Citation Nr: 21040059 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 14-35 642 DATE: July 2, 2021 ORDER Entitlement to a rating in excess of 30 percent for status-post left total knee arthroplasty for the appeal period prior to September 26, 2019 is denied. Entitlement to a rating of 60 percent, but not higher, for status-post left total knee arthroplasty for the appeal period beginning on September 26, 2019 is granted. REMANDED Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU) is remanded. FINDINGS OF FACT 1. For the appeal period prior to September 26, 2019, the Veteran's status-post left total knee arthroplasty manifested in, at worst, intermediate degrees of residual weakness, pain, or limitation of motion and without severe painful motion or weakness in the affected extremity. 2. For the appeal period beginning in September 26, 2019, the Veteran's status-post left total knee arthroplasty manifested in chronic residuals consisting of severe painful motion and weakness in the affected area. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for the appeal period prior to September 26, 2019 for status-post left total knee arthroplasty are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1 4.14, 4.71a, Diagnostic Codes 5055, 5260, 5261. 2. The criteria for a rating of 60 percent, but not higher, beginning on September 26, 2019 for status-post left total knee arthroplasty are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1 4.14, 4.71a, Diagnostic Codes 5055, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1967 to August 1968. These matters come to the Board of Veterans' Appeals (Board) on appeal from a December 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) Portland, Oregon. Jurisdiction of this appeal is currently with the RO in Atlanta, Georgia. In July 2017, the Veteran testified before a Veterans Law Judge. A copy of the transcript has been associated with the claims file. This hearing was before a now-retired judge. In April 2021 correspondence, the Veteran was given the opportunity to request another hearing and was notified that if he did not provide a response in 30 days, it would be assumed that he did not want another hearing. The Veteran did not respond to the April 2021 correspondence, and the Board will therefore proceed with adjudication. This case was most recently before the Board in November 2020, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, this case was remanded to obtain outstanding treatment records and to afford the Veteran an new examination to determine the current nature and severity of his status-post left total knee arthroplasty. Updated VA treatment records have been associated with the record and a VA examination was conducted in February 2021. A December 2020 letter to the Veteran requested that he complete an appropriate authorization form to allow VA to obtain identified treatment records; the Veteran did not respond to this letter. The Board therefore determines that there has been substantial compliance with its previous remand. The case has now been returned to the Board for appellate action. Increased Rating Status-Post Left Total Knee Arthroplasty The Veteran seeks a higher rating for his service-connected status-post left total knee arthroplasty. The Veteran generally asserts his symptoms are worse than contemplated by the current ratings assigned. In this regard, he reported he required the use of a cane and brace at all times, was no longer able to participate in usual activities; and fell due to his knee. See VA Form 21-4138 Statement in Support of Claim, April 20, 2011. The Veteran also indicated that his left knee produced severe pain upon motion, pain, and laxity; that his condition interfered with his employment and requiring him to retire from truck driving; that it interfered with social activities, such as bowling; and that the VA examination is inadequate because it was performed by a physician's assistant and not an orthopedic doctor. See VA Form 21-4138 Statement in Support of Claim, April 20, 2011. Moreover, the Veteran stated his left knee resulted in unemployability and that he will always have knee problems. See VA Form 21-4138 Statement in Support of Claim, November 16, 2011. The Veteran also asserted that he believed he should be rated as 60 percent disabling for his left knee because he had severe painful motion and weakness. See Notice of Disagreement, January 25, 2012. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). 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. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 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; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he 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). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's service connected status-post left total knee arthroplasty is rated as 100 percent prior to August 1, 2010, and 30 percent thereafter under 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). In the present case, the Veteran's claim for increased rating stem from a claim filed in April 2011 and there is no medical evidence relevant to the left knee dated after February 7, 2021. Diagnostic Code 5055 was revised under the new criteria. However, as the Veteran's appeal was certified to the Board in April 2021, and there is no relevant evidence to the Veteran's claim for an increased rating for status-post left total knee arthroplasty dated after February 7, 2021, the February 2021 musculoskeletal criteria do not apply to the Veteran's claim on appeal and appropriate criteria are discussed below. Effective July 16, 2015, VA published a final rule that added an explanatory note after 38 C.F.R. § 4.71a, Prosthetic Implants, Diagnostic Codes 5051 to 5056. The note states that the term "prosthetic replacement" as used for these codes "means a total replacement of the named joint," except as noted for Diagnostic Code 5054 for the hip. In Hudgens v. McDonald, the Federal Circuit held that Diagnostic Code 5055 is not limited to total knee replacements and that a partial knee replacement may be compensated under Diagnostic Code 5055. 823 F.3d 630, 639 (2016). The Federal Circuit found that it would be consistent with Hudgens v. McDonald, 823 F.3d 630 (2016), and permissible to conclude that Diagnostic Code 5055 applies to partial knee replacements prior to the July 16, 2015 regulatory amendment. The amendment does not specify retroactive applicability and, thus, applies from July 16, 2015, forward. If a claim was pending at the time the regulation change was made, the Veteran is entitled to application of the more favorable (prior) version. However, it should be explicitly stated why the assignment of Diagnostic Code 5055 to a partial knee replacement is necessary, with citation to Hudgens v. McDonald, 823 F.3d 630 (2016). Under Diagnostic Code 5055, a 30 percent rating is warranted for a prosthetic replacement of a knee joint with intermediate degrees of residual weakness, pain or limitation of motion. A 60 percent rating is warranted for a prosthetic replacement of a knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. A 100 percent rating is warranted for one year following the implantation of prosthesis. 38 C.F.R. § 4.71a. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 3 8 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a Diagnostic Code 5257. Board notes that the Veteran is already in receipt of a separate rating for instability. Ratings can also be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege, that he has tibia or fibula impairment, genu recurvatum, or ankylosis of either knee. As such, those diagnostic codes are not for application. Initially, the Board notes that service connection is in effect for left knee surgical scar associated with his status-post left total knee arthroplasty. This issue is currently not on appeal. Therefore, the Board will not consider an increased rating for the left knee based on the left knee scar, and such will not be discussed further in this decision. Turning to the evidence, the Veteran was afforded a VA examination in September 2010. At that time, the Veteran reported that he had several surgeries on his left knee and that his knee was stable with no signs of infection. There was no heat, redness, or drainage. He denied the use of assistive devices but indicated that he had a cane that he did not use and that the Veteran's wife tried to make him use the cane. The Veteran reported he could do all activities at home such as eating, bathing, grooming, toileting, dressing, and driving. He worked as a foster caregiver at home as a supervisor, that he could perform his work without any problems, that his job did not require moving or transporting his foster care recipients and that he was discharged from physical therapy when he achieved 120 degrees of flexion. The Veteran reported that had chronic aches in his knee that were not as strong as his right side, that he was unstable with stumbling that occurred daily to weekly and that he reported occasional swelling but did not have any locking or mechanically getting stuck. The examiner noted that a review of the Veteran's private treatment records showed an increase in laxity in the collateral ligament but that he was stable. The Veteran reported daily functions of eating, bathing, grooming, toileting, and dressing were all within normal limits. The Veteran endorsed flare-ups with repetitive movement if he walked to far, or if he stood, lifted, or carried, that the flare-ups were described as an increase in ache and occasional swelling at the end of the day. The Veteran used a Bledsoe hinge brace which did not provide him much comfort because it slid down constantly. The Veteran was trying to get stronger but was able to do normal function and travel without any deficits. He reported that he had no mechanical locking but had some stumbles without trauma and believed he was stable at this point without any signs of infection. He did not have heat, redness, or drainage. On objective physical examination in September 2010, there was no gross swelling, deformity, or discoloration