Citation Nr: 21040425 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 18-10 414 DATE: July 3, 2021 ORDER 1. A compensable disability rating for status-post methicillin-resistant staphylococcus aureus (MRSA) infection prior to October 9, 2019 is denied. 2. A disability rating greater than 10 percent for a left knee strain with osteoarthritis is denied. 3. A disability rating greater than 10 percent for a right knee strain with osteoarthritis before March 21, 2019, and after June 1, 2019 (status-post arthroscopy surgery), is denied. FINDINGS OF FACT 1. Prior to October 9, 2019, the Veteran's status-post MRSA infection was manifested by exposed areas and total areas of less than 5 percent, without the use of intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the previous 12-month period. 2. The Veteran's left knee strain with osteoarthritis has not been manifested by limitation of flexion to less than 60 degrees or limitation of extension greater than 5 degrees. 3. Prior to March 21, 2019, the Veteran's right knee strain with osteoarthritis was not manifested by limitation of flexion to less than 60 degrees or limitation of extension greater than 5 degrees. 4. Since June 1, 2019, the Veteran's right knee strain with osteoarthritis status-post arthroscopy surgery has not been manifested by limitation of flexion to less than 60 degrees or limitation of extension greater than 5 degrees. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for status-post MRSA infection prior to October 9, 2019 have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.118, Diagnostic Code 7820. 2. The criteria for a disability rating greater than 10 percent for a left knee strain with osteoarthritis have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5003-5260. 3. The criteria for a disability rating greater than 10 percent prior to March 21, 2019 for right knee strain with osteoarthritis have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5003-5260. 4. The criteria for a disability rating greater than 10 percent since June 1, 2019 for right knee strain with osteoarthritis post-arthroscopy surgery have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.3, .7, 4.59, 4.71a, Diagnostic Codes 5003-5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from November 2000 to February 2005. He testified before the undersigned Veteran's Law Judge in October 2019 in support of his claims. Thereafter, his appeal was remanded by the Board for additional development in December 2019. The Veteran currently has a combined disability rating of 100 percent, with a grant of special monthly compensation pursuant to 38 U.S.C. § 1114, subsection (s) and 38 C.F.R. § 3.350 (i). Procedurally, in an August 2016 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for bilateral knee strains, residuals of an MRSA infection, and bilateral pes planus. All four disabilities were assigned noncompensable disability ratings with effective dates of March 31, 2016. In a July 2018 rating decision, the AOJ re-evaluated the Veteran's pes planus disability and increased the disability rating to 10 percent with the same assigned effective date. The AOJ based its decisions, in large part, on VA examination reports dated in July 2016. Thereafter, the Veteran underwent right knee arthroscopy surgery. He was granted a temporary total evaluation effective March 22, 2019 to May 31, 2019 based upon surgical treatment necessitating convalescence. Beginning June 1, 2019, his right knee disability was assigned a noncompensable rating. During his October 2019 BVA hearing, the Veteran asserted that his disabilities were more severe than rated. He testified about constant knee pain and stated that his skin condition as a residual of MRSA infection had worsened and spread to other areas of his body. He requested that he be scheduled for additional medical examinations. The Board remanded the Veteran's appeal for updated medical examinations in December 2019. In an August 2020 rating decision, the AOJ increased the Veteran's disability ratings for all four of his service-connected disabilities. The Veteran's bilateral pes planus disability was increased from 10 percent to 50 percent effective from the date of claim (March 31, 2016). His status-post MRSA disability rating was increased to 60 percent effective October 19, 2019. His left knee strain and right knee strain disabilities were increased to 10 percent effective also from the date of claim (March 31, 2016). In terms of the Veteran's right knee, he was granted a 100 percent convalescence disability rating for right knee surgery from March 22, 2019 to May 31, 2019. After the end of convalescence, the Veteran's right knee disability was reassigned a 10 percent disability rating effective June 1, 2019. Momentarily turning to the Veteran's claim of entitlement to an increased rating for bilateral pes planus, the Board observes that in the August 2020 rating decision mentioned above, the AOJ stated that as a 50 percent disability rating is the highest schedular evaluation allowed under the law for acquired flat foot (rated analogous to pes planus in this instance), the rating decision provided a full and final resolution to this issue and that "[n]o further or additional action is required." In the same decision, the AOJ noted that a 60 percent rating for status-post MRSA infection is the maximum level of entitlement offered by the rating schedule. As such, the rating decision states that "[f]or the period beginning October 10, 2019, this grant of benefits represents a full and final resolution to this issue since you were provided the maximum level of entitlement offered by the rating schedule. No further action is required related to this issue for the period since October 10, 2019." To date, the Veteran has not expressed disagreement with those ratings assigned. Therefore, the remaining issues on appeal are noted on the title page of this decision. See AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claim remains in controversy where less than the maximum available benefit has been awarded). Increased Ratings Disability evaluations are 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. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each service-connected disability is rated based on specific criteria identified by Diagnostic Codes (DC). 38 C.F.R. § 4.27. These DCs designate percentage ratings based on the average functional impairment of the veteran due to a service-connected disability. 38 C.F.R. §§ 3.321, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. a). Skin Disability Regulations When the Veteran was service connected for status-post MSRA infection in August 2016, his disability was evaluated in the Rating Schedule pursuant to hyphenated DCs 7820-7806. Hyphenated DCs are used when a rating under one DC 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. Since August 2020, the Veteran's MSRA disability has been rated pursuant to DC 7820 alone. The change from DCs 7820-7806 to 7820 is the result of an amendment to the rating criteria for skin disabilities that was made during the pendency of this appeal, effective from August 13, 2018. The new regulations apply to all applications for benefits received by VA or that were pending before the AOJ on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, for the period prior to August 13, 2018 in this appeal, the Board will apply the pre-amendment criteria of DC 7280-7806; and after August 13, 2018, both the prior version and the amended version of DC 7280 will be considered. Prior to August 2018, DC 7820 provides that disabilities are to be rated as disfigurement of the head, face, or neck under DC 7800, as scars under DCs 7801-7805, or as dermatitis under DC 7806, depending on the predominant disability. 38 C.F.R. § 4.118, DC 7820. As the medical evidence does not reflect that the Veteran's disability involves scarring, or disfigurement of the head, face, or neck, it will be rated as dermatitis under DC 7806 under the former rating criteria. Prior to August 13, 2018, DC 7806 provides: a 10 percent rating where dermatitis affects at least five percent but less than 20 percent of the entire body or least five percent but less than 20 percent of exposed areas, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The next higher rating, 30 percent, is warranted with involvement of 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. The highest disability rating, 60 percent, is warranted with involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118, DC 7806 (emphasis added). Of note, the Board observes that "corticosteroids or other immunosuppressive drugs" refers to any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder. For claims filed prior to August 13, 2018, the United States Court of Appeals for Veterans Claims held that compensation is available for all systemic therapies that are "like or similar to corticosteroids or other immunosuppressive drugs." Warren v. McDonald, 28 Vet. App. 194, 197-99 (2016). A topical corticosteroid could be administered on a large enough scale to affect the body as a whole, thus meeting the definition of "systemic therapy." Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). A systemic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie,30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Pursuant to the amended rating criteria effective August 13, 2018, DC 7820 (alone) provides that disabilities evaluated under that DC are to be rated under a "General Rating Formula for the Skin." 38 C.F.R. § 4.118. Under the General Rating Formula for the Skin: a 10 percent disability rating will be assigned if the disability meets one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating will be assigned if the disability meets one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks or more, but not constantly, over the past 12-month period. The highest disability rating available, 60 percent, will be assigned if the disability meets one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118, General Rating Formula for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824 (emphasis added). b). Status-Post MRSA Infection As mentioned previously, the Veteran currently has a disability rating of 60 percent for his service-connected status-post MRSA infection disability that became effective on October 9, 2019. The issue in this appeal is whether he is entitled to a compensable disability rating for his service-connected status-post MRSA infection prior to October 9, 2019 under either the former or revised rating criteria. 