Citation Nr: 21040396 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 11-11 950 DATE: July 3, 2021 ORDER Entitlement to a rating in excess of 10 percent for left knee disability based on limitation of flexion is denied. Entitlement to a rating in excess of 10 percent for right knee disability based on limitation of flexion is denied. Entitlement to a separate 10 percent rating for left knee meniscal impairment is granted for the entire appeal period. Prior to December 23, 2020, a 10 percent rating is granted for left knee instability. From December 23, 2020, a rating in excess of 10 percent for left knee instability is denied. Prior to December 23, 2020, a separate rating for right knee instability is denied. From December 23, 2020, a rating in excess of 10 percent for right knee instability is denied. FINDINGS OF FACT 1. During the appeal period, the Veteran's left knee disability at worst has been manifested by flexion limited to 65 degrees and the right knee disability at worst has been manifested by flexion limited to 70 degrees with painful motion in each knee. 2. For the entire appeal period, the Veteran has been show shown to have meniscal impairment of the left knee compatible with removal of the left knee semilunar cartilage; semilunar cartilage impairment that was symptomatic to the point that it involved recurrent episodes of effusion, locking and pain into the joint has not been shown. 3. For the entire appeal period, the Veteran is reasonably shown to have exhibited slight instability of the left knee; moderate instability or recurrent subluxation has not been shown. 4. The Veteran has not been shown to have instability or recurrent subluxation of the right knee during the appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for limitation of flexion of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5260-5003. 2. The criteria for entitlement to a rating in excess of 10 percent for limitation of flexion of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5260-5003. 3. For the entire appeal period, the criteria for entitlement to a separate 10 percent rating for meniscal impairment of the left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5258, 5259. 4. Prior to December 23, 2020, the criteria for a 10 percent, but no higher, rating for left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 5. From December 23, 2020, the criteria for a rating in excess of 10 percent for left knee instability or recurrent subluxation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 6. Prior to December 23, 2020, the criteria for a separate rating for right knee instability or recurrent subluxation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 7. From December 23, 2020, the criteria for a rating in excess of 10 percent for right knee instability or recurrent subluxation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1986 to December 2005. This matter is on appeal before the Board of Veterans Appeals (Board) from a September 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2014, a Board hearing was held before a Veterans Law Judge (VLJ) who is no longer employed by the Board. A transcript of the hearing is of record. In May 2014, the case was remanded for further development. In a June 2016 decision, the Board denied the instant claims. The Veteran appealed. In an April 2017 Order, the Court of Appeals for Veterans Claims (Court) granted a joint motion for remand of the parties, vacated the Board decision, and remanded the matter back to the Board for action consistent with the joint motion. In October 2017, the Board remanded the case for further development. In April 2018, the Board again denied the instant claims. The Veteran appealed. In an October 2019 Memorandum Decision, the Court partially vacated the April 2018 Board decision and remanded the appeal back to the Board for action consistent with the Memorandum Decision. In July 2020, the Board remanded the case for further development. In an April 2021 letter, the Veteran was advised that as the VLJ who conducted the April 2014 hearing is no longer employed by the Board, he had a right to request another optional Board hearing. In May 2021 correspondence, the Veteran indicated that he did not wish to appear at an additional Board hearing and desired his case to be decided based on the evidence of record. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can 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 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Code 5260 provides for rating based on limitation of flexion of the knees. Flexion limited to 45 degrees is rated at 10 percent; flexion limited to 30 degrees is rated at 20 percent; and flexion limited to 15 degrees is rated at 30 percent. 38 C.F.R. § 4.71a, Code 5260. Code 5261 provides for rating based on limitation of extension of the knees. Extension limited to 10 degrees is rated at 10 percent; extension limited to 15 degrees is rated at 20 percent; extension limited to 20 degrees is rated at 30 percent; extension limited to 30 degrees is rated at 40 percent; and extension limited to 45 degrees is rated at 50 percent. 38 C.F.R. § 4.71a, Code 5261. For rating purposes, normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. The VA General Counsel has held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997); VAOPGCPREC 9-98, (August 1998). Moreover, the General Counsel also held that separate ratings under 38 C.F.R. § 4.71a, Code 5260 (limitation of flexion of the leg) and under Code 5261 (limitation of extension of the leg), may be assigned for disability of the same joint. VAOGCPREC 9-2004 (September 2004). Under Lyles v. Shulkin, 29 Vet. App. 107 (2017), as a matter of law, separate ratings are not precluded for limitation of motion (Codes 5003, 5260 and 5261), meniscal disability (Codes 5258 and 5259) and instability (Code 5257). Under Code 5257, in effect prior to February 7, 2021, a 10 percent rating is warranted for slight recurrent subluxation or instability, a 20 percent rating is warranted for moderate recurrent subluxation or instability, and a 30 percent rating is warranted for severe recurrent subluxation or instability. 38 C.F.R. § 4.71a, Code 5257. Effective February 7, 2021, 38 C.F.R. § 4.71a, Code 5257 was amended to provide ratings for recurrent subluxation or lateral instability. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing 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 prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Amended Code 5257 also provides for ratings based on patellar instability. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note [1] to DC 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to DC 5257 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration. Under Code 5258, cartilage, dislocated, semilunar, with frequent episodes of locking, pain and effusion into the joint is rated 20 percent disabling. Under Code 5259, symptomatic removal of the semilunar cartilage is rated as 10 percent disabling. