Citation Nr: 21040299 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 16-08 548 DATE: July 3, 2021 ORDER Entitlement to a rating in excess of 20 percent for right knee, status post anterior cruciate ligament reconstruction, based on instability, prior to June 22, 2018, is denied; a 30 percent rating is granted thereafter. Entitlement to a rating in excess of 20 percent for left knee, status post anterior cruciate ligament reconstruction, based on instability, prior to June 22, 2018, is denied; a 30 percent rating is granted thereafter. Entitlement to a separate 10 percent rating for left knee, symptomatic removal of semilunar cartilage, left knee, effective May 14, 2012, is granted. Entitlement to a rating in excess of 10 percent for right knee degenerative joint disease (DJD) based on reduced range of motion is denied. Entitlement to a rating in excess of 10 percent for left knee DJD based on reduced range of motion is denied. FINDINGS OF FACT 1. The evidence of record indicates that the Veteran's right knee, status post anterior cruciate ligament reconstruction, manifested moderate instability prior to June 22, 2018, and severe instability thereafter. 2. The evidence of record indicates that the Veteran's left knee, status post anterior cruciate ligament reconstruction, manifested moderate instability prior to June 22, 2018, and severe instability thereafter. 3. The evidence of record indicates that throughout the appellate period the Veteran's left knee has been manifested by symptomatic removal of the semilunar cartilage. 4. The evidence of record indicates that the Veteran's right knee DJD has been manifested by limitation of motion; the preponderance of the evidence does not indicate that it has manifested by flexion limited to 60 degrees or extension limited to 5 degrees. 5. The evidence of record indicates that the Veteran's left knee DJD has been manifested by limitation of motion; the preponderance of the evidence does not indicate that it has manifested by flexion limited to 60 degrees or extension limited to 5 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 20 percent for right knee, status post anterior cruciate ligament reconstruction, based on instability, prior to June 22, 2018, have not been met; thereafter, the criteria for entitlement to a 30 percent rating have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5299-5257. 2. The criteria for entitlement to a rating in excess of 20 percent for left knee, status post anterior cruciate ligament reconstruction, based on instability, prior to June 22, 2018, have not been met; thereafter, the criteria for entitlement to a 30 percent rating have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5299-5257. 3. The criteria for entitlement to a 10 percent rating for left knee, symptomatic removal of semilunar cartilage, left knee, effective May 14, 2012, is granted. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5259. 4. The criteria for entitlement to a rating in excess of 10 percent for right knee DJD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC5 5003-5010. 5. The criteria for entitlement to a rating in excess of 10 percent for left knee DJD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5003-5010. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1984 to January 1985 and from January 1988 to August 1991. The matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a travel board hearing before the undersigned Veterans Law Judge (VLJ) in April 2019. The hearing transcript is of record. In October 2019, the Board denied the Veteran's claims for ratings in excess of 20 percent for right and left knee status post anterior cruciate ligament reconstruction, based on instability, and in excess of 10 percent for right and left knee DJD. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In November 2020, pursuant to a Joint Motion for Partial Remand (JMPR), the Court vacated, in part, the Board's October 2019 denial and remanded the matter to the Board for compliance with the instructions included in the parties' JMPR. Increased Rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as 'staged ratings.' Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. In determining the adequacy of assigned disability ratings, consideration is also given to factors affecting functional loss. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Such factors include a lack of normal endurance and functional loss due to pain and pain on use, specifically limitation of motion due to pain on use, including that experienced during flare ups. 38 C.F.R. § 4.40. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that § 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32, 4243 (2011) (holding that pain alone does not constitute functional loss and is just one fact to be considered when evaluating functional impairment). That said, 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Under DC 5256, knee ankylosis, a favorable angle in full extension, or in slight flexion between 0 and 10 degrees warrants a 30 percent disability rating; in flexion between 10 and 20 degrees warrants a 40 percent rating; in flexion between 20 and 45 degrees warrants a 50 percent rating; and extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more, warrants a 60 percent rating. Under DC 5257, where there is recurrent subluxation, lateral instability, or other impairment of a knee, a 10 percent evaluation may be assigned where the disability is slight, a 20 percent evaluation will be assigned for moderate disability, and a 30 percent for severe disability. 