Citation Nr: 21039833 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 11-00 050A DATE: July 1, 2021 ORDER A 60 percent rating, but no higher, for status post total right knee replacement due to degenerative joint disease with scar (right knee disability) is granted. A rating higher than 10 percent for chondromalacia of left knee (left knee disability) is denied. A separate 20 percent rating, but no higher, for left knee instability, is granted. FINDINGS OF FACT 1. The Veteran's right knee disability more nearly approximates chronic residuals consisting of severe painful motion or weakness. 2. The Veteran's left knee disability did not more nearly approximate limitation of flexion to 30 degrees; there was no limitation of extension; and there was no left knee ankylosis, meniscal dislocation, symptomatic tibia or fibula impairment, or genu recurvatum. 3. The Veteran has experienced at most moderate left knee instability and required a medical provider-prescribed cane for ambulation during the entire claim period. CONCLUSIONS OF LAW 1. The criteria for a 60 percent rating, but no higher, for the right knee disability are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71A, Diagnostic Code (DC) 5055. 2. The criteria for a rating in excess of 10 percent for the left knee disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, DCs 5010, 5260. 3. The criteria for a separate 20 percent rating, but no higher, for left knee instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.71A, DC 5257; 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5257). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1978 to June 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2012 and December 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In the October 2012 decision, the RO, inter alia, denied an increased rating in excess of 10 percent for the left knee disability. In the December 2013 rating decision, the RO, inter alia, denied an increased rating in excess of 30 percent for the right knee disability. The lengthy procedural history of this case has been detailed in the prior actions in the appeal, and will only be repeated herein as needed to explain the state of the issues currently before the Board. In a March 2018 decision, the Board, inter alia, denied a rating in excess of 30 percent for the Veteran's right knee disability. The Board also increased the Veteran's left knee rating to 20 percent, but not higher, for the period prior to July 14, 2011, but denied a rating in excess of 10 percent for the period from September 1, 2011. In this regard, the Veteran was assigned a temporary total evaluation for her left knee for the period from July 14, 2011, to September 1, 2011, in accordance with the provisions of 38C.F.R. §4.30. The Veteran appealed the March 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a January 2019 Order, the Court granted a Joint Motion for Partial Remand (Joint Motion), vacating the portion of the March 2018 Board decision that denied a rating in excess of 10 percent for the left knee disability and a rating in excess of 30 percent for the right knee disability and remanding it for action consistent with the terms of the Joint Motion. In July 2019, April 2020, and January 2021, the Board remanded the appeal for additional development. Notably, in its April 2020 action, the Board expanded the Veteran's appeal regarding her left knee rating to include the period prior to July 14, 2011, for which the Veteran was awarded an increased rating of 20 percent, but not higher, by the Board in its March 2018 decision. Notably, the parties' Joint Motion does not address the Board's March 2018 award of an increased rating for the Veteran's left knee disability for the period prior to July 14, 2011, to include raising any assertion of error with the Board's determination that a rating in excess of 20 percent was not warranted for the period prior to July 14, 2011. Indeed, the parties requested only that the Court vacate the March 2018 Board decision insofar as it had denied a rating in excess of 10 percent for the left knee disability. Given the terms of the parties' Joint Motion, to include that nothing in the Joint Motion can be read as requesting vacatur of the March 2018 determination that a rating greater than 20 percent was not warranted for the appeal period prior to July14, 2011,the Board finds that the appeal with regard to her left knee rating is limited to the period from July 14, 2011, forward, and that the Board's inclusion of the appeal period prior to July 14, 2011, in the April 2020 recent remand action was in error. Accordingly, the Board, in its January 2021 remand, recharacterized the issues on appeal accordingly. Duty to Assist During the appeal period, the Veteran was afforded several VA examinations to determine the current severity of her right and left knee disabilities, to include VA examinations in May 2017, February 2020, and October 2020. Initially, the Board finds that the May 2017, February 2020, and October 2020 examination reports are inadequate to evaluate