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Service connection for left and right knee disability was granted by a February 2007 rating decision. A single 10 percent rating was assigned applicable to both knees effective January 1, 2006. The 10 percent rating was assigned under Code 5003. The Veteran filed the instant claim for an increased rating in May 2009. In a September 2009 rating decision, the RO continued the single 10 percent rating applicable to both knees, recharacterizing the applicable rating code as Code 5260-5003, to reflect that the knees had exhibited painful but otherwise non-compensable limitation of motion. In a January 2018 rating decision, the RO granted an increased rating, assigning a 10 percent rating to each knee effective January 1, 2006 in place of the previous single rating applicable to both knees. In a January 2021 rating decision, the RO granted separate 10 percent ratings for slight left knee subluxation/instability and slight right knee subluxation/instability effective December 23, 2020. These ratings were assigned under Code 5257. The Veteran continues to seek higher ratings. At a June 2008 VA medical visit, the Veteran reported that his knee had become painful in the past 6 weeks. He indicated that he got stiffness with sitting for 15 minutes. The Veteran was diagnosed with knee arthralgia and a knee brace was ordered. At an October 2008 VA mental health visit, the Veteran reported that he had been jogging several days per week but was experiencing knee pain. At a November 2008 medical visit, the Veteran reported bilateral knee pain, more painful on the left. He was using a knee brace, which provided support but did not alleviate the pain. Physical examination showed no redness, warmth, or swelling of either knee with crepitus present on flexion of both knees. There was no instability or joint laxity in either knee. The lower extremities showed no edema, equal strength bilaterally, and normal gait. November 2008 VA X-rays of the bilateral knees showed no evidence of fractures, dislocations, or joint effusions; there was moderate joint space loss with sclerosis within the medial compartment bilaterally and early osteophytosis within the left medial compartments. At an April 2009 VA orthopedic consultation, the Veteran complained of bilateral knee pain left much worse than right over the last 3 to 4 years. The knee seemed to bother him mostly in flexed positions (and he had a positive theater sign). He indicated that his right knee was only occasionally bothersome. His pain was improved by changing his position frequently and walking. There were no mechanical symptoms. Physical examination showed full range of motion (ROM) in the bilateral knees, no joint line tenderness, crepitus, or effusions, and both knees were stable without pain upon stressing. The Veteran ambulated well. A left knee corticosteroid injection for pain was administered in the left knee. In July 2009 the Veteran submitted a statement that he had fluctuating pain in the left knee all the time that would intensify with activities, limiting his physical activities to include bending and lifting. He stated that injections with a corticosteroid eased the pain for several weeks before the pain would return. He noted that after prolonged sitting, his left knee became stiff and sore. He indicated that upon getting up from prolonged sitting, he would have to place his weight on the right side and move his left knee back and forth until he could gradually put weight on it. He reported that when walking his knee felt weak, tight, and full. The Veteran indicated that when he raised his knee, the pain could be so intense that it was painful to move it back and forth and that he could hear his knee popping and grinding. He noted that he had good and bad months with his right knee and reported pain worsening from October to December. The Veteran reported that per his physician's recommendation, he wore a front-line medial Kool flex knee orthosis. This helped ease the pain somewhat but when he removed it the pain would immediately return and could increase in severity. The Veteran was afforded a VA contract examination in July 2009 in which he reported left knee pain that intensified with activity, left knee stiffness when sitting for long periods of time, and both knees feeling weak when walking. He also reported giving way, lack of endurance, locking, tenderness, and popping. He denied swelling, heat, redness, fatigability, deformity, drainage, effusion, subluxation, and dislocation. He noted flare-ups as often as one time per day, lasting for one day, precipitated by physical activity and alleviated by rest. He reported that the flare-ups consisted of left knee stiffness and limitation motion of the joint after the joint had been idle. He noted in these situations, he had to gradually put pressure on his knee when standing up. He described his left knee as becoming stiff and tender after standing and walking for brief periods. He also described the additional symptom of left knee popping. He denied any incapacitation but noted functional impairment in that strenuous activities like jogging, lifting, and lots of bending were hindered by pain. Physical examination showed that gait was within normal limits. Bilaterally, there were no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement, and no locking pain, genu recurvatum or crepitus. Range of motion testing showed bilateral knee flexion to 140 degrees and full extension. Repetitive range of motion was possible with no additional degree of limitation. The left knee had pain at 140 degrees. Regarding the right knee, the joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use; the left knee was limited by pain after repetitive use but it did not result in additional limitation of motion. The medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test, and the medial/lateral meniscus ligaments stability test were all within normal limits for both knees. The examiner commented that the objective factors for the bilateral knees were pain with motion in the left knee and the subjective factors were weakness, stiffness, pain, giving way, lack of endurance, locking and popping. The effect of the bilateral knee condition on the Veteran's usual occupation was mildly limiting in that the Veteran would experience pain and discomfort with prolonged walking and standing. The effect of the condition on the Veteran's daily activity was very mildly limiting in that the Veteran would experience pain and discomfort with prolonged walking and standing. At a September 2009 VA orthopedic visit, review of the Veteran's prior X-ray was noted to show very mild osteoarthritis. The Veteran stated that his left knee pain currently was as bad or worse as it had ever been. He indicated that he had developed periodic locking episodes, which occurred after he had been siting a while and then attempted to get up. He stated that he had to manipulate the knee in order to straighten it. He also reported giving way episodes of the knee particularly when negotiating stairs. He was unaware of any swelling. He pointed to the medial aspect of the knee as the primary source of pain. Range of motion on the left was 0 degrees extension to 120 degrees flexion with patellofemoral crepitus. The Veteran had fairly significant medial joint line tenderness especially posteriorly. There was no lateral joint line tenderness and no effusion. There was a mildly positive Apley's sign with medial knee pain. The knee was stable in all planes without pain upon stressing. The diagnostic assessment was mild osteoarthritis of the left knee with possible torn medial meniscus. A November 2009 VA MRI of the left knee produced a diagnostic assessment of posterior horn of the medial meniscus tear, full thickness trochlea chondral defect and high signal within the suprapatellar fat, which could be a source of pain. At a December 2009 VA orthopedic visit, the Veteran reported left knee pain and stiffness