Citation Nr: 21031678 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 10-39 860 DATE: May 24, 2021 ORDER Entitlement to an increased rating for chondromalacia patellae and osteoarthritis of the right knee with limitation of flexion, presently rated as 10 percent disabling prior to November 20, 2020, and as 20 percent disabling thereafter, is denied. Entitlement to an increased rating for chondromalacia patellae and osteoarthritis of the right knee with limitation of extension, presently rated as 20 percent disabling from November 20, 2020, is denied. Entitlement to an increased rating for chondromalacia patellae and osteoarthritis of the left knee with limitation of flexion, presently rated as 10 percent disabling, is denied. Entitlement to an increased rating for chondromalacia patellae and osteoarthritis of the left knee with limitation of extension, presently rated as 30 percent disabling from November 20, 2020, is denied. REMANDED Entitlement to an earlier effective date than November 20, 2020 for total disability for individual unemployability (TDIU) is denied. FINDINGS OF FACT 1. Prior to November 20, 2020, the Veteran's chondromalacia patellae of the right knee was characterized by pain and limitation of flexion to, at most, 90 degrees; limitation of flexion to 60 degrees or less; limitation of extension, ankylosis, recurrent subluxation, instability, symptomatic removal of semilunar cartilage, dislocated semilunar cartilage with frequent episodes of "locking" pain and effusion into the joint, or impairments of the tibia and fibula were not shown. 2. As of November 20, 2020, the Veteran's chondromalacia patellae of the right knee has been characterized by pain, crepitus, limitation of flexion to 25 degrees, and limitation of extension to 15 degrees; ankylosis, recurrent subluxation, instability, limitation of flexion to 15 degrees, limitation of extension to 20 degrees, or impairments of the tibia and fibula have not been shown. 3. Prior to November 20, 2020, the Veteran's chondromalacia patellae of the left knee was characterized by pain and limitation of flexion to, at most, 95 degrees; limitation of flexion to 60 degrees or less, limitation of extension, ankylosis, recurrent subluxation, instability, symptomatic removal of semilunar cartilage, dislocated semilunar cartilage with frequent episodes of "locking" pain and effusion into the joint, or impairments of the tibia and fibula were not shown. 4. As of November 20, 2020, the Veteran's left knee chondromalacia patellae of the left knee has been characterized by pain, crepitus, limitation of flexion to 35 degrees, and limitation of extension to 20 degrees; ankylosis, recurrent subluxation, instability, limitation of flexion to 30 degrees, limitation of extension to 30 degrees, or impairments of the tibia and fibula have not been shown. CONCLUSIONS OF LAW 1. Prior to November 20, 2020, the criteria for a rating in excess of 10 percent for chondromalacia patellae and osteoarthritis of the right knee, manifested by limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5010, 5260. 2. From November 20, 2020, the criteria for a ratings for chondromalacia patellae and osteoarthritis of the right knee, in excess of 20 percent based on limitation of extension, and 20 percent based on limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260, 5261. 3. Prior to November 20, 2020, the criteria for a rating in excess of 10 percent for chondromalacia patellae and osteoarthritis of the left knee, manifested by limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260. 4. From November 20, 2020, the criteria for a ratings for chondromalacia patellae and osteoarthritis of the left knee, in excess of 30 percent based on limitation of extension, and 10 percent based on limitation of flexion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from January 1981 to October 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a 2009 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). As a matter of procedural background, this matter previously came before the Board in June 2016 and October 2020 at which time the Board remanded the appeal for further development. Increased Rating Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here 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. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance" in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). When rating disabilities of the knee based on limitation of motion, a separate rating may be assigned for knee disabilities based on limitation of flexion as well as limitation of extension of the knee. Likewise, separate ratings may be assigned based on limitation of motion, as well as instability or subluxation, if found. See VAOPGCPREC 23-97 (Multiple Ratings for Knee Disability). Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. 