the Veteran's right and left knee range of motion as they fail to indicate the point at which the Veteran experienced pain during range of motion testing. Indeed, this failure was identified in the 2019 Joint Motion and the Board's July 2019 remand and does not comply with the Court's holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). As indicated, the appeal was most recently remanded in January 2021. Specifically, in January 2021, the appeal was remanded to obtain a VA examination to assess the severity of the Veteran's right and left knee disabilities. In March 2021, the Veteran was afforded a VA examination that evaluated the current severity of his right and left knee disabilities. The March 2021 VA examination provided sufficient details to adequately decide the appeal, to include compliance with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Additionally, the Board finds that the October 2020 and March 2021 VA examinations (taken together) provide sufficient details that comply with the requirements in Correia v. McDonald, 28 Vet. App. 158 (2016). For the reasons stated above, the agency of original jurisdiction (AOJ) substantially complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Musculoskeletal Disabilities Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations, if feasible, are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.59. Further, in claims for higher ratings for musculoskeletal disabilities, where a veteran has a noncompensable rating and complaints of pain on motion, the veteran may be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the Court held that under 38 C.F.R. § 4.59, "the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint," and it explained that 38 C.F.R. § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that 38 C.F.R. § 4.59 does not require "objective" evidence but can be satisfied with lay and other nonmedical evidence. Id. at 429. The provisions of 38 C.F.R. § 4.59 are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Id. Moreover, the plain language of § 4.59 indicates that it is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable, or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is being evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71A were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 3 8 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021 and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. 1. A rating higher than 30 percent for the right knee disability. The Veteran's right knee disability is rated as 30 percent disabling under 38 C.F.R. § 4.71A, DC 5055. The Veteran's claim for an increased rating for her service-connected right knee disability was received in December 2012. Prior to February 7, 2021, under DC 5055, a 100 percent rating is warranted for one year following implantation of a knee prosthesis for a service-connected knee disability, followed by a 60 percent rating when there are chronic residuals consisting of severe painful motion or weakness. With intermediate degrees of residual weakness, pain, or limitation of motion, a rating is made by analogy to DCs 5256, 5261, and 5262. The minimum rating is 30 percent under DC 5055. 38 C.F.R. § 4.71a, DC 5055. Under the new rating criteria, DC 5055 provides a 100 percent rating for the four months following implantation of a knee prosthesis for a service-connected knee disability. Thereafter, the rating criteria remains the same with the exception that a separate evaluation for resurfacing after the conclusion of the 100 percent evaluation period may be warranted. Here, there is no evidence the Veteran's right knee has undergone resurfacing during the appeal period. In this case, the Veteran underwent a total right knee replacement in August 2005. See, e.g., operation report (August 2005). A 100 percent rating was assigned pursuant to DC 5055 from that date through September 30, 2006, and the minimum 30 percent rating under DC 5055 was assigned from October 1, 2006. For the following reasons, a 60 percent rating for the right knee disability under DC 5055 is warranted. Throughout the appeal period, the Veteran reported right knee pain; aching pain; moderate to severe flare ups; decreased range of motion; and that she had difficulty with weight bearing, climbing stairs, prolonged walking, sitting, and standing. See, e.g., VA examination report (May 2017). For example, in the Veteran's December 2012 claim, she indicated that she has had "chronic nagging" right knee pain, had difficulty climbing stairs, and rated her pain as a 5 out of 10. In the February 2014 notice of disagreement (NOD), the Veteran's attorney indicated that the Veteran had rated her pain as a 5 out of a 10 because she had a high pain tolerance. The Veteran's attorney explained that the Veteran's right knee pain is rated as an 8 out of 10, and that her right knee pain "gets so bad that it feels as if her knee is going to give out." At the March 2021 VA examination, the Veteran reported that her right knee flare-ups were precipitated by prolonged standing, walking, bending, going