on his knee. He had a range of motion from zero to 128 degrees in his right knee and that repetitive motion testing did not reveal any additional loss of range of motion. He had no gross instability for anterior drawer and posterior drawer, but varus and valgus stress testing both revealed an increase in laxity compared bilaterally with the medial collateral ligament being looser than the lateral collateral. He was negative for the McMurray's click test, there was no intraarticular effusion, there was mild medial joint line pain but no peripatellar structural pain and muscle strength testing was normal. The September 2010 examiner found the Veteran had total knee replacement with limited range of motion status-post multiple infections and surgeries, not stable and that his homelife was unaffected. The examiner noted the Veteran would be able to continue his work in foster care. The Veteran's wife helped him put on shoes on occasion and he was otherwise tolerating life well with a brace and daily functions and physical therapy type activities. An April 2011 private treatment record by Dr. T.S. At that time, Dr. T.S. noted that the Veteran continued to experience laxity issues of the medial collateral ligament, grade II. The Veteran had full extension and flexion to 108 degrees. Dr. T.S. indicated he considered functional braces for his chronic medial collateral ligament instability. Strength was a four out of five in extension and flexion. Dr. T.S. noted the Veteran's diminished range of motion, chronic medial collateral ligament instability, daily pain and difficulty with ambulation on uneven surfaces, and with activities that require deeper flexion. An August 2011 VA treatment record that indicates the Veteran had pain regularly in his knee but not "all the time," that he used ice and that he used a cane to prevent falls. The Veteran was afforded a VA examination in October 2011. At that time, the Veteran reported his leg felt not as stable and ached. He endorsed flare-ups of the left knee, described as an inability to lead a normal life due to pain, described an inability to work in advertising or truck driving and reported that he was working in foster care. Range of motion measurements were as follows: flexion was to 95 degrees and extension was to zero degrees without objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions and there was not additional limitation in range of motion following repetitive-use testing. The Veteran had functional loss or functional impairment of the left knee due to less movement than normal, weakened movement, excess fatigability and atrophy of disuse. He did not have tenderness or pain to palpation for joint line or soft tissues of either knee. Muscle strength testing showed active movement against some resistance in flexion and extension. Joint stability testing showed 1+ (0-5 millimeters) anterior instability (Lachman test). There was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have any meniscal condition or surgical procedures for a meniscal condition. The examiner noted the Veteran had a total knee replacement in June 2009 with intermediate degrees of residual weakness, pain or limitation of motion. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran endorsed the regular use of a brace as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies did not document arthritis. There was not x-ray evidence of patellar subluxation. The examiner noted the Veteran's left knee impacted his ability to work because the Veteran's knee kept him from being able to perform duties as a foster parent for high maintenance adults due to feelings of instability. A January 2013 VA treatment record that indicates the Veteran reported left knee weakness. A February 2013 VA treatment record that indicates the Veteran had an abnormal gait due to his left knee problem and that he ambulated near normal with a lift. A May 2013 VA treatment record that indicates the Veteran reported continuing pain and weakness of his left knee. A June 2013 VA treatment record that indicates the Veteran reported persistent discomfort and clicking, some giving-way, and had range of motion from zero to 110 degrees in his left knee. He reported a lot of balance problems, was not wearing a brace and quit using a cane following his physical therapist's advice. The VA treatment provider noted he had excellent stability, that his left knee was obviously a posterior stabilized knee, there was trace effusion, temperature was normal and there were no areas of localized tenderness and no unusual crepitus. X-rays showed the Veteran had well-fixed implants and there was no evidence of any mechanical loosening or asymmetric poly wear. The VA treatment provider encouraged the Veteran to use a cane in the opposite hand for both his balance problems and to unload the knee. January 2014 and February 2014 VA treatment records that indicate the Veteran had left knee range of motion measurements as follows: flexion was to 95 degrees and extension was to zero degrees. The Veteran was afforded a VA examination in September 