Citation Nr: 21029844 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 16-41 929 DATE: May 17, 2021 ORDER Entitlement to an evaluation in excess of 10 percent for the period prior to November 23, 2016, and in excess of 30 percent thereafter, for right knee limitation of motion, is denied. Entitlement to a separate evaluation of 10 percent, and no higher, for right knee impairment manifested by instability is granted, subject to regulations governing payment of monetary awards. Entitlement to an evaluation of 30 percent, and no higher, for the period prior to January 1, 2014, for left knee limitation of motion, is granted, subject to regulations governing payment of monetary awards. Entitlement to an evaluation of 20 percent, and no higher, for the period from April 1, 2014, to prior to November 23, 2016, for left knee limitation of motion, is granted, subject to regulations governing payment of monetary awards. Entitlement to an evaluation in excess of 30 percent, for the period from November 23, 2016, for left knee limitation of motion, is denied. Entitlement to an evaluation in excess of 10 percent for left knee impairment manifested by instability, is denied. Entitlement to a separate evaluation of 10 percent for left knee meniscal disability, for the period beginning April 1, 2014, is granted, subject to regulations governing payment of monetary awards. FINDINGS OF FACT 1. During the period prior to November 23, 2016, the preponderance of the evidence is against a finding that the Veteran's right knee manifested extension limited more nearly approximating limitation to 15 degrees or higher. 2. The preponderance of the evidence from November 23, 2016, is against a finding that the Veteran's right knee manifested extension limited to 20 degrees or higher. 3. The preponderance of the evidence is against a finding that the Veteran's right knee manifested limitation of flexion to 45 degree or less. 4. The Veteran's right knee manifested slight instability during the entire period on appeal. However, the Veteran's right knee did not manifest sprain, ligament tear, or patellar surgery. 5. During the period prior to January 1, 2014, the Veteran's left knee manifested extension limited to 20 degrees or less. However, the preponderance of the evidence is against a finding that the Veteran's left knee manifested extension limited more nearly approximating limitation to 30 degrees or more during this period. 6. During the period from April 1, 2014, to prior to November 23, 2016, the limitation of the Veteran's left knee extension more nearly approximated limitation to 15 degrees or less. 7. During the period from November 23, 2016, the Veteran's left knee extension did not more nearly approximate limitation to 30 degrees or more. 8. The preponderance of the evidence is against a finding that the Veteran's left knee manifested limitation of flexion to 45 degree or less. 9. At no point during the period on appeal did the Veteran's left knee manifest more than sight instability, or any sprain, ligament tear of the left knee, or patellar surgery. 10. During the period on appeal from April 1, 2014, the Veteran's left knee manifested symptomatic removal of semilunar cartilage. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the period prior to November 23, 2016, and in excess of 30 percent thereafter, for right knee limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 2. The criteria for a separate rating of 10 percent, and no higher, for right knee impairment manifested by instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. The criteria for a rating of 30 percent, and no higher, for the period prior to January 1, 2014, for left knee limitation of motion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 4. The criteria for a rating of 20 percent, and no higher, for the period from April 1, 2014, to prior to November 23, 2016, for left knee limitation of motion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 5. The criteria for a rating in excess of 30 percent, for the period beginning November 23, 2016, for left knee limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 6. The criteria for a rating in excess of 10 percent, for left knee impairment manifested by instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 7. The criteria for a rating of 10 percent for left knee meniscal disability, for the period beginning April 1, 2014, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5259. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1968 to September 1977. The claims were most recently before the Board in April 2020 when they were remanded for additional development. The Board finds there has been substantial compliance with the remand directives for the claims decided herein. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability evaluations are determined by comparing a veteran's present symptoms with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the rating period on appeal, the Board will assign staged ratings for separate periods of time. Hart v. Mansfield, 21 Vet. App. 505 (2007). 1. Entitlement to an evaluation in excess of 10 percent for the period prior to November 23, 2016, and in excess of 30 percent thereafter, for right knee disability. 2. Entitlement to an evaluation in excess of 10 percent, for the period prior to January 1, 2014; in excess of 10 percent from April 1, 2014 to November 23, 2016, and; in excess of 30 percent thereafter, for left knee limitation of motion. 