1. Entitlement to a rating in excess of 10 percent for chondromalacia patellae and osteoarthritis of the right knee with limitation of flexion prior to November 20, 2020, and in excess of 20 percent thereafter 2. Entitlement to a rating for chondromalacia patellae and osteoarthritis of the right knee with limitation of extension prior to November 20, 2020, and in excess of 20 percent thereafter 3. Entitlement to a rating in excess of 10 percent for chondromalacia patellae and osteoarthritis of the left knee with limitation of flexion 4. Entitlement to a rating for chondromalacia patellae and osteoarthritis of the left knee with limitation of extension prior to November 20, 2020, and in excess of 30 percent thereafter The Veteran's chondromalacia patellae and osteoarthritis of the right knee was rated 10 percent prior to November 20, 2020 under 38 C.F.R. § 4.59 for functional loss due to painful motion. As of November 20, 2020, the Veteran's right knee disability has been rated 20 percent based on limitation of flexion to 25 degrees, painful motion of the knee, and traumatic arthritis under 38 C.F.R. § 4.71a, DC 5010-5260. An additional 20 percent rating was added under DC 5010-5261 as of November 20, 2020 for right knee limitation of extension to 15 degrees. The Veteran's chondromalacia patellae and osteoarthritis of the left knee was rated 10 percent prior to November 20, 2020 under 38 C.F.R. § 4.59 for functional loss due to painful motion. As of November 20, 2020, he was instead rated 10 percent under 38 C.F.R. § 4.71a, DC 5010-5260 for limitation of flexion to 35 degrees, painful motion of the knee, and x-ray evidence of degenerative arthritis. An additional 30 percent rating was added for the left knee under DC 5010-5261 as of November 20, 2020 for limitation of extension to 20 degrees. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In the present matter, DC 5010 indicates traumatic arthritis, and DCs 5260 and 5261 indicate limitation of motion manifested by limitation of flexion and extension respectively. The Veteran contends that he is entitled to increased disability ratings for the bilateral knee disabilities throughout the entire period at issue, reporting that his knees have never fully extended to zero degrees, and that the VA examiners incorrectly measured the Veteran's range of motion. It should be noted that, during the course of this appeal, the schedular rating for evaluating other impairments of the knee has been amended. Specifically, the criteria pertaining to recurrent subluxation or instability of the knee and impairment of the tibia and fibula under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See 85 Fed. Reg. 76, 453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enhancement of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, 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 the change. 38 U.S.C. § 5110; Kamas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's knee disabilities under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. DC 5010 compensates for posttraumatic arthritis. Under the pre-amended criteria, posttraumatic arthritis was to be rated as degenerative arthritis pursuant to DC 5003. Under that criteria, degenerative arthritis 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 (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a, DCs 5003, 5010. Under the amended criteria, posttraumatic arthritis is to be rated based on "l imitation of motion, dislocation, or other specified instability under the affected joint." Id. Specifically, it is noted that posttraumatic arthritis is limited to ratings under the diagnostic criteria for the specific joint, and does not provide for a single compensable rating based on painful motion as it did under the pre-amended criteria. However, the Board may continue to consider the old criteria should it provide for a higher rating. Under the pre-amended criteria, in order to warrant a 20 percent rating for a knee disability, the evidence must show: Moderate recurrent subluxation or lateral instability (20 percent under DC 5257); Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint (20 percent under DC 5258); Limitation of flexion of the leg to 30 degrees (20 percent under DC 5260); Limitation of extension of the leg to 15 degrees (20 percent under DC 5261); or Impairment of the tibia or fibula with moderate knee or ankle disability (20 percent under DC 5262) 38 C.F.R. § 4.71a Under the amended criteria, in order to warrant a 20 percent rating for a knee disability, the evidence must show: Recurrent subluxation or instability and one of the following: o Sprain, complete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation; or o Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation (20 percent under DC 5257); Patellar instability: 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 (20 percent under DC 5257); Dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint (20 percent under DC 5258); Limitation of flexion of the leg to 30 degrees (20 percent under DC 5260); Limitation of extension of the leg to 15 degrees (20 percent under DC 5261); or Medial tibial stress syndrome (MTSS), or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other consecutive treatment in one lower extremity (20 percent under DC 5262). 38 C.F.R. § 4.71a. In order to warrant a rating in excess of 20 percent for a knee disability under the pre-amended criteria, the evidence must show: Ankylosis of the knee of favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees (30 percent under DC 5256); Ankylosis of the knee in flexion between 10 degrees and 20 degrees (40 percent under DC 5256) Severe recurrent subluxation or lateral instability (30 percent under DC 5257); Limitation of flexion of the leg to 15 degrees (30 percent under DC 5260); Limitation of extension of the leg to 20 degrees (30 percent under DC 5261); Limitation of extension of the leg to 30 degrees (40 percent under DC 5261); Malunion of the tibia and fibula with marked knee or ankle disability (30 percent under DC 5262); or Nonunion of the tibia and fibula with loose motion requiring a brace (40 percent under DC 5262). 