1). Diagnostic Code 7806 (former diagnostic criteria) The Veteran's MRSA disability can be evaluated in two ways. It can be rated: (1) under the former rating criteria of DC 7806 from March 31, 2016 to the present; or (2) under the former rating criteria of DC 7806 from March 31, 2016 to August 13, 2018, and the revised rating criteria thereafter. As set forth above, in order to be assigned a 10 percent disability rating pursuant to DC 7806, the evidence would need to show that the Veteran previously suffered from a dermatitis that affected at least five percent, but less than 20 percent, of his entire body or at least five percent, but less than 20 percent, of exposed areas. Alternatively, the evidence would need to show that he was required to use intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or less during a 12-month period. Unfortunately, the claims file contains scant evidence upon which to rate the Veteran's MRSA disability prior to August 2020, when his disability evaluation was increased to 60 percent. However, the available evidence clearly shows that the Veteran is not entitled to a compensable disability rating for his status-post MSRA infection prior to October 9, 2019. In this regard, a July 2016 examination report reveals that the Veteran was evaluated by a medical doctor and was diagnosed with MRSA and superficial acne. The Veteran reported to the doctor that he had recurrent pimple-like lesions throughout his body and face that required treatment with a topical medication during the previous 12 months. The topical medication was reported as being a "special soap" specifically for his acne that he reported using on a constant or near-constant basis. The doctor examining the Veteran left blank/did not mark sections of the report indicating that the Veteran used systemic corticosteroids or other immunosuppressive medications, topical corticosteroids, antihistamines, immunosuppressive retinoids, sympathomimetics, or oral medications for his MRSA. The Veteran did not report having any debilitating or non-debilitating episodes related to his MRSA disability. No scarring was reported. The measurement of the Veteran's exposed areas and total areas of the face, hands and neck related to his status-post MSRA infection and superficial acne were noted as less than 5 percent, as he was found to be asymptomatic at the time of examination. Thus, according to the June 2016 examination report, the Veteran's MRSA infection did not affect at least five percent of his entire body or at least five percent of his exposed areas. In terms of the remaining criteria of DC 7806, the use of intermittent systemic therapy required for a total duration of less than six weeks, the only "topical medication" used by the Veteran during this time was "special soap" related to his superficial acne. The record does not reflect that the Veteran's topical soap was prescribed by a medical professional; nor does it indicate whether the soap was used exclusively on the face or on both the face and body. Even if one assumes that the Veteran used the topical soap on his entire body and it constituted systemic therapy, an increased rating would still not be warranted pursuant to DC 7806 since there is no evidence of the soap treating the affected skin "like or similar to corticosteroids or other immunosuppressive drugs." The Veteran's October 2019 BVA hearing testimony and available post-service medical records support the Board's findings. Regarding his testimony, the Veteran only stated that his skin condition had worsened over time, without further indication of what that entailed, and his willingness to attend a new VA skin examination. Medical records in the claims file dated from July 2016 to March 2021 reveal that the Veteran was seen on January 2020 for complaints of a skin rash of greater than three months duration. At that time, a physical examination revealed a diffuse pruritic rash. The Veteran was diagnosed with eczema and acne. It was at this time that he was prescribed Triamcinolone Acetonide ointment for his eczema and Benzoyl Peroxide for his acne. The Board found no references in the record of the Veteran being prescribed these medications, or any other steroidal medications, prior to January 2020. The bulk of the remaining medical records reveal that the Veteran was noted as having skin rashes while being seen in the context of other medical treatment; however, the documents do not identify the Veteran as having a MRSA infection (and not a generic skin infection from unknown causes) or indicate that he was provided any medical care in relation to his rashes. In response to his Board hearing testimony, the Veteran was afforded a second VA examination related specifically to the skin in August 2020. It should be noted that this examination report was the basis upon which the Veteran's service-connected disability rating was increased from noncompensable to 60 percent. At the time of the exam, the Veteran reported severe MRSA symptoms that included having boils all over the body, to include his feet, rashes over the body and the face with boils and pimples that turned into sores, and scars due to itching and scratching. He reported that his treatment was Triamcinolone Acetonide ointment for the body and Benzoyl Peroxide for the face. The medical examiner evaluating the Veteran diagnosed him with status-post MRSA (not acne) that was symptomatic; identified his treatment as including corticosteroids or other immunosuppressive medications on a constant/near-constant basis of use; and reported that there was more than 5 percent, but less than 20 percent, of the entire body and exposed surfaces of the skin affected. The Board agrees with the increased rating of 60 percent granted to the Veteran effective October 9, 2019, but it concludes that there is insufficient evidence of the Veteran having an outbreak of a MRSA infection meeting the requirements of a compensable disability rating during the initial period on appeal. All the higher ratings of 10 percent, 30 percent, and 60 percent require that lesions are present on at least 5, 20, or 40 percent of the body, or likewise for the affected area, in order to receive those respective ratings. 