with sitting for long periods or negotiating stairs. He noted that after sitting for long periods it would take a minute or so for him to straighten out his knee. However, the Veteran noted no real locking, clicking, or swelling. Physical examination of the left knee showed mild posteromedial joint line tenderness. Range of motion was noted as being 0-125 degrees without much pain. The patella tracked well grossly, there was palpable crepitus with range of motion and there was a mildly positive grind test. Lachman's and posterior drawer testing were negative. Varus stress at 0 and 30 showed 1+ laxity, which was symmetrical to the right. Valgus stress was stable and McMurray's and Apley's testing were negative. The evaluating clinician commented that the Veteran's symptoms correlated with his MRI findings of medial meniscus tear and patellofemoral arthritis. The Veteran had not noted any real locking or swelling. He had not tried physical therapy (PT) since 2004 when the pain began, and he did remember experiencing some relief. He had had the pain injection which only helped for about 1 month. He had tried Piroxicam previously with some relief but was told to only take it for 1 month since he had reflux. A request for fee basis physical therapy was made and the Veteran was prescribed Ibuprofen for pain. He was advised to return to the orthopedic clinic in mid-March for re-evaluation after PT. At a March 2010 VA follow-up orthopedic visit, the Veteran stated that his left knee pain was much improved with physical therapy and the use of NSAIDs. He was mildly concerned that the pain may have been coming back. He noted discomfort with strenuous exercise only. He was not having problems on stairs and was not experiencing locking or weakness. Physical examination showed that the knees were symmetric with no swelling. The left knee was non-tender to palpation. There was full range of motion without pain. There was no joint laxity on varus, valgus, or anterior/posterior drawer testing. There was patellar crepitus. The Veteran was advised to continue with physical therapy exercises for knee strengthening. The Veteran was also advised that he could exercise and was encouraged to perform low knee resistance exercises such as biking, using the elliptical trainer, swimming etc. At a May 2010 follow-up visit, the Veteran reported that he noticed discomfort with increased activity. He was not having problems on stairs and was not experiencing locking or weakness. Physical examination produced similar findings to the earlier March 2010 evaluation. The evaluating physician noted that the Veteran's pain was primarily along the medial border of the tibia along the joint line. Treatment options were discussed including continued conservative care or consideration of arthroscopic meniscectomy and chondroplasty/microfracture. The Veteran was going to consider these options. The Veteran was afforded a VA contract examination in April 2010 in which he reported weakness, stiffness, swelling, giving way, lack of endurance, tenderness, and pain. He denied heat, redness, locking, fatigability, deformity, drainage, effusion, subluxation, and dislocation. The Veteran reported flare-ups as often as one time per day and each time these lasted for 24 hours, precipitated by physical activity, and alleviated by rest. During the flare-ups he experienced functional impairment with pain when standing, walking, and sitting. He generally reported difficulty with standing and walking and described his pain as becoming severe after prolonged sitting. He reported overall functional impairment as an inability to lift or move heavy items due to the pain. Range of motion testing showed bilateral knee flexion to 140 degrees and full extension. Repetitive range of motion was possible with no additional degree of limitation. Medial/lateral collateral ligament stability testing, anterior/posterior cruciate ligament stability testing, and medial/lateral stability test were all within normal limits in both knees. The examiner noted that the objective factors of disability for the Veteran's bilateral knees were those that had been VA established. The subjective factors were weakness, stiffness, swelling, pain, giving way, lack of endurance and tenderness. The examiner commented that neither the right nor left knee showed signs of subluxation or instability. The examiner also commented that the effect of the Veteran's bilateral knee condition on his usual occupation and daily activities was non-limiting. The Veteran submitted a statement in July 2010 indicating that his left knee hurt all the time. He noted that Naproxen appeared to be beneficial in controlling his knee pain. He reported that that his knee pain resulted in discomfort and affected his ability to walk, work, enjoy life, climb stairs, exit his vehicle, and enjoy day-to-day activities. He stated that it also affected his ability to enjoy active sports and physical work. He also noted that working at his desk caused his knees to become stiff and worsen his pain, which resulted in him moving his leg and taking breaks in an effort to relieve the pain. He indicated that when he was working in the field, performing housing and landscaping inspections, he had to set limitations that would allow him to perform the requirements of his job without exposing himself to an increased level of pain. In his March 2011 formal appeal, VA Form 9, the Veteran stated that his knee condition caused constant pain. He indicated that his left knee gave way several times a week, and he had swelling in both knees. The Veteran was seen for follow-up VA orthopedic surgery visits in June 2011, February 2012, August 2012, and February 2013. In June 2011, it was noted that the Veteran was seen for follow up for bilateral knee pain. He was noted to have primarily anterior knee pain which he described as "burning." The earlier 2009 left knee findings were noted. It was also noted that the Veteran had had a left knee cortisone injection that helped reduce his pain somewhat for about one month, but that he reported that when the pain came back it was more severe than before. Additionally, it was noted that the Veteran walked for exercise but with pain. Further, it was noted that the Veteran had undergone physical therapy (PT), which had helped, and he was still trying to do the PT exercises. In February 2012, it was noted that the Veteran had managed his left greater than right knee symptoms conservatively with low-impact exercise, Naproxen, and a knee brace. The Veteran reported that he was still getting by on a daily basis without too much difficulty. In August 2012, it was noted that the Veteran had returned for follow up for left knee pain and had reported that the pain had been relatively unchanged. He reported that the pain was tolerable with Naproxen and tramadol on occasion. The Veteran denied the presence of mechanical symptoms at the visit. In February 2013, the Veteran again reported that his left knee pain was tolerable using a pull-on neoprene brace, tramadol, and Naproxen. The Veteran indicated that did not currently want surgical intervention. Physical examinations generally showed left knee range of motion of at least 0 degrees extension to 90 degrees flexion. There was no significant joint effusion, no erythema, warmth or crepitus and the knee was stable to varus and valgus stress with slight tenderness to the posteromedial joint line on the left. Patellar grind test was equivocal, Lachman test was stable and McMurray test