38 C.F.R. § 4.71a. In order to warrant a rating in excess of 20 percent for a knee disability under the amended rating criteria, the evidence must show: Ankylosis of the knee of favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees (30 percent under DC 5256); Ankylosis of the knee in flexion between 10 degrees and 20 degrees (40 percent under DC 5256) Recurrent subluxation or instability: unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation (30 percent under DC 5257); Patellar instability: 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 walker (30 percent under DC 5257); Limitation of flexion of the leg to 15 degrees (30 percent under DC 5260); or Limitation of extension of the leg to 20 degrees (30 percent under DC 5261); Limitation of extension of the leg to 30 degrees (40 percent under DC 5262); MTSS or shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other consecutive treatment in both lower extremities (30 percent under DC 5262); or Nonunion of the tibia and fibula with loose motion requiring a brace (40 percent under DC 5262). 38 C.F.R. § 4.71a. Based on the evidence of record, the Board finds that a rating in excess of 10 percent each for the Veteran's bilateral knee disabilities prior to November 20, 2020 is not warranted under either the pre-amended or amended criteria. First, the Board has reviewed all the evidence of record, and there is no evidence in either the medical evidence of record, the Veteran's statements, or VA examinations of any ankylosis, recurrent subluxation or instability, removal of the semilunar cartilage, or impairment of the tibia and fibula of either knee to warrant additional ratings under DCs 5256, 5257, 5259, or 5262. Next, although the Veteran complained of a history of joint pain in the knees and he was diagnosed with a history of arthralgia in September 2008, a physical examination demonstrated good balance, normal reflexes, and normal motor functioning. The Veteran underwent a VA knee examination for the bilateral knees in December 2008 where he reported bilateral knee pain, pain with squatting, stiffness, and severe flare-ups that occurred weekly and were precipitated by yard work. He reported that this resulted in less mobility, and he was limited to standing for only 15-30 minutes and walking less than a mile. Despite these reported symptoms, a physical examination of the Veteran's knees was mostly normal. The examiner found some guarding of movement and evidence of abnormal weight bearing, but otherwise the Veteran had a normal gait, full range of flexion and extension bilaterally, no abnormalities of the patella or meniscus, no crepitus, no instability, no ankylosis, and normal imaging of the Veteran's knees. The examiner diagnosed the Veteran with chondromalacia of the bilateral knees that caused pain, some decreased mobility, and problems with lifting and carrying, but opined that this caused only mild or no limitations on the Veteran's ability to perform daily activities of living. As such, there was no evidence of limitation of flexion or extension or dislocated semilunar cartilage with frequent episodes of "locking" pain and effusion into the joint to support ratings under DCs 5258, 5260, or 5261. The examiner's opinions were predicated on a full understanding of the Veteran's medical history and contentions and provided enough evidentiary basis for the claim to be adjudicated. The findings are also consistent with the mostly normal physical findings of the Veteran's knee in the medical records before and after the examination. Even though the examiner did not opine as to the Veteran's range of motion limitations during flare-ups, the Board finds the opinion has probative value. Particularly, the examiner recorded the Veteran's own assertions describing the severity of flare-up symptoms during such a period, which the Board may consider in assessing this claim. Between December 2008 and June 2015, the Veteran's medical records indicate that he consistently sought treatment for bilateral knee pain, but there is no evidence that he experienced symptoms to warrant a rating in excess of 10 percent for either knee. Specifically, he reported chronic pain rated 8 on a scale of 10 in July 2009 and noted in January 2010 that he has never been able to bend over properly since injuring his knees. He consistently received treatment through a pain clinic. His physicians observed crepitus bilaterally in July 2009, as well as cracking, popping, difficulty with flexion, and some difficulty getting out of a chair in June 2011, but there is no evidence that range of motion testing was performed. Despite these noted symptoms, physical examinations during that period noted a normal gait, no balance problems, and no falls, and the medical records do not contain evidence of limitation of flexion to 45 degrees, limitation of extension to 10 degrees, or dislocated cartilage with frequent episodes of "locking" pain and effusion into the joint. The Veteran underwent a June 2015 VA examination, which indicated some slight range of motion limitations, but was otherwise mostly normal. The Veteran reported that he had pain bilaterally and experienced flare-ups that caused such severe pain, he could hardly walk. Upon examination the examiner found that the Veteran's flexion was limited to 100 degrees in the right knee and 115 degrees in the left knee, and there was pain with weightbearing, but there were no limitations of extension. The examiner also noted that repeated use over time did not result in additional pain, weakness, fatigability, or