downstairs, and activities of daily living. Upon physical examination, the Veteran's right knee flexion was, at worst, limited to 95 degrees, and with pain at 90 degrees, and extension was limited to 0 degrees with pain. See VA examination reports (October 2013; March 2021). The Board notes that the March 2021 VA examiner appeared to mistakenly reserve the range of motion for flexion and extension for the right knee. Specifically, the examiner wrote that flexion was to 0 degrees and that extension was to 95 degrees. Thereafter, the March 2021 examiner indicated that upon repetitive use testing flexion was to 90 degrees and extension was 0. In this instance, considering the March 2021 VA examination as a whole, it appears that the March 2021 examiner made a small notation error, rather than a technical error. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (noting that medical reports "must be read as a whole" in determinations of adequacy). In light of the extent of the Veteran's right knee pain, the significant functional limitations caused by her right knee disability, and the extent of the flare ups associated with the disability, her symptoms more nearly approximate the criteria for a 60 percent rating under DC 5055 (which contemplates chronic residuals consisting of severe painful motion or weakness). This is the maximum schedular rating under DC 5055. Also, regardless of any other impairments that may be associated with the service-connected right knee disability, the amputation rule allows for no more than a 60 percent rating for the Veteran's entire right knee disability. See 38 C.F.R. §§ 4.68, 4.71a, DC 5164. Therefore, a 60 percent rating, but no higher, for the Veteran's right knee disability under DC 5055 is warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are 2. A rating higher than 10 percent for the left knee disability. The Veteran's left knee disability is rated as 10 percent disabling from September 1, 2011, under DC 5010. Here, the use of DC 5010 reflects that the Veteran's left knee disability is partially described as traumatic arthritis under DC 5010 and that the rating assigned is based on painful, limitation of knee flexion under DC 5260. Prior to the February 7, 2021 regulatory changes, traumatic arthritis was rated under the same diagnostic criteria as degenerative arthritis. 38 C.F.R. § 4.71A, DC 5010 (in effect prior to February 7, 2021). Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate codes for the specific joint or joints involved. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for X-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71a, DC 5003. Effective February 7, 2021, DC 5003 expressly excludes application to post-traumatic arthritis. The rest of the rating criteria remained unchanged. Since the regulatory changes, post-traumatic arthritis under DC 5010 is rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. 38 C.F.R. § 4.71A, DC 5010 (in effect since February 7, 2021). Under DC 5260, limitation of knee flexion is rated as follows: a 10 percent rating is warranted when it is limited to 45 degrees; a 20 percent rating is warranted when it is limited to 30 degrees; and a 30 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71A, DC 5260. VA's General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Under DC 5261, limitation of extension of the leg, is rated as noncompensable when extension is limited to 5 degrees; a 10 percent rating is warranted when extension is limited to 10 degrees; a 20 percent rating is warranted when extension is limited to 15 degrees; a 30 percent rating is warranted when extension is limited to 20 degrees; a 40 percent rating is warranted when extension is limited to 30 degrees; and a 50 percent rating is warranted when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Turning to the evidence, the Veteran was afforded VA examinations in October 2013, October 2016, May 2017, February 2020, October 2020, and March 2021. During the VA examinations, VA treatment visits, and in the Veteran's statements, she reported constant, daily knee pain that was aggravated with weight bearing; flare ups; decreased range of motion and endurance; increased pain with walking and standing; and knee weakness. See, e.g., VA examination report (October 2013). She reported that she had knee pain with climbing stairs and prolonged standing; she avoided prolonged standing and walking. See VA examination report (October 2016). At the March 2021 VA examination, she reported that she was unable to walk or stand for prolonged periods, unable to climb stairs, and that she had difficulty bending. See VA examination report (March 2021). She stated that she was unable to work as a VA clerk due to her right knee replacement and left knee disability. See VA examination report (October 2013). With respect to left knee flare-ups, she denied flare ups at the October 2016 examination. At the May 2017, February 2020, and March 2021 VA examinations, she stated that she had left knee flare-ups. She indicated that during flare ups, she had