was negative. In June 2011, the treating orthopedic physician prescribed hinged knee braces on an as needed basis and quadricep exercises. In February 2012, it was noted that the Veteran was currently satisfied with his treatment regimen of exercise, NSAIDs, and bracing and did not feel his symptoms currently merited surgical intervention. In August 2012 and February 2013, the Veteran reported that his left knee pain was tolerable; that he wanted to continue the current treatment regimen and he did not currently did want surgical intervention. In an April 2014 statement, the Veteran indicated that he had constant pain in his left knee and pain mainly on the inner side of his right knee. He indicated that his left knee felt sore all the time and that he experienced intense pain in both knees when the weather changed. He reported that both knees became weak when he squatted or attempted to stand from a squatting position. He also reported that both knees became stiff and tender after staying in the same position for periods of time, including while sitting in the car traveling or sitting at his desk at work for an hour or more. Additionally, sometimes his left or right knee would feel like it locked up or slipped from under him when walking. The Veteran indicated that each time he had been examined, he had taken pain pills. Thus, the pills resulted in him not totally feeling the pain in his knees when his range of motion was evaluated. He asserted that his pain would have been much more intense when his flexion and extension were evaluated if he had not been taking pain pills. Accompanying the April 2014 statement, the Veteran submitted logs as to the symptoms he felt throughout the day in his left knee, on certain days from March 2014 to April 2014. He noted that on March 22, 2014, he spent about two hours outside picking up and raking debris. At that point, he felt pain in his left knee, which quickly intensified. He noted that with his left leg slightly bent, he limped to the house. He indicated that his knee appeared to be locked and it was painful to straighten it out. He reported that he went into the house and removed his pants and discovered that his knee was swollen. Thus, he iced his knee and took an extra pain pill. He noted that on March 23, 2014, he drove for an hour to the mall and as he attempted to exit his car, his left knee felt that it was stiff/locked in place. He reported that he could not stand without pulling himself up. He stated that he used his car door as an anchor and gradually pulled himself out of the car. He indicated that the knee was very stiff and tender. Additionally, he reported that on the return trip home, his left knee felt like pins were sticking into it. He noted that he stretched his leg while driving as much as he could to relieve the pain and that while in the bent position, the left knee was stiff, sore, and painful. The Veteran noted that on March 25, 2014, while he was walking up the stairs at work, his knee gave way causing him to fall to the left. He noted that he grabbed the railing to balance himself to keep from falling. The Veteran reported that on March 29, 2014, while lying in bed attempting to sleep, his left knee felt sore and tender. He noted that he went to the bathroom to examine it and the knee was red and slightly swollen on the right inner side. He indicated that he took an extra pain pill and iced his knee. The Veteran noted that on April 6, 2014, he was walking on the field inside a running track. He reported that his left knee weakened causing him to lean to one side, almost falling. In a separate April 2014 statement, the Veteran's wife reported that her husband had complained of chronic knee pain for many years. She indicated that he avoided sleeping on his left side and wedged a pillow on his left side at night to protect himself from turning on to his knee. She also indicated that she had seen his left knee swell many times, indicating that this often occurred when the temperature changed, after extended periods of walking and sitting and when performing outside yard work. The Veteran's wife reported that on March 7, 2014, while traveling, she was walking with him to the airport terminal. She noted that she was walking on his left side when his knee sprung forward causing him to lose his balance. She noted that when the Veteran walked upstairs, it always appeared to be a challenge. She indicated that he had reported that his left knee would often get weak going up the steps resulting in him having to grab something for balance. She reported that she had also noticed that after he sat for a while, his knees would get stiff or lock when he attempted to stand. This often caused him to be in pain and to have to use the side of his chair for support to stand. She reported that when possible, he sat with his legs stretched out and not bent. She noted that the Veteran took several Naproxen and Tramadol pills daily for knee pain. In a separate April 2014 statement, friends of the Veteran indicated that they recalled volunteering with him on October 19, 2013 at a fundraiser. They noted that the Veteran was responsible for unloading boxes of donuts from a van and relocating them to a table, which was located in front of a store. They indicated that the walking distance for this task was approximately 25 feet. They reported that the donut sale started at 9 AM and that by 10:30, they noticed that the Veteran was limping and asked him what was wrong. They indicated that he stated that his knee was aching. They reported that as he was wearing shorts, they took a look at his knees and noticed that his left knee was swollen. They noted that he informed them that he had problems with his knees and that his left knee often became painful and would swell. In a separate April 2014 statement, a friend indicated that the Veteran visited her house on March 19, 2014. She indicated that he reported that he had just left the car wash. She noted that they talked for over an hour and she noticed he kept moving his left leg and rubbing his knee. She indicated that she asked him about it, and he informed her that bending his knees at the car wash had probably aggravated them. She noted that he reported that his left knee felt swollen. She reported that he rolled up his left sweat pant leg and in fact, hs left knee was swollen. As the April 2014 Board hearing, the Veteran testified that he had constant pain primarily in his left knee. He noted that he wore a left knee sleeve. He reported that he took Naproxen daily and Tramadol daily and that his pain occurred at any time though he had good days and bad days. He indicated that it affected his daily activities because there were things he used to do that he could no longer do. The Veteran testified that he experienced quite a bit of swelling occurring approximately 3 to 4 times per week. He reported that he used to put an ice pack on his knee and elevate his knee when the swelling occurred. He indicated that he also had guarding of movement, and was always thinking about how to move his knee so that he did not create more pain. The Veteran testified that he had had a recent incident in an airport where his knee just gave out and that this was a common occurrence. He also reported that he experienced instability of the knee. He noted that he used a cane to prevent himself from falling. He also indicated that his pain intensified with activity. He gave the example of driving for a long distance and having trouble getting out of