range of motion limitations. Additionally, the examiner indicated that there was no evidence of crepitus, instability, tenderness or pain to palpation, ankylosis, or meniscal conditions. Although, the examiner did not opine as to the degree of additional limitations during flare-ups, the examination report did record the Veteran's own lay assertions regarding the severity of the knee disability during such a period of flare, and there is no evidence in the record before or after this examination to indicate that his pain with flare-ups was so limiting as to reduce the Veteran's flexion in his knee demonstrated during the examination by 70 degrees or more, or to cause limitation of extension by 15 degrees or greater. The findings during the examination are also consistent with the mostly normal physical findings of the Veteran's knee in the medical records before and after the examination. Similarly, medical records between June 2015 and June 2018 fail to demonstrate any evidence of ankylosis, limitation of flexion to 45 degrees or less, limitation of extension to 10 degrees or more, dislocated semilunar cartilage with frequent episodes or "locking," pain, and effusion into the joint, recurrent subluxation, or instability. The Veteran's complaints of chronic pain were consistent, and he reported taking Aleve, ibuprofen, or suboxone to help. He also reported that the pain caused some difficulty sleeping and prevented him from doing things he used to, like playing sports. Furthermore, he was observed using a cane for ambulation in September 2017. Despite this, physical examinations were generally normal with a normal gait, unaided ambulation, no balance deficit, and normal extremities, and he did not require assistance toileting, moving in and out of the bed or chair, or getting his clothes and dressing while under hospital care in July 2017. In June 2018, the Veteran underwent another VA examination for his bilateral knees, and he reported chronic pain that is aggravated with prolonged standing, kneeling, or climbing. Furthermore, he reported that he experienced flare-ups that cause increasing pain with activity, but he denied any recurrent effusion. Upon examination, the Veteran's right knee flexion was limited to 90 degrees and left knee flexion was limited to 95 degrees, and there were no limitations in extension in either knee. The examiner noted pain with flexion bilaterally on examination, but no evidence of pain with weight bearing, crepitus, or tenderness to palpation. Additionally, the examiner opined that pain, weakness, fatigability, or incoordination do not significantly limit functional ability during flare-ups or with repeated use over time. Unfortunately, the examiner did not opine additional range of motion limitations during these periods, and the Board determined that this examination was inadequate. However, the examiner noted that there was no evidence of ankylosis, instability, recurrent subluxation, episodes of "locking" pain and effusion into the joint, or patellar dislocation, and the Veteran did not use any assistive device for ambulation. Although the examiner failed to provide range of motion estimations during flare-ups or after repeated use over time, like with the June 2015 examination, there is no evidence to support that the Veteran's flare-ups were so severe as to reduce flexion in either knee to 45 degrees or less, or to reduce extension in either knee to 10 degrees or more. Specifically, the Veteran's initial bilateral flexion between June 2015 and June 2018 was reduced by 10 degrees in the right knee and 20 degrees in the left knee, but based on the Veteran's own reports during the June 2018 VA examination, his flare-ups caused him increasing pain with activity, prolonged standing, and climbing. He did not report further range of motion limitations during flare-ups, which does not support that his flexion during flare-ups was so limited as to result in a further 30 degrees or more decrease in each knee that is required to obtain a compensable rating under DC 5260. Additionally, medical records between June 2018 and November 2020 show mostly normal physical examinations. Specifically, although the Veteran reported pain in March 2019 that was aching, sharp, shooting, and chronic, the Veteran's pain was often described as "stable," and physicians noted that the Veteran had good functional range of motion, no joint deformity, no joint swelling, and normal gait. It was not noted that the Veteran had an altered gait until September 2020, at which time he reported that his left knee pain is greater than his right. However, despite exhibiting some tenderness adjacent to the patella bilaterally, it was noted that his knees revealed no gross deformity, he had full range of motion with popliteal area pain bilaterally, and he was conservatively treated with a topical gel. Although the June 2018 VA examiner did not opine as to the range of motion limitations during flare-ups, the opinion still has some probative value because the examiner's opinions were predicated on a full understanding of the Veteran's medical history and contentions and provided some evidentiary basis for the claim to be adjudicated. The findings during the examination are also consistent with the mostly normal or mild physical findings of the Veteran's knee in the medical records before and after the examination. Throughout the period prior to November 20, 2020, the Veteran was not shown to have compensable symptoms under any potentially applicable diagnostic