3. Entitlement to an evaluation in excess of 10 percent for left knee impairment manifested by instability. The Veteran seeks entitlement to higher evaluations for his right and left knee disabilities. Specifically, the Veteran argued that he had difficulties with his knee giving out, had difficulty going up and down stairs, has pain in his knees for which he takes pills, and uses braces, a walker, and a cane. The Veteran's right knee disability is currently evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Veteran's left knee limitation of motion is currently evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5261. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. This hyphenated diagnostic code may be read to indicate that traumatic arthritis is the service-connected disorder, and it is rated as if the residual condition is limitation of extension under Diagnostic Code 5261. The Veteran's left knee impairment manifested by instability is currently evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5257. 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). During the pendency of the Veteran's claim and appeal, the criteria for rating musculoskeletal disabilities were changed, effective on February 7, 2021. 85 Fed. Reg. 76,453 (November 30, 2020). The amendments provide that the Board should apply the criteria which are more favorable to the Veteran. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The February 2021 changes to the rating criteria for the knee pertain to Diagnostic Code 5257 (instability) and Diagnostic Code 5262 (impairment of the tibia and fibula). The rest of the rating criteria for the knee are unchanged. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5260, as in effect before and after February 7, 2021, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5257 as in effect prior to the February 2021 change, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5257, as in effect after February 7, 2021, for recurrent subluxation or lateral instability, a 10 percent is warranted 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 20 percent is warranted for one of the following: (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 prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent 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. For patellar instability, a 10 percent 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 20 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent is warranted 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. Based on a review of the record, the Board finds an increased rating is not warranted for the right knee disability based on limitation of motion at any time during the appeal period and a separate 10 percent rating is granted for instability. For the left knee disability, a 30 percent is warranted for limitation of extension for the period prior to January 1, 2014; a 20 percent rating from April 1, 2014 to prior to November 23, 2016, but a rating in excess of 30 percent from November 23, 2016, is not warranted. An increased rating (in excess of 10 percent) for left knee instability is denied. A separate 10 percent evaluation is warranted for the meniscal disability from April 1, 2014. A September 2010 x-ray of the left knee shows stable mild hypertrophic changes at the anterior margins of the patella. However, there was no acute abnormality. On VA examination in December 2010, the Veteran reported that he suffered from pain, weakness, stiffness, swelling, instability, giving way, locking, fatigability and lack of endurance. He was prescribed medication, used a cane, and had bilateral knee braces. The knees popped and locked. There was painful, limited range of motion in both knees. Left knee flexion was 90 degrees and there was 2 degrees of additional loss of motion after 5 motions. Extension was -12 degrees with 3 degrees of additional loss of motion after 5 motions. Right knee flexion was 90 degrees and there was 0 degrees of additional loss of motion after 5 motions. Extension was 0 degrees with 0 degrees of additional loss of motion after 5 motions. The right knee was mild for varus/valgus of medial collateral ligaments, varus/valgus lateral collateral ligaments, and anterior cruciate ligaments tests. The right knee was normal for posterior cruciate ligaments test. The left knee was normal for varus/valgus of medial collateral ligaments, varus/valgus lateral collateral ligaments, anterior cruciate ligaments, and posterior cruciate ligaments tests. Both knees were positive for medial meniscus and lateral meniscus tests. There was objective evidence of painful motion, instability, tenderness, abnormal movement, and guarding of movement bilaterally. However, there was no edema, effusion, redness, or heat. His gait was abnormal and he used a cane on the left, walked slowly, stiffly and antalgically. There was functional limitation on standing and walking with the Veteran being able to stand for 15 minutes and walk for 25 yards. The examiner concluded that the Veteran had degenerative joint disease of the left knee with chronic strain, varus deformity and slight instability. There was an incidental finding of chronic strain, right knee with varus deformity and slight instability. In January 2011 