his vehicle after having sat for so long because his knee had locked in place. The Veteran testified that it was very hard for him to stoop and to get up from stooping or sitting to a standing position. He noted that he would feel his knees lock when he was in the same position for so long and then when he tried to stand, his knees would just be locked in place. The Veteran indicated that he was experiencing more episodes of locking, more episodes of knee pain and could not bend his knee currently as much as he could before. The Veteran testified that he had a desk job and while sitting, he had to spend a lot of time trying to straighten his leg under his desk rather than keeping it bent at all times. He noted that he would back away from his desk and straighten out his leg and he found himself wiggling his leg and wiggling his feet to try and ease his knee pain. The Veteran emphasized that his left knee problems were much worse than his right knee problems. He noted that he had pain bilaterally, but his instability was primarily on the left. He indicated that his right knee problems mainly consisted of pain and weakness when he squatted and attempted to go back to a standing mode. He reported that the locking and associated symptoms were all primarily on the left and that he wore the sleeve/brace on the left every day. He also reiterated that he used the cane to help with the knee instability. At a June 2014 VA orthopedic surgery visit, the Veteran was seen for follow up for left knee pain with known chronic meniscal tear and trochlear chondral damage. It was noted that he had managed the pain in the knee with oral NSAIDs for the past several years with good success. He reported that he was still able to do the things he would like to do despite this pain. Surgery has been discussed multiple times in the past and he had expressed no interest in pursuing it. He also reported trying an injection in the knee several years previously without significant relief. Physical examination showed range of motion from 0 degrees extension to 80 degrees flexion. There was no significant effusion and minimal tenderness to palpation at the medial joint line. Patellar grind testing was equivocal, Lachman testing was stable, and the knee was stable to varus/valgus stress at 0 and 30 degrees. The evaluating physician noted that the Veteran had left knee pain with known chronic meniscal tear and trochlear chondral damage. His symptom of chronic dull ache that was worsened with extended activity was consistent with arthritis. The Veteran was noted to have significant pain at the visit as he had not taken NSAIDS and had marked limitation of motion. The physician indicated that he discussed with the Veteran that he needed to keep flexibility in his leg at all costs. The Veteran was afforded a VA examination in August 2014 in which he reported constant bilateral pain in his knees, worse in his left. He indicated that standing was limited to 30 to 45 minutes and walking was limited to a mile, and the left knee felt like it wanted to give way. He also indicated that he had difficulty with squatting and negotiating stairs. He noted that sitting did not bother him if he was able to stretch his legs out. The Veteran did not report flare-ups. Range of motion testing showed flexion to 115 degrees in the right knee, with painful motion starting at 110 degrees, and full extension; left knee flexion was to 110 degrees with painful motion at 105 degrees and full extension. The Veteran was able to perform repetitive-use testing with no additional loss of motion. Functional impairment after repetitive use was noted as less movement than normal, excess fatigability, pain on movement, and disturbance of locomotion. There was pain to palpation of the joint line or soft tissue of both knees. Muscle strength and joint stability testing were normal. The examiner found that there was no evidence or history of recurrent patellar subluxation/dislocation. The Veteran reported constant use of a left knee brace due to pain. The examiner found that the functional impact of the Veteran's knee condition was limited use of stairs and squatting, standing limited to 30 to 45 minutes and walking limited to about a mile. The examiner also noted that the severity of functional loss was moderate, but exact degrees could not be determined due to the limitations of the history and because the Veteran had no additional loss of motion on examination. At an October 2014 VA physical therapy evaluation, the Veteran reported some level of knee pain all the time. He was also wearing a neoprene sleeve. He reported episodic buckling about once per week, but he had not fallen. He walked for exercise about 12 to 1 mile about every other day. He also performed various calisthenics. A pain assessment indicated that the character of the pain was aching, the frequency was constant, and it sometimes interfered with sleep. The Veteran reported that negotiating stairs, squatting, pressure and going from sitting to standing increased pain and pain medication, heat and ice decreased pain to some extent. Physical examination showed right knee range of motion from 0 degrees extension to 120 degrees flexion and left knee range of motion from 0 degrees extension to 110 degrees flexion. Patellar compression testing was positive bilaterally and Nobles testing was positive on the left. At a February 2016 VA orthopedic surgery visit, the Veteran was noted to have medial left knee pain that was increased with walking and kneeling. He also reported occasional catching and the sensation that the knee wanted to give way. However, the knee had not given way. Additionally, he reported that the knee felt worse when the weather was bad. Physical examination of the right and left knee showed no swelling or effusion and range of motion from 0 degrees extension to 140 degrees flexion. The knees were stable to varus and valgus stress. The left knee showed an equivocal patellofemoral grind test. The Veteran was advised that there was no indication for current surgical intervention. The Veteran was also advised to continue his Naproxen and was sent to prosthetics for a neoprene knee brace. At a November 2016 VA orthopedic surgery visit, it was noted that the Veteran continued to suffer with chronic left knee pain, currently managed conservatively with Naproxen, physical therapy, and a knee sleeve. It was noted that one month previously, he experienced a flare up while doing a lot of work requiring knee flexion and that his pain and symptoms had since improved with RICE therapy. It was also noted that most of his pain was with deep flexion or squatting and going up stairs. The Veteran reported 1 to 2 episodes of locking or catching. Physical examination showed no effusion with range of motion from 0 degrees extension to 120 degrees flexion. There was mild pain in full flexion, normal patellar mobility, mild pain with patellar compression, moderate patellofemoral crepitus with range of motion and mild medial joint line tenderness. McMurray's and Lachman's testing were negative, and the knee was stable to varus and valgus stress. At an October 2017 VA contract examination, the Veteran reported that his knee condition had gotten worse over the years. He indicated that he was taking 1000 mg of Naproxen per day and was still experiencing pain. He noted that he heard clicking and felt popping and swelling and that it was hard/painful to go from a sitting to standing position. He also indicated that he got frequent