criteria pertaining to the knee. Under the revised Diagnostic Code, the Veteran's posttraumatic arthritis would not be afforded a compensable rating, however, under the pre-amended criteria, a single 10 percent rating based on noncompensable motion with pain is supported, which accounts for the single disability rating of 10 percent for each knee. Further, neither the medical evidence of record nor the VA examinations indicate that, prior to November 20, 2020, the Veteran had ankylosis, recurrent subluxation or instability, semilunar cartilage with frequent episodes of "locking" pain and effusion into the joint, limitation of flexion to 45 degrees or less, limitation of extension to 10 degrees or greater, or impairment of the tibia and fibula to support a rating in excess of 10 percent for either knee. The Veteran's symptoms, including pain during flare-ups and difficulty with prolonged standing, climbing, or squatting, were properly contemplated by the single 10 percent rating under 38 C.F.R. § 4.59 for painful motion of the knees. From November 20, 2020, the Veteran was granted partial increased ratings for both the right and left knee, as reflected above. Based on the evidence, the Board determines that a rating in excess of 20 percent for chondromalacia patellae of the right knee with limitation of flexion, and in excess of 20 percent for limitation of extension of the right knee is not warranted under either the amended or pre-amended criteria. Additionally, the Board determines that a rating in excess of 10 percent for chondromalacia patellae with limitation of flexion of the left knee and a rating in excess of 30 percent for limitation of extension of the left knee is not warranted under either the amended or pre-amended criteria. Specifically, the Veteran underwent a VA examination in November 2020 where he was diagnosed with bilateral chondromalacia patellae and osteoarthritis. He reported that he experiences daily bilateral knee pain that is aggravated by prolonged standing and that he has "cracking and crunching noises" in his knees. Furthermore, he reported buckling in both knees, pain with bending, and daily irritating flare-ups that occur with prolonged standing and cause a burning sensation. Lastly, the Veteran reported that he is no longer able to do things he used to, he constantly uses a cane for ambulation, he uses a motorized cart at the grocery store, he has difficulty traversing uneven terrain, and he has difficulty with repetitive motions like squatting, crawling, or climbing. Upon examination, the examiner found that, during flare-ups, the Veteran experiences pain with range of motion in both directions, flexion limited to 25 degrees, and extension limited to 15 degrees in the right knee. He also experiences pain with range of motion in both directions, limitation of flexion to 35 degrees, and limitation of extension to 20 degrees in the left knee. The examiner observed disturbance of locomotion, interference with standing, bilateral crepitus, bilateral pain with weightbearing, and bilateral diffuse tenderness to palpation of the knee. The Veteran would not complete weightbearing range of motion testing due to anxiety around pain with those movements, and the examiner noted a reduction in normal excursion decreasing efficiency in physical activities requiring full range of motion. Finally, imaging of the Veteran's knees revealed moderate bilateral degenerative joint disease. However, the examiner noted that there is no ankylosis, no instability, no recurrent patellar dislocation, no tibial or fibular impairment, and no meniscus condition bilaterally. The examiner's opinions were predicated on a full understanding of the Veteran's medical history and contentions and provided enough evidentiary basis for the claim to be adjudicated. The examiner examined the Veteran and estimated the additional range of motion limitations based on the Veteran's own descriptions of his symptoms. As such, the Board finds these opinions highly probative. Based on this evidence, the Board finds that the claims for increased rating should be denied. Specifically, for the Veteran's right knee to receive a rating in excess of 20 percent for flexion under DC 5260, a limitation of flexion to 15 degrees must be shown, but the Veteran's right knee flexion during flare-ups was estimated at 25 degrees. For a rating in excess of 20 percent for extension of the right knee under DC 5261, limitation to 20 degrees must be shown, but the Veteran's extension was limited to 15 degrees. In order to warrant a rating in excess of 10 percent for flexion of the left knee, the Veteran must demonstrate limitation of flexion to 30 degrees, but his flexion was estimated to be 35 degrees in the left knee. In order to warrant a rating for left knee extension in excess of 30 percent, extension limited to 30 degrees must be shown, but the Veteran's left knee extension was estimated to be 20 degrees during flare-ups. Furthermore, because no ankylosis, recurrent subluxation, instability, meniscal conditions, patellar conditions, or tibia or fibula conditions were demonstrated as of November 20, 2020, ratings under DCs 5256, 5257, 5258, 5259, and 5262 are not warranted. The Board considered the Veteran's statements in determining the appropriate disability ratings. Specifically, the Board considered the Veteran's reported range of motion limitations, severe pain, and functional limitations. However, the Board finds these statements of limited probative value. While the Veteran, as