38 C.F.R. § 4.71a. The Board observes that the words "slight," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Use of terminology by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Pursuant to DC 5258, a 20 percent evaluation, the highest and only rating available under that schedular provision, may be assigned where there is evidence of dislocated cartilage, with frequent episodes of "locking," pain, and effusion into the knee joint. 38 C.F.R. § 4.71a. Under DC 5259, symptomatic residuals of removal of a semilunar cartilage warrants a maximum rating of 10 percent. 38 C.F.R. § 4.71a. The diagnostic codes pertaining to limited motion of the knee are DCs 5260 and 5261. Limited flexion of the knee is rated under DC 5260, which assigns a noncompensable rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and, a 30 percent rating when limited to 15 degrees. Id., DC 5260. Limited extension of the knee is rated under DC 5261, which assigns a noncompensable rating when extension is limited to 5 degrees; a 10 percent rating when limited to 10 degrees; a 20 percent rating when limited to 15 degrees; a 30 percent rating when limited to 20 degrees; a 40 percent rating when limited to 30 degrees; and a 50 percent rating when limited to 45 degrees. Id., DC 5261. VA's General Counsel has held that separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). Separate ratings may be assigned for compensable limitation of both flexion and extension, or for limitation of motion and instability or subluxation of the knee, or meniscal pathology. However, a separate rating can only be assigned where additional compensable symptomatology is shown that is not duplicative of that used to assign another rating. 38 C.F.R. § 4.14; VAOPGCPREC 09-04 (2004), 69 Fed. Reg. 59990 (2004); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56704 (1998); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Under DC 5262, impairment of the tibia and fibula with malunion, a slight knee or ankle disability warrants a 10 percent rating; a moderate knee or ankle disability warrants a 20 percent rating; and a marked knee or ankle disability warrants a 30 percent rating. A maximum 40 percent rating is warranted when there is nonunion and loose motion requiring a brace. 38 C.F.R. § 4.71a. Under DC 5263, acquired genu recurvatum with weakness and instability in weight-bearing objectively demonstrated warrants a maximum 10 percent rating. 38 C.F.R. § 4.71a. Diseased joints may be manifested by crepitation on motion in the tendons or ligaments, or within join structures. 38 C.F.R. § 4.40. Pain, swelling, locking and crepitus may be compensated under the DCs for limited motion, i.e., DCs 5260 and 5261. Lyles v. Shulkin, No. 16-0994, slip op. at 14 (U.S. Vet. App. Nov. 29, 2017) (acknowledging popping and grinding as symptoms of crepitus and that to the extent that crepitus or locking cause disturbance of locomotion, sitting, standing, and weight-bearing they are contemplated under § 4.45(f)). The Board notes that this version of DCs 5003, 5010, 5257 and 5262 were amended effective February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). The amended versions of these DCs may not be applied prior to the effective date of February 7, 2021. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003 (Nov. 19, 2003). However, the Board finds it may still apply the prior version of these DCs to the entire period on appeal, as the Board is not prohibited from applying a prior regulation in effect during the pendency of a claim to the period on or after the effective date of the new version of the regulation. Thus, the Board finds that it may still apply the prior version of 38 C.F.R. § 4.71a, DCs 5003, 5010, 5257 and 5262 to the period on or after February 7, 2021, which is the effective date of the amended criteria, if this would afford a more favorable outcome. 1. Entitlement to a rating in excess of 20 percent for right knee, status post anterior cruciate ligament reconstruction, based on instability, prior to June 22, 2018, is denied; a 30 percent rating is granted thereafter. 2. Entitlement to a rating in excess of 20 percent for left knee, status post anterior cruciate ligament reconstruction, based on instability, prior to June 22, 2018, is denied; a 30 percent rating is granted thereafter. 3. Entitlement to a separate 10 percent rating for left knee, symptomatic removal of semilunar cartilage, left knee, effective May 14, 2012, is granted. The Veteran's right and left knee status post anterior cruciate ligament reconstruction is rated under DCs 5299-5257. 38 C.F.R. § 4.71a. This pertains to an unlisted disability that will be rated as if it were, in this case, knee instability. 