2014. At that time, the Veteran reported his left knee continued to feel unstable, and had pain above and below the prosthesis. He endorsed flare-ups of the left knee described as reduced range of motion due to increased pain during flare-ups. Upon physical examination in September 2014, range of motion measurements were as follows: flexion was to 110 degrees, with pain beginning at 100 degrees and extension was to zero degrees, with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with at least three repetitions and there was no additional limitation in range of motion following repetitive-use. The Veteran had functional loss and/or functional impairment of the knee due to less movement than normal and weakened movement. There was no tenderness or pain to palpation of the left knee, muscle strength testing was normal, joint stability testing was normal and there was no evidence or history of recurrent patellar subluxation or dislocation. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had a meniscal tear and meniscectomy on the left knee. The examiner noted the Veteran had a total knee replacement in June 2009 with intermediate degrees of residual weakness, pain or limitation of motion. The Veteran had numerous wash outs and revision secondary to infection without any residual signs and/or symptoms. The Veteran denied the use of any assistive device as a normal mode of locomotion. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies did not document arthritis. There was not x-ray evidence of patellar subluxation. The examiner noted the Veteran's left knee did not impact his ability to work. The September 2014 VA examiner remarked that the Veteran's left knee condition was mild in severity. The examiner remarked that an opinion as to whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during a flare-up or when the joint was used repeated over a period of time, and any additional imitation could not be provided with resorting to mere speculation. In this regard, the Veteran was not having a flare-up at the time of the examination, and was not examined under the conditions specified in the request. A September 2014 VA treatment record that indicates the Veteran had chronic pain following a left total knee replacement performed in 2007. The Veteran was shown to have chronic pain, limited range of motion, developed swelling and warmth that lasted on day, some weakness and popping, and no drainage. His range of motion measurements showed 90 degrees of flexion and zero degrees of extension. A November 2014 VA treatment record that indicates the Veteran had no effusion, no increased temperature, and some global instability of the knee for which he wore a brace. His range of motion was from zero to 95 degrees. A March 2016 VA treatment record that indicates the Veteran's left knee did not have effusion, redness, heat, and no ligamentous instability. A May 2016 VA treatment record that indicates the Veteran reported severe pain in his bilateral knees, that was severe enough to wake him at night and that he used natural pain relieving gel to treat his symptoms. A July 2016 VA treatment record that indicates the Veteran reported he had frequent and severe knee buckling pain. A November 2016 VA treatment record that indicates the Veteran had left knee range of motion measurements as follows: flexion was to 110 degrees and extension was to zero degrees. The Veteran was afforded a VA examination in September 26, 2019. At that time, the Veteran reported his knee was sore, stiff, pain, and had limited motion. He reported his knee was better than having a completely worn out knee. The Veteran reported he had soreness and stiffness at all times and could extend but could not bend. When he stands and walks, or has extended standing and walking, the Veteran reported he would tire easily and always felt weaker, and as if the knee was looser. He did not have any instability trauma or falls, but did have a cane and a walker that he used almost daily. He stated he retired from his last job as a foster care provider in 2010. The Veteran could drive and participated with "Meals on Wheels," but did not walk so his wife delivered the note and meals instead. He endorsed flare-ups of the knee described as limited range of motion that caused increased soreness and stiffness with standing and walking, lifting, and carrying on a daily basis. The Veteran reported functional loss or functional impairment described as limited motion due to pain. Upon physical examination in September 2019, range of motion measurements were as follows: flexion was to 100 degrees and extension was to zero degrees. Range of motion itself contributed to a functional loss due to limited motion due to pain. Pain was noted on flexion and caused a functional loss. There was evidence of pain with weight-bearing, there was objective evidence of mild pain on joint lines bilaterally on palpation and there was no objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions and there was not additional functional loss or range of motion after three repetitions. The