increased pain when walking, standing, climbing stairs, and sitting; she stated that activities (such as climbing steps, standing, walking, and bending) were limited during flare ups. See VA examination reports (May 2017 and February 2020). During the March 2021 VA examination, the Veteran stated that she had constant left knee flare-ups that were precipitated by prolonged standing, walking, sitting, bending, going downstairs, activities of daily living. Upon physical examination, there was no left knee atrophy, ankylosis, recurrent patellar subluxation/dislocation. See, e.g., VA examination report (March 2021). Muscle strength was normal. Id. Id. There was functional loss and/or functional impairment in terms of less movement than normal and pain on movement. See VA examination report (October 2013). There was tenderness or pain to palpation for joint line or soft tissues of the knee and left knee pain with weight bearing. See VA examination reports (October 2013, October 2016, February 2020, March 2021). The October 2016 examiner indicated that the Veteran had a meniscal tear with frequent episodes of joint pain. The October 2020 VA examiner indicated that there was pain on passive range of motion testing and when the joint was used in non-weight bearing. During all the VA examinations during the appeal period, instability testing was normal. The VA examiners noted that the Veteran required a cane for ambulation. See, e.g, VA examination report (March 2021). At a December 2019 VA treatment visit and at a March 2021 VA examination, the Veteran reported instability and that without her cane, her knee would give out. With respect to range of motion testing of the left knee, at the October 2013 examination, range of motion of the right knee was recorded as flexion to 105 degrees with pain and extension was to 0 degrees with pain. At the October 2016 examination, range of motion of the left knee was recorded as flexion to 130 degrees with pain and extension was to 0 degrees with pain. At the March 2021 VA examination, active and passive range of motion of the left knee was recorded as flexion to 110 degrees with pain and extension to 0 degrees with pain. The March 2021 VA examiner found that pain, weakness, fatigability, and incoordination significantly limited the Veteran's functional ability with repeated use over a period of time and with flare ups. The March 2021 examiner estimated that during periods of pain, weakness, fatigability, incoordination, flare ups, and repeated use over a period of time her flexion would be limited to 105 degrees and extension would be limited to 0 degrees. During the October 2013 and October 2016 VA examinations, the Veteran was able to perform repetitive-use testing without additional limitation of motion. At the March 2021 VA examination, repetitive-use testing was limited to 105 degrees for flexion. The October 2016, February 2020, and March 2021 VA examiners opined that the Veteran's knee disabilities impacted her ability to perform occupational tasks such as standing, walking, lifting, and sitting. The October 2016 examiner explained that the Veteran had knee pain when climbing stairs and standing. The February 2020 and March 2021 VA examiners stated that the Veteran had severe knee aching, pain and that she was unable to engage in activities requiring prolonged walking or standing. For the following reasons, a rating in excess of 10 percent for the left knee disability is not warranted. During the appeal period, the Veteran reported left knee pain, limited and painful range of motion, flare ups, and functional impairment. The Veteran is competent to report the symptoms associated with her left knee disability and the extent of her impairment during flare ups of symptoms, and the Board has no reason to challenge the credibility of her contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's left knee symptoms have most closely approximated the criteria for at most a single 10 percent rating for painful limitation of knee flexion under DC 5260 during the entire claim period. The March 2021 VA examiner indicated that he reviewed the Veteran's claims file and considered her reports of pain and flare ups when he provided estimated range of motion measurements during such periods of pain and other symptoms. Specifically, the March 2021 VA examiner estimated that during periods left knee pain, functional impairment, weakness, fatigability, incoordination, flare ups, and repeated use over a period of time, the Veteran's flexion for the left knee would be limited to, at worst, 105 degrees and extension would be limited to, at worst, 0 degrees. Thus, even considering pain, flare ups, and other functional factors, the Veteran's left knee symptoms have not been so severe, frequent and/or prolonged to warrant the next higher percent ratings at any time during the claim period. The Veteran's knee symptoms have not been shown to have been so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 30 degrees or limitation of knee extension more nearly approximating 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating limitation of knee extension under DC 5261, respectively. Overall, the Veteran's left knee disability has resulted in limitation of knee flexion that is no more than 10 percent disabling during the entire claim period. Accordingly, a rating in excess of 10 percent for the left knee disability is not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71A, DCs 5260-5261. 