength in the knee and lateral hip. Patient demonstrates the ability to perform a squat to parallel and a lunge, with minimal support for balance purposes, without discomfort or dysfunction. Patient has reached his maximum skilled therapeutic benefit. Advised patient to maintain activity level and continue with a home exercise program. Skilled PT not recommended at this time." He was evaluated by Fayetteville Orthopedics on December 10, 2019 that he had normal gait, good strength, and no instability. The orthopedist did not note any need for regular use of knee braces and/or cane. Based on the medical evidence in e-VBMS and CPRS from his orthopedist, physical therapy, and primary care physician, the veteran had a normal gait with good strength, and no instability with occasional use of a cane for pain. There was no mention of knee braces needed for instability. At a January 2021 VA examination, the appellant's range of motion in the left and right knees actually showed some improvement since his previous examination. The appellant reported more mild flare-ups which occurred several times a week. Flexion in the left knee was measured from 0 to 100 degrees and flexion in the right knee was measured from 0 to 90 degrees. The appellant was found with full extension in both knees. Repetitive use testing showed an additional 20 degrees of lost flexion in the left knee, with no additional loss in extension, and no loss of flexion or extension in the right knee. Based on the appellant's reports of symptoms and the results of the examination, the examiner opined that during flare-ups or after repeated use over time, the appellant's range of motion in the left knee measured from 0 to 80 degrees and in the right knee from 0 to 90 degrees, with full extension in both knees under both sets of circumstances. Both knees showed reduced muscle strength, but with no signs of muscle atrophy or ankylosis. The examiner noted the functional impact of the disability was that the appellant was prevented from performing an occupation that required bending or flexing the knees beyond 80 degrees, climbing stairs, or sitting, walking, or standing for prolonged periods of time (more than 30 minutes at a time). The examiner reported that the Veteran exhibited bilateral knee instability. Joint stability testing revealed instability of 1+ (0-5 mm.) on anterior instability testing and posterior instability testing of the right knee. Anterior and posterior instability testing of the left knee revealed instability of 2+ (5-10 mm). The Veteran reported that he relies upon a cane and braces to help with swelling. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against an initial rating in excess of 10 percent for painful motion of the left and right knee, rated as limitation of flexion. During the period on appeal, the appellant has not had limitation of flexion to 30 degrees or less, even during periods of flare-ups or after repeated use over time. VA examination results have not shown limitation of flexion of 30 degrees or less in either knee. VA treatment records have also now shown limitation of flexion to 30 degrees or less. Further, the appellant's own statements do not approximate symptoms consistent with loss of flexion to 30 degrees or less. Additionally, the Board also finds that the preponderance of the evidence is against a rating in excess of 10 percent for limitation of extension in either knee from January 24, 2018; moreover, a compensable rating for limitation of extension of either knee is not warranted prior to January 24, 2018. Limitation of extension has never been observed at a compensable level during any of the appellant's VA examinations. The current 10 percent ratings are based on the July 2019 medical opinion, which estimated an additional loss of extension during a period of flare-ups, with extension limited to 10 degrees from the January 24, 2018 VA examination. This estimate was made based on symptoms observed and recorded by the examiner 18 months prior at the time of the January 2018 VA medical examination. Prior to that examination, there was no indication in the record that the appellant had any limitation of extension in either his left or right knee. Subsequent testing has shown improvement in that range of motion, with the appellant no longer even having limitation of extension, even during flare-ups or after repeated use over time which would warrant a compensable rating. The appellant has, at no point prior to the January 2018 VA examination, reported that he was unable to fully extend his knee due to pain, weakness, fatigability, or incoordination. The Board acknowledges the appellant's lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the appellant's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that the appellant has increases in pain and decreased ability to stand, walk, climb stairs, bend or squat down would not result in limitation of motion more nearly approximating flexion limited to 30 degrees or extension limited to 15 degrees. As indicated above, the Veteran is also in receipt of separate ratings for instability of the right and left knees. The Veteran's right knee is evaluated as 10 percent and his left knee is evaluated at 20 percent for instability; both ratings were assigned from January 12, 2021 pursuant to the former DC 5257 (in effect prior to February 7, 2021). In this regard, although the Veteran repeatedly reported the use of a