Veteran was not examined immediately after repetitive-use over time and the examination was medically consistent with the Veteran's statements describing a functional loss with repetitive-use over time. Pain was shown to significantly limit functional ability with repetitive-use over a period of time. The Veteran was not examined immediately during a flare-up and the examination was medically consistent with the Veteran's statements describing a functional loss during a flare-up. Pain was shown to significantly limit functional ability during a flare-up, and the examiner was able to describe in terms of range of motion as follows: flexion to 90 degrees with full extension. There were no additional factors that contributed to the disability. Muscle strength testing was normal and there was no reduction in muscle strength. The Veteran had muscle atrophy in his left lower extremity above the knee; circumference of the atrophied side was 38 centimeters, and the normal side was 43 centimeters. The examiner noted the Veteran also had below the knee atrophy on the left side that was 33 centimeters. The examiner noted the atrophy was due to the limited use of the musculatures in the quad and the lower leg due to the total knee replacement. The Veteran did not have ankylosis. Joint stability was normal. There was not a history of recurrent subluxation, lateral instability, nor effusion. The Veteran did not have or ever had "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had a meniscal tear requiring a total knee replacement. The examiner noted the Veteran had a total knee replacement in June 2010 with intermediate degrees of residual weakness, pain or limitation of motion. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran endorsed the regular use of a cane and walker due to knee pain as a normal mode of locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. Diagnostic imaging studies did not document arthritis. The examiner noted the Veteran's knee impacted his ability to work due to no lifting, carrying, extended standing, or walking would be tolerated and that sedentary employment was not precluded. The September 2019 VA examiner remarked that there was evidence of pain with weight-bearing, nonweight-bearing, and passive motion on examination of the left knee was moderate to severe in severity. There was mild evidence of pain to the scars. The Veteran was afforded a VA examination in January 2021. At that time, the Veteran reported his left knee had progressed or worsened. Current symptoms included weakness, instability, and occasional pain. The Veteran endorsed flare-ups of his knee that was described as severe pain, swelling, and "feeling mushy," occurring two times per month, lasting one day in duration, severe in nature, precipitated by too much activity, and alleviating factors of ice and rest. The Veteran reported functional loss described as limited walking, standing, climbing, and sitting. He reported a "clunk" with a loss of support as a history of instability or recurrent subluxation of the knee. He denied a history of frequent effusion of the knee. Upon physical examination in January 2021, range of motion measurements were as follows: flexion was to 90 degrees and extension was to five degrees. Range of motion itself contributed to a functional loss due to a limited ability to climb steps. Passive range of motion was the same as active range of motion in both flexion and extension, that there was no evidence of pain on motion, that there was objective evidence of mild pain located on the medial joint. The Veteran was able to perform repetitive-use testing with at least three repetitions and there was not additional loss of function of range of motion after three repetitions. The Veteran was examined immediately after repetitive-use over time. The procured evidence suggested that pain significantly limited functional ability with repetitive-use over a period of time. The examiner was able to estimate range of motion in degrees for the left knee immediately after repetitive-use over time as follows: flexion to 90 degrees and extension to five degrees. The Veteran was not examined during a flare-up. The evidence procured suggested that pain and weakness significantly limited functional ability with a flare-up. The examiner was able to estimate range of motion in degrees for the left knee during a flare-up as follows: flexion to 70 degrees and extension to 20 degrees. There were no additional factors contributing to the disability. The Veteran had muscle atrophy in the left lower extremity that was 15 centimeters proximal the medial joint line. Circumference of the atrophied side was 46 centimeters, and the normal side was 52 centimeters. The Veteran did not have ankylosis. Joint stability testing was normal. The Veteran required a prescription of a walker and brace by a medical provider for ambulation. There was no recurrent patellar instability. The Veteran did not require a prescription by a medical provider for ambulation of a cane, walker, crutch, or brace for patellar instability. The January 2021 noted the Veteran underwent left total knee replacement in 2007 and 2009 and had mild intermittent pain, instability, and restricted range of motion as residuals of such surgeries. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms shown. The Veteran endorsed the constant use of a brace and walker as assistive devices as a mode of normal locomotion. Functioning was not so diminished that the Veteran was equally well served by amputation with prosthesis. The examiner noted the Veteran's left knee impacted his ability to work due to very limited walking, standing, sitting, and climbing. The examiner found the Veteran had developed left knee instability associated with his multiple surgeries, and therefore the instability was a progression of his status-post left total knee arthroplasty. The examiner remarked the 2014 x-rays indicated there was loosening of the knee prosthesis, and the Veteran was prescribed a knee brace for instability. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities, to include his left knee. However, there is no indication from the treatment notes of record that the Veteran has reported left knee symptoms or range of motion measurements that are worse than those noted above. Based on the foregoing, the Board finds that a rating in excess of 30 percent for status-post left total knee arthroplasty for the appeal period prior to September 26, 2019 is not warranted as chronic residuals of severe painful motion of weakness in the affected extremity. As noted above, range of motion testing was performed and showed that range of motion was, at worst, 100 degrees of flexion and zero degrees of extension. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's statements. Additionally, the VA examiners found that the Veteran did not experience additional functional loss following repetitive-use nor was the Veteran shown to be additionally limited by pain on motion. Additionally, the Veteran was not shown to have mechanical locking, heat, redness, drainage, or clicking at any time. His muscle strength was either normal or showed active movement against some resistance and there was some slight effusion but otherwise did not have any swelling. The Veteran was shown to have some muscle atrophy in the left lower leg and instability on occasion. The Veteran complained of severe pain, that would interrupt sleep on occasion, and endorsed the use of a cane and walker for locomotion. However, the September 2014 VA examiner noted the Veteran's left knee condition was mild in severity. Accordingly, the Board finds that a rating in excess of 30 percent for the appeal period prior to September 26, 2019 for status-post left total knee arthroplasty is not warranted. The Board acknowledges that the September 2010, October 2011, and September 2014 VA examiners were not able to provide an opinion regarding additional functional impairment during flare-ups and following repetition. However, the Board finds that all information required for rating purposes was provided. In this regard, the Board notes that the examiners clearly noted that the Veteran specifically reported pain, weakness, and the reported interference with daily activities of the joint during a flare-up or following repetition. There is no other indication from the record, to include the Veteran's own statements, that he experiences additional decreased range of motion, weakness, or incoordination during flare-ups or following repeated use other than shown above. The Veteran endorsed flare-ups at these examinations, and was able to describe functional loss and/or functional impairment as discussed above. Therefore, the Board finds the examinations of record to be adequate for rating purposes. See Correia v. McDonald, 28 Vet. App. 158 (2016); see also Sharp v. Shulkin, 29 Vet. App. 26 (2017). For the appeal period beginning in September 26, 2019, the Board finds that a rating of 60 percent for status-post left total knee arthroplasty is warranted. In this regard, the Board concludes that the evidence of record, lay and medical, demonstrates that, beginning September 26, 2019, the Veteran's status-post left total knee arthroplasty was productive of chronic residuals consisting of severe painful motion and weakness in the affected area. As noted in the above-mentioned VA examination reports, beginning in September 26, 2019, the Veteran was shown to have moderate to severe pain with weight-bearing, nonweight-bearing and passive motion as well as weakness. Moreover, pain was shown to significantly limit functional ability with repetitive-use over a period of time. The Veteran also had muscle atrophy in his left lower extremity due to limited use of the musculatures in the lower leg due to his left total knee replacement. The Veteran also endorsed flare-ups which were productive of severe pain, reduced movement, and weakness. Accordingly, the Board finds that the Veteran's status-post left total knee arthroplasty most closely approximate the criteria for a 60 percent rating under Diagnostic Code 5055 for the appeal period beginning in September 