the Veteran reported that over the years his knee pain worsened. His left knee hurts when he sits or stands too long, and when he walks. Braces helped to prevent the knees from giving way. On VA examination in October 2011, the Veteran had limited extension of the right knee. Both knees gave way, there was pain on standing, and he was unable to walk for extended periods of time. He had flare-ups of periods of increased pain, swelling and stiffness. Initial range of motion of the right knee was flexion to 90 degrees with objective evidence of pain beginning at 30 degrees and extension of 10 degrees with objective evidence of pain at 20 degrees. Initial range of motion of the left knee was flexion of 90 degrees with objective evidence of pain beginning at 30 degrees and extension of 0 degrees with objective evidence of pain beginning at 15 degrees. After repetitive use the Veteran had right knee flexion of 90 degrees and extension of 10 degrees. The left knee showed 90 degrees of flexion and 0 degrees of extension after repetitive use. There was no additional limitation in range of motion of the knee following repetitive use testing. He had functional loss and/or functional impairment identified as less movement than normal, pain on movement, swelling, and interference with sitting, standing, and weight-bearing. There was tenderness or pain to palpation for the joint line or soft tissues of the knees. Joint stability tests were normal throughout. There was no patellar subluxation/dislocation. There were shin splints, stress fractures, chronic exertional compartment syndrome, evidence of acquired, traumatic genu recurvatum with weakness and insecurity in weight-bearing, or leg length discrepancy. There were no meniscal conditions or surgeries. The Veteran was not noted to have any locking or effusion. He used braces and a walker occasionally. In March 2013 the Veteran reported that he had painful patellar motion with all movement. In treatment notes in April 2013 and May 2013 the Veteran was reported to be issued a knee sleeve for the left knee. An orthopedic surgery reported in April 2013 that the Veteran lacked full extension actively by 25° on the right and 30° on the left. He had flexion only to 80 degrees on the left and 105 on the right. Passive motion though was much better. He was very protective of the knees but there did not appear to be any gross laxity with stressing either knee. The Veteran complained of some tenderness along the superior patella more so on the left side. There was some tenderness along the medial patellar retinaculum bilaterally. There is no effusion in either knee. On standing the Veteran lacked full extension in both knees. X-ray examination showed an essentially normal knees but he is unable to flex adequately for a sunrise view of either knee. An April 2013 physical therapy note showed range of motion of 20 to 80 degrees in the left and 15 to 90 degrees in the right. There was pain of 8 out of 10 in the left knee with gait. There was decreased left knee active range of motion. In June 2013 the Veteran reported that he could not walk more than 10 steps and used a community walker. He lacked full extension of the left knee by 20 degrees. There was no effusion in the knee. He was tender to palpation over the medial aspect of the joint and there was tenderness along the medial border of the patella. There was no laxity with varus or valgus stressing. He could flex to 90 degrees actively. He underwent a left knee injection. In July 2013 the Veteran was concerned about knee pain and locking. Magnetic Resonance Imaging (MRI) of the left knee in July 2013 showed longitudinal horizontal tearing involving the body and posterior horn of the medial meniscus, small to moderate sized joint effusion, and small popliteal cyst with leakage of fluid inferiorly. In July 2013 and February 2014 the Veteran's right knee had range of motion of 3 to 120 degrees, and left knee had range of motion of 20 to 105 degrees. The Veteran reported in August 2013 that he had extreme limitation in his ability to walk due to his knee pain. He reported lack of endurance, weakness, and giving way. He stated that he had knee braces and that he had been prescribed a cane. In December 2013 the Veteran had persistent left knee pain. He lacked 25 degrees of full extension and flexed to 100 degrees. There was no laxity with varus or valgus stressing. He had some tenderness to palpation over the patellar region but none medially or laterally. There was no significant effusion in the knee. The Veteran had knee pain in January 2014. He had left knee pain about the medial joint line. There was no left knee effusion. The patella tracked well and ligaments were stable. On January 28, 2014, the Veteran underwent left knee arthroscopic medial meniscus repair. The Veteran was diagnosed with torn left knee meniscus in a February 2014 note. In February 2014 the Veteran had a range of motion of 20 to 105 degrees that was painful at the end ranges on the left and 3 to 120 degrees on the right. Functional problems included 6 out of 10 left knee pain with gait, decreased left knee active range of motion, decreased strength in the left knee, and needed assist with gait. In March 2014 the Veteran's knee showed no effusion, nearly full motion, good strength, and nearly full comfort. The Veteran was noted to have had a good result to an