crepitus/swelling with increased pain. He noted that he could not bend/squat well. He reported that he was able to walk or stand for 20 minutes before having to sit down. The examiner found that the Veteran's bilateral knee condition limited his ability to squat, limited his ability to bear weight to only 2 to 3 hours with frequent breaks and caused disturbance of locomotion, interference with standing, decreased range of motion and pain. The Veteran reported flare-ups of the bilateral knees described as increased pain when standing, a weak and popping sensation and pain on bending and straightening. Range of motion testing showed 0 degrees extension to 90 degrees flexion of the right knee. Pain was noted on flexion and was found to cause functional loss. Pain on palpation was found to a mild degree at the medial tibial plateau. There was no pain on weight bearing and no objective evidence of crepitus. Left knee range of motion was from 0 to 75 degrees flexion. There was pain noted on flexion and extension to a moderate degree found in the whole knee. There was evidence of pain on weight bearing and evidence of crepitus. The pain noted on examination was found to cause functional loss. Repetitive use testing did not show additional loss of function or range of motion after 3 repetitions. The examiner opined that pain and lack of endurance limited functional ability with repeated use over time. The examiner found that this limited right knee flexion to 80 degrees and left knee flexion to 65 degrees. The examiner also opined that pain and lack of endurance limited functional ability upon flare-ups. The examiner found that this limited right knee flexion to 70 degrees and left knee flexion to 65 degrees. Additional factors contributing to disability were noted to include swelling, disturbance of locomotion and interference with standing. No history of recurrent subluxation was found, and no history of recurrent effusion was found. Joint stability testing was normal bilaterally. At a June 2020 VA physical therapy consultation, the Veteran reported chronic left knee pain with history of torn meniscus without surgery. He reported weakness and soreness with stair climbing and also limiting the ability to exercise. He indicated that he had been taking Naproxen for knee pain for years and that he thought he had become immune to it. The Veteran provided a circumference measurement for the left knee for purposes of fitting an appropriate left knee brace. At a January 2021 VA contract examination, the diagnoses were bilateral knee arthritis and bilateral patellofemoral pain syndrome. The Veteran reported current symptoms of severe pain when standing, attempting to squat, or walking up steps. Current treatment included Naproxen, Vitamin D3 and Omega 3. The Veteran described the impact on his functional ability as the inability to squat, intense pain walking up steps, and severe pain while sitting for 30 minutes or more. The Veteran reported daily right knee flare-ups, which were severe, intense, and involved tenderness to the area. He indicated that the flare-ups lasted 1 to 6 days or for weeks. He indicated that the flare-ups were precipitated by a stressful day at work, intense activity, long periods of sitting and long periods of standing. The right knee flare-ups were alleviated by pain medicine, heat, or cold pad, and/or Vicks Vapor Rub. The Veteran also reported severe flare-ups of the left knee that were intense and involved tenderness to the area. He noted that they occurred daily and lasted 1 to 6 days or for weeks. He indicated that the left knee flare-ups were precipitated by change of weather, stiffness of knee and walking up steps. The left knee flare-ups were alleviated by pain medicine, heat, or cold pad and/or Vicks Vapor Rub. The Veteran reported functional loss from flare-ups in that he could not squat, had intense pain when walking up stairs and had severe pain while sitting for 30 minutes or more. Range of motion testing showed 0 degrees extension to 105 degrees flexion of both knees. Pain was noted on examination but was not found to result in any functional loss. Pain was located in the patella of the right knee and the patella and the medial aspect of the left knee. The severity was found to be moderate bilaterally. There was also evidence of pain with weight bearing bilaterally. After repetitive use testing, pain resulted in decrease in flexion of the right knee to 95 degrees and decrease in flexion of the left knee to 95 degrees. The examiner also found that pain significantly limited functional ability after repeated use over time, resulting in an additional limitation of flexion down to 90 degrees bilaterally. Similarly, the examiner found that pain significantly limited functional ability with flare-ups, again finding that it reduced flexion down to 90 degrees bilaterally. The examiner noted that the Veteran had a history of slight recurrent subluxation and a history of slight left lateral instability. The examiner indicated that the Veteran did not have a history of recurrent effusion. Joint stability testing showed that anterior, posterior, medial, and anterior instability tests were all normal bilaterally. The examiner noted that a left medial meniscus tear was present during a November 2009 left knee MRI (the examiner also checked a box indicating a right meniscal tear while at the same time not checking a box indicating that a left knee meniscal tear was present. Given that there is no other evidence of any right meniscal impairment and clear evidence of the ongoing left meniscal tear, the check box notation of right meniscal tear instead of left meniscal tear was clearly an error on the part of the examiner). The examiner also noted that the Veteran regularly used a knee brace and occasionally used a cane to manage his knee impairment. The examiner commented that the functional impairment from the bilateral knee disability was that the Veteran could not squat, experienced intense pain when walking up steps and severe pain while sitting for 30 minutes or more. The examiner also commented that there was objective evidence of pain on passive range of motion testing of the left knee; there was no evidence of pain on non-weight bearing testing of the left knee; there was objective evidence of pain on passive range of motion testing of the right knee; there was no evidence of pain on non-weight bearing testing of the right knee; and that a goniometer was used for all joint range of motion measurements. The examiner indicated that based on the findings of the examination, the VA established diagnosis had changed, and it was a progression, the current diagnosis was degenerative joint disease of the right knee with patellofemoral pain syndrome. The examiner noted that a thorough physical examination and medical record review were completed, including particular attention to medical visits in August 2005, September 2005 and January 2006, the November 2009 VA MRI, a December 2009 VA medical center physical examination (showing varus stress at 0 and 30 degrees with 1+ laxity). The examiner commented that on the current examination, there was evidence of patellofemoral pain syndrome. However, there was no evidence of subluxation or knee joint instability of either knee. Also, there was no evidence of recurrent knee joint effusion found on review of the medical records. The Veteran did not report knee joint swelling during the current exam and on physical examination, no evidence of swelling or joint effusion