cane and bilateral knee braces, there was no objective evidence of instability documented prior to the January 2021 VA examination. Notably, in the April 2020 VA addendum opinion, the VA examiner reviewed the evidence of record and did not identify objective evidence of instability. As detailed above, the January 2021 VA examiner identified slight (1+) instability in the right knee and moderate (2+) instability in the left knee; the assigned ratings were effectuated in order to compensate the Veteran for this documented instability. See the rating decision dated January 2021. The Board has considered the Veteran's lay statements of instability, but finds that the level of specificity is not sufficient to provide a basis to award higher ratings for instability at any time from the date of service connection. The Board has considered whether higher ratings would be warranted under the revised DC 5257 (in effect from February 7, 2021). To this end, the Board recognizes that the Veteran underwent right and left knee surgeries to repair bilateral torn quadriceps tendons. Although he relies upon a cane and braces for ambulation, there is no documentation in the record that these assistive devices were specifically prescribed to manage the Veteran's knee symptoms following the quadriceps tendon repairs. Accordingly, ratings in excess of those already assigned are not warranted under the revised DC 5257. The Board has also considered the other Diagnostic Codes pertaining to the knee and lower leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Prior to diagnostic testing or lay reports showing extension limited to 10 degrees of motion in January 2018, the assignment of a separate 10 percent rating in each knee for painful motion rated by analogy as limitation of extension, while the appellant is in receipt of a 10 percent rating for painful motion rated by analogy as limitation of flexion would constitute impermissible pyramiding, as the same symptoms would be compensated by separate ratings. 38 C.F.R. § 4.14. During the period on appeal, the appellant has not reported symptoms which would approximate ankylosis of the knee, nor have such limitations been observed at any of his VA examinations. Although degenerative changes of the meniscus were documented in MRI findings as to the right and left knees, there is no documentation of any meniscal tears from the date of service connection. In addition, there has been no evidence or reports of symptoms related to malunion or non-union of the tibia and fibula, no reports of medial tibial stress syndrome, or genu recurvatum. As such, separate ratings under other pertinent diagnostic criteria are not warranted. In sum, the Board has considered the entire record, including the Veteran's reported symptomatology and the objective clinical evidence. For the reasons set forth above, the Board finds that higher initial ratings are not warranted for the Veteran's right and left knee disabilities. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to a temporary total disability rating for convalescence under 38 C.F.R. § 4.30 following a February 2019 surgery on the appellant's left knee is remanded. 2. Entitlement to a temporary total disability rating for convalescence under 38 C.F.R. § 4.30 following an April 2019 surgery on the appellant's right knee is remanded. The appellant's most recent VA examination in January 2021 indicated that the appellant underwent surgery for his left and right knees in February 2019 and April 2019 respectively. In a January 2021 rating decision, the appellant was awarded service connection for residual scarring related to these two surgeries. Considering this, the Board finds there is at least as indication that the appellant's knee surgeries required convalescence and would be entitled to a temporary total rating under 38 C.F.R. § 4.30. The Board finds that entitlement to temporary total disability ratings for convalescence are inherently a part of the claims for an increased rating for the service-connected left and right knee disabilities. However, the record is insufficient to assign the temporary total ratings at this time. Treatment notes, discharge instructions, and other records related to the appellant's February and April 2019 knee surgeries are not currently of record. As such, the Board does not have the evidence necessary for the assignment of the temporary total ratings, as it is impossible to determine the appropriate length of time to assign the temporary total ratings under 38 C.F.R. § 4.30. Remand is necessary prior to adjudicating these issues to obtain the records related to the appellant's February 2019 and April 2019 left and right knee surgeries. It is unclear whether these procedures were done through the VA, through the VA Choice program, or through a private physician. The matters are REMANDED for the following action: Obtain treatment records related to the appellant's February 2019 left knee surgery and his April 2019 right knee surgery. Ask the appellant to complete a VA Form 21-4142 for the physician who performed his February 2019 and April 2019 knee surgeries if done outside of the VA. Make two requests for the authorized records from the physician identified by the appellant unless it is clear after the first request that a second request would be futile. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Kleponis, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.