arthroscopic partial meniscectomy in April 2014. In April 2014 the Veteran had range of motion of the right knee of 3 to 120 degrees and left knee of 20 to 105 degrees with painful end ranges. Reassessment of the left knee was 10 degrees to 95 degrees with painful movement. There was point tenderness at the left knee medial joint line on palpation. In June 2014 the Veteran's active knee range of motion was limited tolerated secondary to pain. He had mild left knee swelling. Flexion of the left was 106/110 and extension lacked 17 degrees. Flexion of the right knee was 118/125 and extension 0. His knee pain was aggravated by walking 2 to 3 blocks. In July 2014 the Veteran's active knee range of motion was limited tolerated secondary to pain. Flexion of the left was 106/110 and extension lacked 17 degrees. The Veteran was noted to be missing about 10 degrees of knee extension bilaterally in October 2015. Upon a VA examination in December 2015, the Veteran reported flare-ups on increased pain in the knees. When he had knee pain he had functional loss or functional impairment. He had knee pain with prolonged standing/walking. Range of motion of the right knee was flexion of 0 degrees to 110 degrees and extension of 110 degrees to 0 degrees. Range of motion of the left knee was flexion of 0 degrees to 115 degrees and extension of 115 degrees to 0 degrees. The decreased knee range of motion affected knee function when engaged in physical activity involving the knees. There was no pain on examination or with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue and no objective evidence of crepitus. Observed repetitive use did not result in additional functional loss or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time or during a flare-up. The examiner stated that it was not practical or feasible to objectively quantify range of motion or any limitation in functional ability due to pain, weakness, fatigability, or incoordination with repeated use over a period of time, or during a flare-up, without resorting to mere speculation. Prolonged standing/walking can cause knee pain. There was no ankylosis. There was no joint instability on examination and there was no history of recurrent effusion. The Veteran did not have or ever had a meniscus condition. However, the Veteran was noted to have undergone left knee arthroscopy and had residual pain, stiffness, and decreased range of motion. He had a scar of the anterior left knee of 1 centimeter by 0.1 centimeter. The Veteran occasionally used a brace and scooter and regularly used cane and walker. In December 2015 the Veteran was noted to have had frequent falls in the past. The Veteran was issued a large hinged knee brace in April 2016. The Veteran reported this right knee was getting worse in July 2016. It was worse with any weight bearing. In July 2016 the Veteran was noted to have no acute fracture or dislocation, mild degenerative changes of the medial and lateral femorotibial compartments, patellar enthesopathy was seen, and small joint effusion was present. The impression was mild osteoarthritis. At the hearing before the undersigned the Veteran reported that his knees gave out sometimes. He had trouble going up and down stairs and had a left total knee replacement. He took pain medication for his knees and used a cane to get around. He was issued braces for both knees. A November 23, 2016 VA treatment recorded motion from 20 degrees to 90 degrees on the left and from 20 degrees to 80 degrees on the right. The Veteran's biggest concern was that his knees periodically give way. The record includes reports of VA examinations in July 2019 and August 2019 that the Board has previously determined are inadequate; the findings will not be discussed further. In September 2019 the Veteran reported that the problems with his knees interfered with his ability to participate in sports and getting up from chairs and walking. He reported that the examiner did not mention the swelling he had in his legs, ankles and feet. Further he reported that there was no addressing one leg being shorter than the other. The Veteran reported that the examiner did not discuss the Veteran's inability to bend his knees at certain times and that he did not know when that was going to take place. He stated he had sudden locking. The Veteran identified that the examiner gave an opinion of the flexion of 0 to 60 and extension of 60 to 0 but did not take his sudden locking into account. The Veteran complained of chronic right knee pain in February 2020. He had a hinged support brace on the right knee and requested a similar brace for the left. He was noted to have had a cortisone injection many years ago with relief in the left knee. The Veteran underwent a right knee intra-articular injection in February 2020. The Veteran was evaluated for bilateral knee braces and new braces were issued in March 2020. In July 2020 the Veteran presented with a wheeled walker. He had right lower extremity below the knee swelling, +3 pitting edema. The skin was tight and shiny, tender to touch. Extensor mechanism of the knee was intact. There was no effusion to the knee, mildly tender on palpation at the medial joint line. Flexion was at the Veteran's baseline. In August 2020 the Veteran's right knee had no deformity or effusion. There was no warmth. His extensor mechanism was intact. Range of motion was 0- degrees