was shown. Therefore, there was not sufficient evidence to find that there was effusion into the left knee joint associated with dislocated semilunar cartilage. Considering the rating under Code 5260, the Board notes that the Veteran has already been assigned 10 percent ratings for each knee for the entire appeal period under this Code based on painful but otherwise noncompensable limitation of flexion of the knee according to Code 5003. This is the maximum available rating under Code 5003. Also, there is no basis for assigning ratings in excess of 10 percent for either knee under Code 5260. In this regard, during the appeal period flexion of the left knee has not been found to be less than 65 degrees and flexion of the right knee has not been found to be less than 70 degrees. In his April 2014 statement, the Veteran asserted that he regularly took pain medication prior to knee examinations so that range of motion testing has not accurately reflected the true limitation of motion of his knees. However, the Board notes that during the June 2014 orthopedic surgery visit just two months later, the Veteran specifically reported that he had not taken his pain medication prior to that visit and left knee flexion was noted to be reduced, measured as to 80 degrees. This is still a much greater level of flexion that the 30 degrees, which would be required to grant a higher 20 percent rating under Code 5260. Moreover, there is no other medical evidence of record nor has the Veteran specifically alleged that his left or right knee flexion is limited to 30 degrees or less when not taking his pain medication. Accordingly, a higher rating is not warranted under Code 5260 for either knee at any time during the appeal period. Considering Code 5261, the Board notes that in the October 2019 Memorandum Decision, the Court specifically upheld the portion of the earlier April 2018 Board decision, which denied a separate rating under this Code. Moreover, extension of the bilateral knees has consistently been found to be normal to 0 degrees. Accordingly, a separate rating is not warranted for the left or right knee under Code 5261. Considering Code 5257, prior to December 23, 2020, the Board notes that the Veteran has been shown to consistently wear a brace or sleeve, which was prescribed by VA and which the Veteran has reasonably reported has helped stabilize his knee. Thus, even though actual stability testing of the knee has been consistently normal (aside from the isolated finding of 1+ laxity at the December 2009 orthopedic visit), based on the consistent use of this brace and the Veteran's subjective reporting of some instability, the Board will assign a 10 percent rating based on left knee instability for the entire appeal period prior to December 23, 2020. A rating in excess of 10 percent is not warranted at any time during the appeal period because the instability is not shown to be to the moderate degree. (Also, moderate recurrent subluxation is neither shown nor alleged). In this regard, as noted, stability testing during the appeal period has been consistently normal. Also, although the Veteran has reported instability, he has generally been shown to be able to manage it with use of his brace. Notably, the Veteran has also reported using a cane, including during the April 2014 Board hearing and during the January 2021 VA contract examination. However, a review of the VA medical records over the course of the appeal period does not indicate that the Veteran was ever prescribed a cane for instability of the knees. Also, given that the Veteran has had multiple medical visits with VA practitioners for his knees during the appeal period, the Board presumes that if his left knee was so unstable to actually require a cane, he would have brought this to the attention of the treating medical providers at some point over the course of this treatment. However, the VA medical records are silent for any finding that the Veteran required a cane for instability or any specific complaint that the Veteran was unable to manage any instability through use of a brace. Thus, to the extent that the Veteran has asserted that he actually has required a cane for left knee instability, the Board does not find this assertion credible. In sum, given the lack of objective findings of instability of the left knee; and given that the instability of the left knee reported by the Veteran is reasonably shown to be managed through use of brace, a 10 percent but no higher rating is warranted for instability of the left knee for the entire appeal period. Regarding the right knee, the evidence similarly shows that stability testing of this knee has consistently been normal (aside from the isolated finding of 1+ laxity at the December 2009 orthopedic visit) and there are no other clinical findings of record of right knee instability during the appeal period. Also, at the April 2014 Board hearing the Veteran testified that his problems with instability were primarily on the left. In this regard, he indicated that his right knee problems mainly consisted of pain and weakness when he squatted and attempted to go back to a standing mode. He also reported that the locking of the knee and symptoms associated with this were all primarily on the left and that he wore the sleeve/brace on his left knee every day. Additionally, although the Veteran was noted to have reported "giving way" of the right knee at certain examinations (See e.g. the July 2009 examination report), to the extent these notations are accurate, the Board does not find them credible. In this regard, the Veteran has had extensive VA treatment for knee disability over the course of the appeal period, yet the VA treatment records are silent for any complaint by the Veteran of the right knee giving way. The Board presumes that he been experiencing this symptom, he would have reported it to VA treating practitioners just as he did with the left knee. Accordingly, the Board is not able to credit the reporting of the right knee giving way at the aforementioned examinations. Also, it does appear that the Veteran was prescribed a right knee brace on an as needed (i.e. PRN) basis in June 2011. However, it does not appear that he has ever required the use of a brace for the right knee. Given the extremely minimal (and isolated) objective evidence of any right knee instability and given that the Veteran himself has not credibly endorsed any significant instability, the Board finds that the weight of the evidence is against a finding that such instability is present. Accordingly, a separate rating under Code 5257 for instability is not warranted prior to December 23, 2020. The Board will not disturb the 10 percent rating assigned for right knee instability from December 23, 2020 (but based on the analysis applied to the whole appeal period, there is no basis for assigning a rating in excess of 10 percent from December 23, 2020). The medical evidence of record is also silent for the presence of any recurrent subluxation of the right knee during the appeal period. Notably, the January 2021 VA contract examiner noted that the Veteran had a history of slight right and left subluxation. However, review of the examination report shows that this history was based on medical findings of record prior to those during the appeal period (e.g. from August and September 2005). Also, the Veteran has not specifically alleged during the appeal period that he has experienced recurrent right knee subluxation (or the right patella sliding