38 C.F.R. § 4.118, DC 7280. Otherwise, for a compensable disability rating, there must be intermittent, systemic, or near-constant systemic therapy to keep the lesions at-bay. Id. As the evidence of record prior to October 9, 2019 reveals only that the Veteran's skin condition had lesions that were (1) less than 5 percent of the entire body affected, (2) less than 5 percent of the exposed areas affected, and (3) required no more than topical therapy required during the past 12-month period, a compensable disability rating for status-post MRSA infection is not warranted. 2). Diagnostic Code 7820 (revised diagnostic criteria) Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118 (a). As set forth above, the only evidence upon which to evaluate the Veteran's increased ratings claim between August 31, 2018 and October 9, 2019 consists of the June 2016 VA examination report, the Veteran's Board hearing testimony, and post-service medical records dated from July 2016 to March 2021. Although this evidence reveals that the Veteran suffered from skin rashes in some form in 2018 and 2019, the Veteran appears not to have been seen for treatment of a skin rash until January 2020. It was at this time that he was prescribed steroidal medication. Prior to that date, it appears that the Veteran treated his rashes with the topical soap referenced above that does not appear to have been prescribed by a medical provider. Because the evidence of record dated between August 13, 2018 and October 9, 2019 reveals only that the Veteran's skin condition prior to August 2020 had lesions that were (1) less than 5 percent of the entire body affected, (2) less than 5 percent of the exposed areas affected, and (3) required not more than topical therapy required during the past 12-month period, a compensable disability rating for status-post MRSA infection prior to October 9, 2019 under the revised rating criteria is not warranted. In closing, the Board notes that it has also considered rating the Veteran under another diagnostic code via both the former and revised rating criteria. However, as there are no signs or symptoms of previous MRSA-caused lesions, and no evidence of another skin irritant, rating under another code is not necessary since the current DC is most applicable, and because no other code would afford the Veteran a higher rating. Therefore, the appeal must be denied. c). Musculoskeletal Disability Regulations In terms of musculoskeletal disabilities, the Board notes that disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The factors involved in evaluating and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. In DeLuca v. Brown, 8 Vet. App. 202, 205 (1995), the Court held that, for disabilities evaluated based on limitation of motion, VA was required to apply the provisions of 38 C.F.R. §§ 4.40 and 4.45 pertaining to functional impairment. The Court instructed that in applying these regulations, VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, or incoordination. Such inquiry was not to be limited to muscles or nerves. These determinations were, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, or incoordination. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Additionally, flare-ups must be factored into an examiner's assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. As with VA's regulations related to skin disabilities, revisions were recently made to certain regulations governing ratings for musculoskeletal disabilities, effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020). As mentioned above, VA must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). However, after doing so, the Board has determined that the none of the new regulations pertaining to service-connected knee disabilities are applicable to the Veteran's increased ratings claims. Specifically, the regulations regarding limitation of the motion of the knees (DC 5260 and 5261) did not change when the musculoskeletal provisions of the Code of Federal Regulations were modified. Therefore, the changes in the rating criteria are insignificant to the Veteran's knee claims. d). Left Knee Disability For the record, full range of knee motion is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71a, Code 5003 and Plate II. Since March 31, 2016, the Veteran's left knee disability has been found to be 10 percent disabling. The question for the Board is whether the Veteran should be assigned a disability rating greater than 10 percent. The Veteran's bilateral knee disabilities have been rated pursuant to DCs 5003-5260. Among other rating criteria, VA's rating schedule includes eight DCs applicable to evaluating knee and leg disabilities, six DCs for rating disabilities involving prosthetic implants and several DCs related to amputations of the lower extremity. See, 