to 120+ degrees. He was tender at the medial joint line. He underwent an injection of the right knee. The Veteran was evaluated for knee brace in the right in November 2020. In December 2020 the Veteran reported that his knee pain varies between 4 and 9. The more intense pain is sharp and severe. The more intense pain does not last long. He felt at times that both knees will give out. He had slight effusion in both knees. He lacked full extension by 20 degrees in the right knee and can flex only to about 90 degrees bilaterally. He had severe pain with even light palpation in the right medial knee. The Veteran was assessed with chronic knee pain. The Veteran was afforded a VA examination in January 2021. The Veteran's knees hurt when walking, the right worse than left. He reported that he had surgery on left knee described as putting a metal ball in the knee. The left knee gives away. He was given a walker, a scooter, and an electric wheelchair. He wore braces on both knees. He reported baseline pain to be 5 out of 10 and when walking the pain was 8 out of 10. He can stand for a short period, he has problems walking and falling because of his knees. He reported flare-ups of the knees identified as cannot move the leg and sharp shooting pain all around the knee. He reported functional impairment with climbing stairs. Range of motion of the right knee was flexion of 5 degrees to 90 degrees and extension of 90 degrees to 5 degrees. He could not bend his right knee to squat. Range of motion of the left knee was flexion of 2 degrees to 100 degrees and extension of 100 degrees to 2 degrees. He found it hard to bend his left knee or squat. Pain was noted on examination and caused functional loss. He had pain in both knees on flexion and extension. There was pain with weight bearing and objective evidence of crepitus. There was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The pain on the right was diffuse and severe. The pain on the left was moderate anterior. described as proximal and lateral pain. The Veteran was unable to perform repetitive use testing due to pain. He had functional loss in the right due to pain, fatigue, weakness, and lack of endurance. He had functional loss in the left due to pain. Repeated use over time caused pain, fatigue, weakness, and lack of endurance in the right knee. The range of motion on the right was described as flexion of 5 to 85 degrees and extension of 85 to 5 degrees. Repeated use over time caused pain and fatigue in the left knee. The range of motion on the left was described as flexion of 2 to 95 degrees and extension of 95 to 2 degrees. Flare-ups caused pain, fatigue, and weakness, lack of endurance, and incoordination in the right knee with a range of motion described as flexion of 5 to 70 degrees and extension of 70 to 5 degrees. Flare-ups caused pain, fatigue, and weakness in the left knee with a range of motion described as flexion of 0 to 85 degrees and extension of 85 to 0 degrees. Additional factors contributing to disability were noted to be less movement than normal due to ankylosis, adhesions, etc.; instability of station; disturbance of locomotion; and interference with standing on the right. The loss of range of motion limited the Veteran's ability to squat or kneel. The Veteran was not able to stand or walk for any period of time secondary to his knee pain. On the left the Veteran had less movement than normal due to ankylosis, adhesions, etc.; disturbance of locomotion; and interference with standing. Due to the left knee pain, the Veteran can only stand or walk for a very short period of time. The Veteran was unable to bend his knee fully due to decreased range of motion. There was no ankylosis of the knees. Stability tests were normal for both knees. There was no history of recurrent effusion. He did not have or ever had recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have or ever had a meniscus condition. He did not have effusion or locking. The examiner noted that the Veteran underwent left knee arthroscopy in 2015 and had residual symptoms of stiffness and pain. He had a scar of the anterior left knee of 1 centimeter by 0.2 centimeter. The Veteran regularly used a wheelchair, constantly used a brace, walker, and scooter. The left knee impairment was manifested by instability. There was objective evidence of pain when the knees were used in non-weight bearing and the range of motion in the knees was the same in passive as in active. The examiner reported that the current right knee condition was severe and the current left condition moderate. There was marked right knee swelling with pain going around the right knee. Veteran reports severe pain in the right knee with walking. The pain in the left knee was not as bad as the pain in the right knee. There was no swelling noted on examination of the left knee. The Veteran stated that he can only stand for a very short time then he has to sit down. Veteran also stated that he walks close to the wall to catch himself from falling since his left knee gives away. The Veteran had lots of obvious pain with weight-bearing. He reported pain as a 5 out of 10 without weight beating and 8 to 9 out 10 with weight-bearing. The pain was all the time. The Veteran's knees flared-up any time he tried to walk or stand for any period of time. He currently used a walker inside the house, he had a scooter to use outside