3. A separate rating for left knee instability. Prior to February 7, 2021, DC 5257 provided that a 10 percent rating was warranted for slight recurrent subluxation or lateral instability; a 20 percent rating was warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating was warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. DC 5257 does not define "slight," "moderate," or "severe," or generally associate those terms with specific symptoms. One possible source for such definitions would be the dictionary. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. As of February 7, 2021, under the amended criteria, DC 5257 provides that a 10 percent rating is warranted for a 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. 38 C.F.R. § 4.71a, DC 5257; 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5257. A 20 percent rating is warranted for (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Id. A 30 percent rating is warranted for severe 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. Id. In addition to the above, the amended rating criteria under DC 5257 also provides ratings specific to patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability. A 10 percent rating is warranted for patellar instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for patellar 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 rating is warranted for patellar instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. at Note 1. The Board has considered the pre- and post-amended rating criteria for DC 5257 and finds that the Veteran is entitled to a 20 percent rating under both sets of criteria. Considering the pre- and post-amended criteria, the Veteran's knee symptoms are most analogous to moderate instability and 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. Specifically, the above evidence reflects that the Veteran reported instability during the appeal period and that she has required a cane for ambulation. See, e.g, VA examination report (March 2021). A VA Physical Therapy Certificate in October 2005 noted the Veteran had been issued a quad cane. Also, during the appeal period, the Veteran reported instability and stated that without her cane, her knee would give out. The Board finds that a rating in excess of 20 percent for instability is not warranted for the left knee under either the pre- or post-amended rating criteria, and the 20 percent disability rating for right knee instability contemplates the Veteran's reports of knee instability. 38 C.F.R. § 4.71a; DC 5257. Specifically, DC 5257 prior to February 7, 2021, does not warrant a higher rating for left knee instability, as stability testing of the left knee had been normal throughout the claim period. Furthermore, the evidence does not support a finding that the Veteran's symptoms are severe such that they are very painful or harmful or of a great degree. Similarly, DC 5257 since February 7, 2021, does not warrant a rating higher than 20 percent for knee instability, as there was no indication the Veteran has an unrepaired or failed repair of complete ligament tear and there is no indication of a diagnosed condition involving the patellofemoral complex. In sum, a separate 20 percent rating, but no higher, for left knee instability is warranted during the entire claim period. Additional Considerations The Board has considered other DCs pertaining to the knee and finds that separate/higher ratings are not warranted under DCs 5256, 5258, 5259, 5262, or 5263 at any time during the appeal period. Specifically, DC 5258 provides for a single 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Although the October 2016 examiner indicated that the Veteran had a meniscal tear with frequent episodes of joint pain, there was no meniscal dislocation. Therefore, a separate 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, is not warranted, as there was no dislocated semilunar cartilage. Additionally, there has been no evidence of knee ankylosis, impairment of the tibia or fibula, or genu recurvatum at any time during the appeal period. See DCs 5256, 5259, 5262, 5263. As the preponderance of the evidence is against higher or separate ratings, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. As a final point, a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether a veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. (Continued on the next page) Here, the Veteran has been awarded a TDIU, effective November 24, 2006. Thus, the Veteran has already been awarded a TDIU during the entire claim period. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Castillo, 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.