38 C.F.R. § 4.71a, DCs 5256 to 5263, 5051 to 5056, and 5160 to 5173. Under DC 5260, limitation of flexion of the knee warrants a 20 percent rating if flexion is limited to 30 degrees. Under DC 5261, limitation of extension of the knee warrants a 20 percent rating if flexion is limited to 15 degrees. Where the Veteran has a compensable rating for limitation of motion in both knee flexion and extension, separate ratings may be assigned. See VAOPGCPREC09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). In this case, the Veteran has been assigned a 10 percent disability rating based upon painful motion of the left knee. It appears that the Veteran's 10 percent disability rating was assigned based upon 38 C.F.R. § 4.59, which allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint - in this instance, 10 percent. Additional evidence considered by the AOJ is that the Veteran has been diagnosed as having arthritis. To be assigned a higher disability rating of 20 percent, the evidence must show (1) x-ray evidence of degenerative arthritis involving two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations; (2) limitation of knee flexion of 16 to 30 degrees; or (3) limitation of knee extension of 16 to 20 degrees. The Veteran has been afforded several VA examinations during the pendency of this appeal pertinent to his bilateral knees. Specifically, a July 2016 knee examination report assessed the Veteran as having a bilateral knee strain. His bilateral knee range of motion was recorded as being 140 degrees flexion and 0 degrees extension. The left knee did present evidence of pain with weight bearing and crepitus. Observed repeated use, repeated use over time, and flare ups were identified. Muscle strength was bilaterally 5/5 with flexion and extension. There was no evidence of muscle atrophy, no ankylosis, no joint instability, and no recurrent patellar dislocation. Meniscal abnormality was reported for bilateral association with frequent episodes of joint pain without joint effusion or locking. The Veteran described having flare-ups symptoms that included increased pain in the knees with physical activity and with extended activities. He also described functional loss in terms of difficulty with squatting, walking up stairs and lifting heavy weights. The Veteran was afforded a second VA examination related to his bilateral knees in May 2019, after his right knee arthroscopy. The VA examiner specifically diagnosed the Veteran with right knee strain status-post arthroscopic surgery, with an implicit diagnosis of left knee strain. Range of motion was not measured but reported as consisting of severe pain in both flexion and extension consistent with a left knee strain. The examiner noted the Veteran's symptoms as consisting of constant pain with intermittent edema caused by prolonged walking or driving and increase aching pain with physical activity, difficulty with squatting, walking up stairs, and lifting heavy items. Lastly, the Veteran was seen for a VA examination in January 2020. He was diagnosed at that time with bilateral knee osteoarthritis and right knee grade 4 trochlear chondromalacia, status-post arthroscopy. During the examination, the Veteran denied periods of flare-ups, reporting his symptoms as being constant and consistent. His initial left knee range of motion was reported as 110 degrees flexion and 0 degrees extension, with pain on flexion, no evidence of pain with weight bearing, no localized tenderness or pain with palpation, and positive crepitus. No changes were found with repeated use or motion. Muscle strength was 5/5 bilaterally, without evidence of atrophy. There was no ankylosis, no recurrent subluxation, no instability or recurrent effusion in either knee. No semilunar cartilage or meniscus issue were detected. Viewing the evidence as a whole, the Board finds that an evaluation greater than 10 percent for the Veteran's right knee disability is not warranted. The evidence reveals no limitation of extension, such that a rating pursuant to DC 5261 is not available. Although there is evidence of limitation of left knee flexion, it is not less than 60 degrees. As such, a noncompensable disability rating would be assigned if the Veteran's symptomatology were rated exclusively under DC 5260. As to functional equivalence, the Board notes that there is evidence of pain of the left knee; however, the Board finds that these manifestations taken together are not the functional equivalent of a 20 percent rating under the rating criteria, as such symptoms can be accurately described as the painful motion warranting a 10 percent right for the left knee. See 38 C.F.R. § 4.59. Alternative or higher ratings are available for ankylosis, dislocation or removal of the semilunar cartilage, moderate or severe recurrent subluxation or lateral instability, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. However, the Board's review of the claims file has failed to reveal any lay or medical evidence in the record of such manifestations. The applicable post-service medical records in the claims file (dated from 2016 to 2021) do not reference any evidence of ankylosis, moderate or severe recurrent subluxation or lateral instability, dislocation of the semilunar cartilage, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, after considering the evidence, the Board finds that the Veteran's 10 percent rating