the yard and an electric wheelchair. The Veteran cannot stand for any period of time and he tried to walk he has to hold on to the wall. This affected any occupational activities the veteran can be engaged in and is barely able to do activities of daily living. Right knee The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the period prior to November 23, 2016, and in excess of 30 percent thereafter, for right knee disability. During the period prior to November 23, 2016, the Board acknowledges that the Veteran had a measurements in April 2013 of extension limited to 15 degrees and higher. In addition, the Board acknowledges that the Veteran had pain that limited range of motion, occurred at the ends of range of motion, and that was aggravated by standing and walking; difficulty with stairs; flare-ups; stiffness; locking that concerned the Veteran; fatiguability; and lack of endurance. However, during the period prior to November 23, 2016, the Veteran's extension was predominantly less than 15 degrees, including in December 2010, July 2013, February 2014, June 2014, October 2015, and December 2015. Therefore, entitlement to a higher evaluation based on limitation of extension of the right knee for the period prior to November 23, 2016, is denied. During the period beginning November 23, 2016, the Board acknowledges that the Veteran's right knee manifested constant knee pain that was worse with standing and walking; additional impairment due to pain and fatigue during flare-ups; difficulty with going downstairs; locking; and problems with activities of daily living due to his knees. However, during this period the Veteran's right knee did not manifest limitation of extension of greater than 20 degrees. Therefore, entitlement to an evaluation in excess of 30 percent, for the period beginning November 23, 2016, is not warranted. The Board has considered whether the Veteran's right knee disability manifests limitation of flexion warranting a separate, compensable evaluation. The Board acknowledges the Veteran's knee pain; flare-ups; stiffness; locking; fatiguability; and lack of endurance; however, with the exception of a single notation in October 2011, where the Veteran was noted to have painful flexion beyond 30 degrees, the Veteran's right knee did not manifest flexion limited to 45 degrees or less. Therefore, a separation compensable evaluation for limitation of flexion of the right knee is not warranted. The Board finds that entitlement to a separate 10 percent evaluation for right knee impairment manifested by instability is warranted under the version of Diagnostic Code 5257 in effect prior to February 2021. Prior to February 2021, objective medical evidence is not required to establish instability under Diagnostic Code 5257. See English v. Wilkie, 30 Vet. App. 347 (2018). During the entire period on appeal, the Veteran complained of right knee instability and was prescribed and issued braces for his right knee. The Veteran was noted to have mild varus/valgus of medial collateral ligaments, varus/valgus lateral collateral ligaments, and anterior cruciate ligaments tests in December 2010. In December 2010 there was objective evidence of instability and the Veteran was found to have slight instability. In October 2011 the Veteran occasionally used a walker. In December 2015 the Veteran occasionally used a brace and scooter and regularly used a cane and walker. The Veteran reported falling, walking close to walls, using a walker, cane, and scooter. However, upon examination in October 2011, December 2015, July 2019, and January 2021, there was no objective joint instability. In addition, the Veteran was not noted to have sprain or ligament tear of the right knee. The Veteran's patella has been noted to have some changes but there is no notation of any diagnosed condition involving the patellofemoral complex. The preponderance of the objective testing results during the period on appeal more nearly approximate a finding of no instability. However, affording the Veteran the benefit of the doubt and taking into consideration the reports of instability and the Veteran's assistive devices, the Board finds that his right knee disability has manifested mild instability, and no greater, during the entire period on appeal. Therefore, a separate 10 percent evaluation is granted. Left knee The Board finds a 30 percent rating, and no higher, is warranted for limitation of extension, for the period prior to January 1, 2014. The Veteran had pain that limited range of motion and that occurred when he sits, stands and walks; locking; fatiguability; and lack of endurance. The Board further acknowledges a single measurement of extension limited to 30 degrees in April 2013; however, the preponderance of the evidence including measurements in December 2010, October 2011, April 2013, June 2013, and December 2013, does not show extension limited to 30 degrees or more. The evidence shows that during the period prior to January 1, 2014, extension is limited to 20 degrees or less. A 20 percent rating, and no higher, is warranted for left knee extension from April 1, 2014, to prior to November 23, 2016. The Veteran had painful knee motion that was aggravated by walking and that prolonged standing and walking can cause knee pain. During this period, although in October 2015 and December 2015, the Veteran's left knee extension was