38 C.F.R. § 4.71a; see also 38 C.F.R. § 4.27 (explaining and setting forth the procedure for assigning diagnostic criteria to unlisted disabilities, including the use of hyphenated ratings). Turning to the medical evidence of record, a May 2012 VA treatment record noted that according to the Morse fall scale, the Veteran was at moderate risk for falls and had no history of falling in the past three months. Another March 2013 VA treatment record noted that according to the Morse fall scale, he was at low risk for falls and had no history of falling in the past three months. An April 2013 VA treatment record notes that the left knee is much more painful with a feeling of instability, especially on stairs. The pain becomes sharp in both knees when twisting. Pain improves with rest. Range of motion was noted as 0 to 120 bilaterally. Some effusion was noted bilaterally. A slightly positive anterior drawer test was noted on the left. The clinician noted that the Veteran had right knee osteoarthritis and mild left knee instability. Bilateral knee braces and a cane were ordered. Physical therapy was ordered to prolong a total left knee replacement. He received a right knee injection but refused a left knee one as he found it too painful. The Veteran underwent a VA examination in August 2013. The Veteran reported that he cannot lift anything with certainty. His left knee sometimes locks at rest. It is constantly swollen. His right knee often slips out of place. He can only walk short distances. When sitting, he continually moves his legs back and forth due to pain. The Veteran reported no flare-ups. Initial right knee flexion was to 140 degrees; painful motion began at 135. Left knee flexion was to 130 degrees; painful motion began at 125. Bilateral knee extension was to 0 degrees. There was no change with repetitive use. However, less movement of the left, and bilateral pain on movement were noted. The left knee had tenderness or pain on palpation. Bilateral muscle strength was 5 of 5. Joint stability testing was normal. No history of patellar subluxation or dislocation was noted. No shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial/fibial impairment were noted. The examiner noted that the right knee had a meniscal tear and frequent episodes of locking and pain; the left was asymptomatic. The Veteran had a left knee meniscectomy in 1998. Residuals were noted, as set out above. Other procedures were noted as ACL and lateral meniscus repair; residuals were noted as pain. Regular use of a brace was noted. The functional impact was noted as causing difficulty squatting, lifting, and carrying heavy loads due to decreased motion and pain. The examiner noted that there are contributing factors of pain, weakness, fatigability, and/or incoordination, but no additional limitation of functional ability during flare-ups or repeated use over time. A May 2015 VA treatment record noted that according to the Morse fall scale, he was at high risk for falls, with a history of falling within the past three months. An April 2015 VA treatment record noted that he has daily knee pain and also during cool weather. A July 2015 VA treatment record noted that he complained of worsening knee pain since resuming exercise and requested a brace. A clinician noted lateral meniscus repair of the left knee in 1992. An October 2015 VA treatment record noted worsening bilateral pain, swelling, occasional giving way, and pain with weight-bearing. He requested bracing. He said that swelling and instability make standing on his feet increasingly difficult. A November 2015 VA treatment record noted his active range of motion was noted as within functional limits. A September 2016 VA treatment record noted that his left knee is more painful than the right. He was advised that he is a candidate for total knee replacement. An antalgic gait was noted. Range of motion was noted as 0 to 120 on the right and -3 to 115 on the left. Tenderness to palpation and crepitus were noted. A Lachman's test noted laxity bilaterally; it was more notable on the left. A posterior drawer test was negative. Valgus/varus stress was applied; there was no gapping/instability. Imaging revealed no evidence for acute fracture, dislocation or subluxation bilaterally. It was noted that steroid injections have not worked for longer than a few weeks in the past few years so he will try Synvisc bilaterally. Another September 2016 VA treatment record noted that according to the Morse fall scale, he was at low risk for falls and had no history of falling in the past three months. A December 2016 VA treatment record noted that he was independent, with no device, but wore knee braces if he needed extra stability. He reported no falls in the past 6 months. His range of motion was noted to be within functional limits. His bilateral knee strength is 4 of 5. His balance sitting and standing, both static and dynamic, was intact. His gait was noted as having no loss of balance and no device. He reported that he walks to the parking garage daily. He regularly ambulated in the hallway