under DC's 5003-5260 for painful noncompensable limitation of motion and arthritis is appropriate. Accordingly, the appeal is denied. e). Right Knee Disability Since March 31, 2016, the Veteran's right knee disability has been rated as 10 percent disabling other than the period from March 22, 2019 to May 31, 2019 during which he was assigned a 100 percent convalescence rating due to his right knee arthroscopy surgery 1). Prior to March 21, 2019 (pre-arthroscopy surgery) There is limited evidence upon which to evaluate the Veteran's right knee prior to his 2019 arthroscopy surgery. As set forth above, the Veteran's July 2016 knee examination report assessed the Veteran as having bilateral knee strain. His bilateral knee range of motion was recorded as being 140 degrees flexion and 0 degrees extension at that time, localized mild medial joint line tenderness or pain with palpation. Observed repeated use, repeated use over time and flare ups were identified, without evidence of change. Muscle strength was bilaterally 5/5 with flexion and extension. There was no muscle atrophy, no ankylosis, no joint instability, and no recurrent patellar dislocation. Meniscal abnormality was reported for bilateral association with frequent episodes of joint pain, but without joint effusion or locking. The Veteran reported symptoms that included pain with extended activities. VA medical records document the Veteran as having right knee range of motion from at least 110 degrees of flexion. Specifically, according to a January 2018 medical record, the Veteran had bilateral knee flexion of 126 degrees to 0 degrees of extension. Records dated in July 2018 and November 2018 reflect range of motion measurements from 110 degrees flexion to 0 degrees extension. Lastly, a March 2019 VA medical record documents the Veteran's active range of motion of the right knee prior to his arthroscopy as 120 degrees flexion and 0 degrees of extension, with pain at extreme of flexion. 2). Since June 1, 2019 (post-arthroscopy surgery) Unfortunately, the Veteran's May 2019 VA examination report does not reflect an actual right knee range of motion. However, the Veteran was diagnosed with right knee strain status-post arthroscopic surgery, and his range of motion was described as involving severe pain in both flexion and extension consistent with his disorder. The VA examiner reported that the Veteran's symptoms consisted of constant pain with intermittent edema caused by prolonged walking or driving and increased aching pain with physical activity, difficulty squatting, walking up stairs and lifting heavy items. According to the January 2020 VA examination report, the Veteran suffered from right knee osteoarthritis and right knee grade 4 trochlear chondromalacia, status-post arthroscopy. Initial range of motion was reported for flexion 120 degrees with 0 degrees extension, with pain on flexion. There was no evidence of pain with weight bearing, no localized tenderness or pain with palpation but the right knee was positive for crepitus. During the examination, the Veteran denied periods of flare-ups as he reported his symptoms were constant and consistent. Muscle strength was 5/5 bilaterally without evidence of atrophy. There was no ankylosis, no recurrent subluxation, no instability or recurrent effusion in either knee. No semilunar cartilage or meniscus issues were detected. Post-service medical records dated in January 2021 reflect the Veteran's reports of starting to go to the gym to exercise more and to lose weight. As with the Veteran's service-connected left knee, the Board finds that an evaluation greater than 10 percent for the Veteran's right knee disability both prior-to March 21, 2019 and subsequent-to June 1, 2019 is not warranted. The evidence reveals no limitation of extension of the right knee, such that a rating pursuant to DC 5261 is not available. Although there is evidence of limitation of right knee flexion, it is not less than 60 degrees. As to functional equivalence, the Board notes that there is evidence of pain of the right knee; however, the Board again finds that these manifestations taken together are not the functional equivalent of a 20 percent rating under the rating criteria, as such symptoms can be accurately described as the painful motion warranting a 10 percent right for the right knee. See 38 C.F.R. § § 4.59. Alternative or higher ratings are available for ankylosis, dislocation or removal of the semilunar cartilage, moderate or severe recurrent subluxation or lateral instability, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. However, the Board's review of the claims file has failed to reveal any lay or medical evidence in the record of such manifestations. The applicable post-service medical records in the claims file (dated from 2016 to 2021) do not reference any evidence of ankylosis, moderate or severe recurrent subluxation or lateral instability, dislocation of the semilunar cartilage, malunion or nonunion of the tibia and fibula, or genu recurvatum. Thus, after considering the evidence, the Board finds that the Veteran's 10 percent rating under DC's 5003-5260 for painful noncompensable limitation of motion of the right knee is appropriate. Accordingly, the appeal for an increased rating for the right knee is denied. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Talpins 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.