out of place). Accordingly, the weight of the evidence is against a finding that right knee subluxation has been present during the appeal period and a rating under Code 5257 for such pathology is not warranted. To the extent the 10 percent rating under Code 5257 was assigned from December 23, 2020 for right knee subluxation, the Board will not disturb this rating (but based on the analysis applied to the whole appeal period, there is no basis for assigning a rating in excess of 10 percent from December 23, 2020). The Board has considered the revised Code 5257 for the period from February 7, 2021. However, this Code does not provide a basis for awarding a rating in excess of 10 percent for either knee. Regarding the left knee, the Veteran is not shown to have ligament sprain, incomplete ligament tear or repaired complete ligament tear, which is causing persistent instability and although he has been prescribed a brace/sleeve, it has not been prescribed to treat any ligament impairment. Also, the Veteran has not alleged any such ligament impairment. Regarding the right knee, the Veteran is not shown to need a brace or other assistive device for any purpose, let alone ligament impairment and he has not undergone any surgical repair of the patellofemoral complex of the right knee. Accordingly, ratings under the revised criteria from February 7, 2021 are not warranted. Considering Code 5258 and 5259, the November 2009 MRI clearly shows that the Veteran has a meniscal (i.e. semilunar cartilage) tear and the evidence does not show that he has ever undergone any surgery to remove any part of this semilunar cartilage. Although it is evident that he does experience some symptoms associated with this condition, the evidence does not show that the meniscus tear has resulted in frequent episodes of locking, pain, and effusion into the joint. In this regard, the medical evidence is silent for any findings of effusion into the left knee joint with the January 2021 VA contract examiner specifically finding that there was no evidence of recurrent effusion found upon review of the Veteran's medical records. Notably the Veteran has reported frequent swelling as a symptom of his left knee disability. See April 2014 hearing testimony and submitted logs and statements indicating that he experienced swelling of the left knee on October 19, 2013. March 22, 2014, March 25, 2014, March 29, 2014. He also reported swelling as a symptom at April 2010 and October 2017 examinations and swelling was noted to be present during the October 2017 examination. Additionally, in her April 2014 statement, the Veteran's wife reported that she had seen his left knee swell multiple times. However, the Board notes that the Veteran received ongoing clinical treatment for knee disability during the appeal period, including significant periodic orthopedic evaluation and care. This care has included VA orthopedic and physical therapy visits in June 2008, October 2008, November 2008, April 2009, December 2009, March 2010, May 2010, May 2011, February 2012, August 2012, June 2014, August 2014, October 2014, February 2016, November 2016, and June 2020. However, the Veteran did not report any swelling during these visits and no swelling was found on any physical examination. The Board presumes that had the Veteran experienced frequent swelling of the left knee, he would have reported it as an ongoing symptom during at least some of these medical visits and/or it would have been detected during at least some of the physical examinations conducted during these visits. Accordingly, to the extent that the Veteran is alleging that he experienced frequent swelling of the left knee over the course of the appeal period as opposed to isolated instances occurring in October 2013 (based on his friends' statement), late March 2014 (based on his logs) and October 2017 (based on the examination report), the Board does not find this assertion credible. Similarly, for this same reason, to the extent the Veteran's wife was asserting in her April 2014 statement that the Veteran's left knee had frequently swelled over the course of the appeal period, the Board also does not find this statement credible. Moreover, although the October 2017 examiner did find the Veteran's left knee swollen, he also did not find that the Veteran had had recurrent left knee effusion. Further, as noted, the January 2021 examiner also did not find recurrent effusion. Accordingly considering the lack of medical evidence of effusion or frequent swelling and the non-credible lay evidence concerning the presence of frequent swelling (as opposed to more isolated instances of it), the weight of the evidence is against a finding that the Veteran's left knee meniscal impairment has resulted in frequent effusions into the joint. Accordingly, as this is a necessary criterion for assigning a 20 percent rating under Code 5258, such a rating is not warranted. The Board notes, however, that the Veteran clearly has been shown to have some level of left knee meniscal impairment during the appeal period. Thus, although he has not had surgical removal of the meniscus, he clearly has been symptomatic. Consequently, a 10 percent rating is warranted under Code 5259 for impairment compatible with symptomatic removal of the semilunar cartilage. The Board has considered whether any other Codes can be applied to rate the Veteran's bilateral knee disability. However, as ankylosis, nonunion or malunion of the tibia and fibula or genu recurvatum were not shown, such rating Codes are not applicable. See 38 C.F.R. § 4.71a, Codes 5256, 5262 and 5263. Finally, the Board has considered whether any higher rating could be warranted on the basis of functional loss. However, as alluded to above, the examinations in this case, including the most recent January 2021 examination, specifically considered and evaluated the Veteran's additional loss of motion/function on repetitive use and on flare-ups. However, this additional loss of motion does not provide a basis for any higher rating. Also, more generally, the Veteran's overall functional impairment, including pain and discomfort on walking and standing with limitations on the duration of these activities, inability to squat, pain and limitation with the use of stairs, pain after sitting for 30 minutes and limitations on the amount of weight bearing he can perform in a day are adequately compensated by the three 10 percent ratings assigned for his left knee disability and the additional 10 percent rating assigned for his right knee disability for the entire appeal period (with twin 10 percent ratings assigned from December 23, 2020). In sum, a separate 10 percent rating is warranted for left knee meniscal impairment for the entire appeal period and a separate 10 percent rating is warranted for instability of the left knee for the entire appeal period prior to December 23, 2020. Higher ratings are not warranted for these impairments at any time during the appeal period and a higher rating is also not warranted for left knee limitation of flexion. Regarding the right knee, a separate rating for instability/recurrent subluxation is not warranted prior to December 23, 2020; a higher rating is not warranted for limitation of flexion and there is no basis for assigning a separate rating based on right knee meniscal impairment as such impairment is neither been shown nor alleged. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dan Brook, 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.