26, 2019. The 60 percent rating for the period on appeal represents the maximum schedular disability rating available for all other applicable knee and leg codes under 38 C.F.R. § 4.71a. The knee and leg regulations do not provide for a rating in excess of 60 percent. Accordingly, a rating in excess of 60 percent for his status-post left total knee arthroplasty is not warranted. In reaching this conclusion, the Board observes that higher ratings are warranted under Diagnostic Codes 5160 and 5161 for amputation of the upper third of the thigh or amputation of thigh with disarticulation and loss of extrinsic pelvic girdle muscles. However, at no time during the course of the appeal has the Veteran's left knee resulted in symptoms analogous to such amputation. Therefore, any further award is not permitted as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board further finds that alternative Diagnostic Codes 5256, 5261, 5262, would not allow for a rating higher than 60 percent already assigned. Therefore, there is no basis to assign a rating in excess of 60 percent by analogy under the provisions of Diagnostic Code 5055. Turning to the Veteran's left knee instability, the symptoms of instability are contemplated by the 60 percent rating that includes weakness. Cf. Tedesco v. Wilkie, 31 Vet. App. 360, 367, n. 5 (2019) (declining to reach the question of whether the Board committed legal error when it found that a separate rating for instability under Diagnostic Code 5257 could be granted in addition to a rating for knee replacement under Diagnostic Code 5055 because to allow such a rating would constitute improper pyramiding). Therefore, a separate compensable rating for left knee instability is not warranted. Moreover, as the Veteran has retained motion in his knee throughout the period on appeal, by definition he does not have ankylosis. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992) (indicating that ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable). The Board acknowledges the Veteran's statements that his status-post left total knee arthroplasty is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard. Layno v. Brown, supra. The Board finds, however, that neither the Veteran's statement nor medical evidence demonstrates that the criteria for ratings in excess of 30 percent for the appeal period prior to September 26, 2019 and in excess of 60 percent thereafter have been met. The Board also acknowledges that the Veteran's VA treatment records and private treatment records note complaints of and treatment for his left knee. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered whether additional staged rating under Hart, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 30 percent for status-post left total knee arthroplasty for the appeal period prior to September 26, 2019. The Board also finds that a 60 percent rating is warranted for the appeal period beginning on September 26, 2019. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND Entitlement to a TDIU The Board has considered here whether an inferred claim for a TDIU has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The record reflects that the Veteran was previously employed as a foster care provider, that he reported that he had retired in an August 2019 VA examination and his current employment status is unknown. The Veteran has previously alleged that he is unable to obtain and maintain employment due to his status-post left total knee arthroplasty. The Board may infer a claim for TDIU due exclusively to the service-connected status-post left total knee arthroplasty as this is the underlying disability at issue in this appeal. Id. Accordingly, a Rice claim has been inferred. The Board generally observes that the Veteran's claim for entitlement to a TDIU has not been developed by the AOJ. There is no VA Form 21-8940 within the claims file, the Veteran's employment status and history is unknown and is there no evidence of record suggesting that the AOJ engaged in any communication with the Veteran so that his claim for a TDIU could be developed. Additionally, the Board notes that the Veteran may not meet the schedular requirements for a TDIU under 38 C.F.R. § 4.16(a); he may nonetheless be entitled to TDIU on an extraschedular bases under 38 C.F.R. § 4.16(b). Therefore, the Board finds that a remand is required in order to fully, fairly, and properly develop and adjudicate the Veteran's claim for a TDIU. The matter is REMANDED for the following action: (Continued on the next page) Send the Veteran and his representative a VCAA notice letter informing him of what is needed to substantiate entitlement to TDIU and of the allocation of responsibilities between the Veteran and VA for obtaining relevant evidence on his behalf. Perform any additional development with respect to the claim for a TDIU, to include obtaining from the Veteran a detailed statement regarding his educational attainment, post-service work history, and additional training (VA Form 21-8940). KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.