without difficulty. Another December 2016 VA treatment record noted that according to the Morse fall scale, he was at moderate risk for falls and had no history of falling in the past three months. A December 2016 private medical treatment record noted that he does not use a cane or walker and can stand for 10 to 15 minutes before his knees hurt and swell. Sitting is not a problem. He can walk about 50 yards before his knees hurt. He cannot squat. A July 2017 VA treatment record noted bilateral knee weakness and thigh soreness. He reported having a recent flare of chronic knee pain and was treated privately with tramadol and prednisone. Another July 2017 VA treatment record noted that according to the Morse fall scale, he was at a low risk for falls and had no history of falling in the past three months. A February 2018 VA treatment record noted that his right knee locks and his left knee gives way. Pain is worse with walking, running, and cold weather; it improves with rest. A contemporaneous record noted that his range of motion was 0 to 90 degrees. His bilateral strength was noted as 4 of 5. Tenderness to palpation and crepitus were noted. A negative McMurray's test was noted. Regarding stability, lateral patella apprehension was noted. A March 2018 VA treatment record noted left knee pain. He reported swimming a few times per week, which helps. He reported taking Tylenol for pain. He reported exercising four days per week, for an hour to an hour and a half each session. He prefers activities that do not involve walking or running. He prefers swimming, a stationary bike, a rowing machine and weightlifting. A June 2018 private medical treatment record noted that walking short distances aggravates his knees, the left worse than the right. He has not tried Tylenol or NSAIDs lately. Another private treatment record dated June 22, 2018, noted that he complained of left knee pain following a fall. He fell due to his knee giving out. He reported pain and swelling. An October 2018 VA treatment record noted that the Veteran complained of ongoing left knee pain and swelling. Pain was worse with walking or standing. There was an intermittent sense of instability. He reported three emergency department visits that year due to knee pain exacerbation. He uses a brace and cane when necessary. A December 2018 private medical treatment record notes 8 of 10 right knee pain and right foot pain, worsened by moving and walking. He reported little improvement with medication. A gait problem was noted. An April 2019 private medical treatment record notes his right knee locked for about four hours. An August 2019 private medical treatment record notes worsening right knee and foot pain. The Veteran underwent a second VA examination in May 2019. The Veteran reported that injections had not helped. His current symptoms were left knee instability, swelling, and weakness and right knee locking, swelling, and pain. Pain is 10/10. He reported no current medications. As for functional impact, he reported that he can stand for 10 minutes at a time, walk for 100 yards, and needs assistance with stairs. The Veteran reported no flare-ups. Initial right knee extension and flexion were noted as 0-95 degrees. There was evidence of pain on weight-bearing and crepitus. Initial left knee extension and flexion were noted as 0-90 degrees. There was evidence of pain on weight-bearing and tenderness on pain or palpation in the lateral aspect, which was mild and related to arthritis. The values were the same with observed repeated use. The Veteran was examined following repetitive use over time. For the right knee, pain and lack of endurance were noted to significantly limit functional ability with repetitive use over time. For the left knee, pain, weakness, and lack of endurance were noted to significantly limit functional ability with repetitive use over time. For both knees, the examiner was unable to describe this in terms of range of motion because there is no additional loss of motion. As for additional contributing factors, the examiner noted, bilaterally, less movement than normal, instability of station, disturbance of locomotion, interference with standing/sitting, and increased pain with weight-bearing and duration. In addition, for the left knee he noted weakened movement due to injury. Reduced muscle strength was noted to 4 of 5 bilaterally. No ankylosis was noted. No history of recurrent subluxation or lateral instability was noted. Joint stability testing shows no joint instability. No shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial/fibial impairment were noted. The examiner did not note a meniscus condition. Two knee reconstructions were noted, and residuals were noted as reduced motion, locking, swelling and sharp pain on the right and reduced motion, instability, swelling, and throbbing on the left. Regular use of a brace was noted. In a separate muscle injuries disability benefits questionnaire, the examiner noted a 1989 left knee ACL tear and lateral meniscus tear. Turning to the lay evidence of record, the Veteran stated in June 2014 correspondence that he can