limited by 10 degrees and 0 degrees respectively, in June and July 2014 the Veteran's left knee extension was limited to 17 degrees. At no point during this period was the Veteran's extension of the left knee limited to 20 degrees or more. A rating in excess of 30 percent, for limitation of extension, for the period beginning November 23, 2016, is not warranted. The Veteran reported knee pain and that he was limited in walking and standing. However, at no point during this period did the left knee manifest limitation of extension to 30 degrees or more. A separate rating for limitation of flexion is not warranted for any time during the appeal period. The Board acknowledges that the Veteran has reported knee pain and that he was limited in walking and standing. However, with the exception of a single notation in October 2011, where the Veteran was noted to have painful flexion beyond 30 degrees, the Veteran's left knee did not manifest flexion limited to 45 degrees or less. Therefore, a separation compensable evaluation for limitation of flexion of the right knee is not warranted. A rating in excess of 10 percent is not warranted for left knee instability at any time during the appeal period, under either version of the rating criteria. The record include the Veteran's complaints of instability, testing in December 2010 identified instability, and he was provided assistive devices. The Veteran was noted to use a scooter; however, this was reported to be due to right knee weakness. In addition, the Veteran reported that he walked close to the wall to catch himself from falling. In October 2011 the Veteran occasionally used a walker. In December 2015 the Veteran occasionally used a brace and scooter and regularly used a cane and walker. In January 2021 the Veteran was noted to have been given a walker, a scooter, and an electric wheelchair, and to wear braces on both knees. The December 2010 VA examination was normal for varus/valgus of medial collateral ligaments, varus/valgus lateral collateral ligaments, anterior cruciate ligaments, and posterior cruciate ligaments tests; there was objective evidence of instability, described as slight. However, in July 2013 and December 2013, there was no laxity on varus or valgus stressing. In October 2011, December 2015, July 2019, and January 2021, there no instability on testing. Thus, as the preponderance of the evidence is against a finding of objective evidence of instability, the Veteran's left knee instability did not manifest more than mild symptoms. Furthermore, the Veteran was not diagnosed with sprain or ligament tear of the left knee and there is no notation of any diagnosed condition involving the patellofemoral complex. Therefore, entitlement to an evaluation in excess of 10 percent for left knee impairment manifested by instability is denied. The Board has also considered the other Diagnostic Codes pertaining to the knee and 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). The Board considered whether separate evaluation was warranted pursuant to Diagnostic Codes 5258 and 5259 for disabilities involving the semilunar cartilage. Regarding the right knee, during the period on appeal the Veteran was reported to have some effusion, locking and pain. Although the Veteran was noted to have had a torn meniscus of the right knee identified on an April 2000 MRI, the Veteran was not diagnosed with any semilunar cartilage, meniscal condition of the right knee during the period on appeal. Therefore, a separate evaluation for a meniscal condition of the right knee is not warranted. Regarding the left knee, the Veteran was found to have a tear of the medial meniscus in July 2013. During the period prior to July 2013 there was locking and pain. However, there was not effusion or meniscal condition identified. Upon MRI on July 2, 2013, the Veteran was noted to have a tear involving the medial meniscus and small effusion. In addition, the Veteran complained of pain and locking. However, thereafter, there is evidence that there is no significant effusion in the knee in December 2013. As such, prior to Veteran's January 2014 arthroscopic repair of the left knee meniscus, the Veteran's left knee did not manifest frequent episodes of locking, pain, and effusion into the joint and an evaluation pursuant to Diagnostic Code 5258 is not warranted. Thereafter, from April 1, 2014, after the Veteran underwent the arthroscopic surgery (involving partial meniscectomy) and total evaluation for convalescence, the left knee meniscal condition manifested residual pain, stiffness, decreased range of motion, slight effusion. Further the Veteran reported sudden locking; however, upon examination in January 2021, the Veteran was not noted to have effusion or locking. Affording the Veteran the benefit of the doubt, the Veteran has had symptomatic removal of semilunar cartilage. Therefore, entitlement to a 10 percent evaluation pursuant to Diagnostic Code 5259 for left knee meniscal disability is granted for the period from April 1, 2014. At no point during the period on appeal did either knee manifest ankylosis, impairment of the tibia and fibula, or genu recurvatum. Therefore, evaluation pursuant to Diagnostic Codes 5256, 5262, and 5263 is not warranted. M.E. LARKIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert J. Burriesci, 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.