a lay person, is competent to report observable symptomatology, once basic competency is met, the Board must consider credibility of testimony. In this case, although the Veteran reported that the VA examination range of motion measurements have been wrong and he was never able to extend his knees to zero degrees, the Veteran's reports are not generally consistent with VA examinations and medical records, which demonstrate extension and flexion limited to only 90 degrees and 95 degrees respectively prior to November 20, 2020, as well as no evidence of subluxation, instability, or ankylosis. As such, not all of the Veteran's assertions are supported by the evidence of record. See Caluza v. Brown, 7 Vet. App. 498 (1995). Additionally, although the Veteran is competent to report observable symptoms, which the Board has considered as part of this appeal, because some ratable characteristics of the knees require complex medical findings (for example, a diagnosis of ankylosis or specific stability testing), he is not competent to identify all specific levels of disability of his bilateral knee disorders according to the appropriate diagnostic criteria. Rucker, 10 Vet. App. at 74; Layno, 6 Vet. App. at 469; see also Cartwright, 2 Vet. App. at 25. On the other hand, such competent evidence concerning the nature and extent of the Veteran's right knee disabilities have been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with their evaluations. The medical findings of the physicians who performed the VA examinations directly address the criteria under which this disability is evaluated. Because the examiners were able to review the medical file, examine the Veteran, and consider his contentions, the Board finds the examiners' assessments of greater probative weight. As such, a rating in excess of 10 percent each for the Veteran's bilateral knee disabilities prior to November 20, 2020 is denied. Additionally, a rating in excess of 20 percent for chondromalacia patellae of the right knee based on limitation of flexion, a rating in excess of 20 percent for limitation of extension of the right knee, a rating in excess of 10 percent for chondromalacia patellae with limitation of flexion of the left knee, and a rating in excess of 30 percent for limitation of extension of the left knee as of November 20, 2020 are denied. There is no doubt to be otherwise resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. Entitlement to an earlier effective date than November 20, 2020 for total disability for individual unemployability (TDIU) is remanded. The Veteran is in receipt of TDIU since November 20, 2020, the first date he met the schedular criteria for such a grant, and he contends that he has been unable to work due to his service-connected disabilities since before November 20, 2020. Prior to that date, he does not meet the schedular rating criteria under 38 C.F.R. § 4.26(a) for such a grant. Specifically, the Veteran is service connected for an acquired psychiatric disorder, to include major depressive disorder with anxious distress, opioid use disorder, and alcohol use disorder at 50 percent from May 17, 2018. Prior to November 20, 2020, he was also rated for chondromalacia patellae of the right knee at 10 percent from October 29, 1983 and 10 percent for chondromalacia patellae of the left knee at 10 percent from October 29, 1983. The Board notes that TDIU may be granted on an extra-schedular basis under 38 C.F.R. § 4.16(b) if it is established that the Veteran was indeed unable to seek or maintain substantially gainful employment on account of his service-connected disabilities. Here, the Veteran worked in grounds maintenance until October 1995, and then in stock and real estate until the early 2000s. However, he reported in an April 2020 TDIU application that he has not been able to work since the early 2000s due to knee pain and mental health symptoms. Therefore, the Veteran's diminished ability in both physical and mental aspects of job performance has affected his employability. Specifically, evidence of record indicates that he may be unemployable due to service-connected disabilities. In a June 2015 vocational rehabilitation form, the Veteran noted that he could not work due to bilateral knee disabilities. He submitted a similar statement in September 2016, as well as during a March 2020 VA examination for psychiatric disorders. Throughout the medical record, the Veteran reported chronic knee pain and consistently sought treatment for mental health symptoms and to overcome opioid and alcohol addiction. Unfortunately, the Board cannot consider entitlement to TDIU on an extraschedular basis in the first instance. Instead, the Board is required to refer all cases of veterans who allege unemployability by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a), to the VA's Director of Compensation Service for extraschedular consideration. 38 C.F.R. § 4.16(b); Bowling v. Principi, 15 Vet. App. 1 (2001). As a result of the Veteran not meeting the schedular criteria prior to November 20, 2020, the Board finds that a remand is warranted to refer his TDIU claim for extraschedular consideration in the first instance. The matters are REMANDED for the following action: (Continued on the next page) Refer the Veteran's claim for TDIU for the period prior to November 20, 2020 to VA's Director for Compensation Service for extraschedular consideration. M. Pryce Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Veltri, 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.