barely walk and does not lift anything heavier than a rake if he can help it. He could not bend upon examination and he contended that a more complete examination would have shown a 15 to 19-degree limitation of extension. In the April 2019 Board hearing, the Veteran reported that the pain is gradual and begins when he starts moving. His right knee locks up if he bends. He takes precautions when standing to prevent falling. His knees lock three days per week, to include when turning and walking. His pain is bad in the winter. In April 2019 correspondence, the Veteran reported recent, continuing bouts of pain, instability, and locking. Bilateral instability under DC 5257 On review of the record, the Board finds that the evidence weighs against a rating in excess of the currently assigned 20 percent rating prior to June 22, 2018. From the beginning of the appeals period through June 22, 2018, the Veteran has competently and credibly reported symptoms of instability. See English v. Wilkie, 30 Vet. App. 347 (2018). However, the evidence preponderates against a maximum rating for instability prior to June 22, 2018, given the Veteran's reports of no falls related to his knee instability and contemporaneous examinations noting significant knee strength and mild instability, at worst. As set out above, May 2012 and March 2013 VA treatment records note no history of falling in the past three months. An April 2013 VA treatment record noted the Veteran's complaints of instability. The clinician evaluated instability and the results were a slightly positive left anterior drawer test. The clinician noted this as mild left knee instability. Bilateral knee braces and a cane were ordered. During the August 2013 VA examination, the Veteran reported a locking left knee and right knee slippage. Muscle strength was noted as 5 of 5 and joint stability testing was normal. He was noted to regularly use a brace. A May 2015 VA treatment record noted that he had fallen within the past three months; however, there were no further details provided and it is unclear if these falls are related to his knee conditions. An October 2015 VA treatment record notes the Veteran reported "occasional" giving way and increasing difficulty standing due to instability. A September 2016 VA treatment record noted an antalgic gait. A Lachman's test noted laxity bilaterally; it was more notable on the left. A posterior drawer test was negative. Valgus/varus stress was applied; there was no gapping/instability. Imaging revealed no evidence for acute fracture, dislocation or subluxation bilaterally. Another September 2016 VA treatment record noted he had no history of falls in the past three months. A December 2016 VA treatment record also noted no falls in the past six months. He did not use a device but wore braces when he needs more stability. Knee strength was noted as 4 of 5. His sitting/standing balance was intact, his gait was noted as balanced. A July 2017 VA treatment record noted he was a low fall risk and had no history of falling in the past three months. A February 2018 VA treatment record noted a locking right knee and a left knee that gives way; his bilateral strength was noted as 4 of 5; lateral patella apprehension was noted. As such, the record does not reflect that the maximum rating under DC 5257 is warranted prior to June 22, 2018. The record indicates that on June 22, 2018, the Veteran presented for private emergency care due to a fall caused by his knee giving out. Subsequent VA and private treatment records as well as the Veteran's lay statements indicate continuing reports of instability. Therefore, the evidence shows that the maximum rating of 30 percent is warranted from June 22, 2018. Symptomatic removal of cartilage, semilunar, left knee, under DC 5259 On review of the record, the Board finds that the disability picture presented supports the grant of a separate 10 percent disability rating, but no higher, for left knee symptomatic removal of semilunar cartilage. VA treatment records and examination reports indicate that the Veteran underwent a meniscal repair procedure of the left knee. The August 2013 VA examination report noted residuals of such procedure. Therefore, when affording the Veteran the benefit of the doubt, the evidence shows that a rating of 10 percent, but no higher, is warranted. Moreover, the record shows that the Veteran has treated his symptoms with medication and injections, thus further supporting a grant. See Jones v. Shinseki, 26 Vet. App. 56 (2012) (a higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria). Additionally, the record shows that he is a candidate for an eventual total knee replacement. See April 2013 and September 2016 VA treatment records. The Board does not find that a higher disability rating is warranted under DC 5258 in the absence of dislocation. The August 2013 VA examination report noted no dislocation. A September 2016 VA treatment record noted that imaging revealed no dislocation. Therefore, the evidence does not show that a rating under DC 5258 is warranted. Under the facts and procedural history of the appeal, the effective date of May 14, 2012, is assigned for the separate rating under DC 5259. 38 C.F.R. § 3.400. 4. Entitlement to a rating in excess of 10 percent for right knee DJD 5. Entitlement to a rating in excess of 10 percent for left knee DJD The Veteran's right and left knee DJD is rated under DCs 5003-5010. 38 C.F.R. § 4.71a. On review of the record, the Board finds that the evidence weighs against a rating in excess of the currently assigned 10 percent ratings for right and left knee DJD, respectively. Throughout the appeal period, the Veteran's range of motion was, at worst, 0 to 90 degrees, and thus do not meet the criteria for a compensable rating under the diagnostic codes for limitation of motion. The Board acknowledges a single indication of a -3 value for left knee extension in a September 2016 VA treatment record; however, there are multiple other treatment records indicating extension limited to 0 degrees, as set out above. Moreover, this value does not approach the range of motion value that must be present in order to support an award for the next higher rating. The Board has considered whether a higher rating would be warranted on the basis of additional functional impairment and loss. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Here, the Board finds that the assigned rating adequately contemplates the Veteran's disability picture to include functional impairment and loss. The Board acknowledges the evidence of record indicating functional loss, as set out in detail above, which includes limitations in lifting, walking long distances, sitting completely still, squatting, running, weakness, fatigability, and incoordination. However, the multiple range of motion tests of record do not contain any indication that the Veteran's motion is so limited as to warrant the next higher rating. The Board has considered the Veteran's lay statements regarding the functional impact of his knee conditions, to include difficulty bending and walking and his estimated values regarding limited extension. See June 2014 correspondence. The Veteran is competent to report his own observations with regard to the severity of his disability, including reports of pain and decreased mobility. However, he is not competent to provide range of motion values because such an opinion requires medical expertise (training in evaluating range of motion), which he has not been shown to possess. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Moreover, his statements regarding functional impact are consistent with the evidence of record and the rating assigned. The occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed and measured in the evidence of record. To the extent that the Veteran argues his symptomatology is more severe than that shown during the VA examinations and in treatment records, his statements must be weighed against the other evidence of record, and the specific examination findings of trained health care professionals are of greater probative weight than more general lay assertions. The Board has considered whether the Veteran is entitled to a higher disability rating under alternative diagnostic codes. However, the evidence does not show the Veteran suffers from symptoms better represented by another diagnostic code. Thus, a higher rating under another diagnostic code is not warranted. To that end, the Board further finds additional ratings for the Veteran's bilateral knee disabilities are not warranted. A rating under DC 5256 is not warranted as there is no evidence of ankylosis. There is no evidence of additional limitation of motion such that would warrant ratings under DCs 5260 or 5261. There is no evidence of tibia and fibula impairment to warrant a rating under DC 5262. Additionally, there is no evidence of genu recurvatum to warrant a rating under DC 5263. Finally, the amended versions of DCs 5003, 5010, 5257 and 5262, effective February 7, 2021, would not afford the Veteran greater relief. See 85 Fed. Reg. 76453 (Nov. 30, 2020). Regarding DC 5257, the Veteran is already in receipt of the maximum rating following the effective date of the regulation. The Veteran is not noted to have any impairment under DC 5256. Due to the presence of limitation of motion higher ratings under DC 5003-5010 are not available. In sum, the Board finds that disability ratings in excess of 20 percent are not warranted for the Veteran's right and left knee disability prior to June 22, 2018; ratings of 30 percent are warranted thereafter. The Board also finds that a separate 10 percent rating is warranted for the Veteran's left knee symptomatic removal of semilunar cartilage throughout the appellate period, effective May 14, 2012. The Board also finds that disability ratings in excess of 10 percent are not warranted for the right and left knee DJD. To the extent that the Veteran contends entitlement to higher ratings, the preponderance of the evidence is against the claim; there is no reasonable doubt to be resolved; and any further increased rating is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Minaya, 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.