Citation Nr: 21040496 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 16-58 377 DATE: July 3, 2021 ORDER Entitlement to an increased 40 percent rating, but not higher, for lumbosacral spine degenerative joint disease (lumbar spine disability) is granted from October 18, 2019, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an initial compensable rating for right thigh limitation of flexion is denied. Entitlement to an initial compensable rating for left thigh limitation of flexion is denied. Entitlement to an initial compensable rating for right thigh impairment is denied. Entitlement to an initial 20 percent rating for left thigh impairment is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an increased rating higher than 10 percent for right hip degenerative joint disease (right hip disability), is denied. Entitlement to an increased rating higher than 20 percent for left femur fracture residuals (left femur disability) is denied. Entitlement to an increased rating higher than 10 percent for right knee degenerative joint disease (right knee disability) is denied. Entitlement to an initial rating higher than 10 percent for left knee limitation of flexion for the period from October 13, 2014, to December 1, 2016, is denied. Entitlement to an increased 60 percent rating for left knee total joint replacement (left knee disability) from February 1, 2018, is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to a separate 20 percent rating for left knee meniscal tear for the period from October 13, 2014, to December 1, 2016, is granted, subject to the laws and regulations controlling the award of monetary benefits. FINDINGS OF FACT 1. From October 18, 2019, the Veteran's lumbar spine disability symptomatology more nearly approximates flexion to 30 degrees or less, but does not more nearly approximate unfavorable ankylosis of the thoracolumbar spine or the entire spine. 2. The Veteran's right thigh limitation of flexion has not at any time more nearly approximated flexion limited to 45 degrees. 3. The Veteran's left thigh limitation of flexion has not at any time more nearly approximated flexion limited to 45 degrees. 4. The Veteran's right thigh impairment symptomatology does not more nearly approximate inability to cross the legs or external rotation limited to 15 degrees. 5. The evidence is at least evenly balanced as to whether the Veteran's left thigh impairment symptomatology more nearly approximates adduction limited to 10 degrees. 6. The Veteran is in receipt of the maximum schedular rating for right hip extension, and there is no indication that he has symptomatology outside that listed in the rating criteria for right hip extension. 7. The Veteran is in receipt of the maximum schedular rating for left hip extension, and there is no indication that he has symptomatology outside that listed in the rating criteria for left hip extension. 8. The Veteran's right knee disability symptomatology does not more nearly approximate flexion limited to 30 degrees. 9. For the period from October 13, 2014, to December 1, 2016, the Veteran's left knee limitation of flexion did not more nearly approximate flexion limited to 30 degrees. 10. The evidence is at least evenly balanced as to whether the Veteran's left knee disability symptomatology more nearly approximates chronic residuals consisting of severe painful motion or weakness for the period from February 1, 2018. 11. For the period from October 13, 2014, to December 1, 2016, the Veteran's left knee meniscal tear more nearly approximated dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating of 40 percent, but not higher, for lumbar spine disability have been met from October 18, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.71, Diagnostic Code (DC) 5242. 2. The criteria for an initial compensable rating for right thigh limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.71a, DC 5252. 3. The criteria for an initial compensable rating for left thigh limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.71a, DC 5252. 4. The criteria for an initial compensable rating for right thigh impairment have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.71a, DC 5253. 5. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial 20 percent rating for left thigh impairment have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.71a, DC 5253. 6. The criteria for an increased rating higher than 10 percent for right hip disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.71a, DC 5251. 7. The criteria for an increased rating higher than 20 percent for left femur disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.20, 4.27, 4.71a, DC 5251. 8. The criteria for an increased rating higher than 10 percent for the Veteran's right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 9. From October 13, 2014, to December 1, 2016, the criteria for an initial rating higher than 10 percent for the Veteran's left knee limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 10. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to an increased rating of 60 percent for left knee disability for the period from February 1, 2018, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5055. 11. For the period from October 13, 2014, to December 1, 2016, the criteria for a separate 20 percent rating for left knee meniscal tear have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1971 to July 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, granted service connection for left thigh impairment, evaluating it as 10 percent disabling, right thigh impairment, left and right thigh limitation of flexion, evaluating each as noncompensable, continued a 10 percent evaluation for lumbar spine disability, left hip limitation of flexion, and left and right knee degenerative joint disease, and continued a 20 percent evaluation for left femur fracture. In February 2016, the Veteran filed his notice of disagreement with the ratings assigned, was issued a statement of the case in November 2016, and in December 2016 perfected his appeal to the Board. In an April 2017 rating decision, the RO, among other things, increased the rating for left total knee joint replacement, to 100 percent effective December 2, 2016, and 30 percent from February 1, 2018. In a November 2018 decision, the Board remanded the Veteran's claims for consideration of additional relevant evidence by the agency of original jurisdiction (AOJ). In a June 2020 rating decision, the RO, among one other thing, granted a rating increase of 20 percent for lumbar spine disability, effective October 18, 2019, creating a staged rating. For the reasons indicated in the discussion below, the remand directives that the Board instructed of the AOJ were in fact satisfied. Thus, the AOJ complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. 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 nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45, but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination, or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. When evaluating a disability under VA's General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), the criteria for a rating based on ankylosis may be met by evidence demonstrating the functional equivalent of ankylosis, i.e., functional loss consistent with that contemplated by ankylosis. See Chavis v. McDonough, _Vet. App. _, No. 18-2928 (Apr. 16, 2021). 1. Lumbar Spine Disability The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred if application is received within one year from such date. See 38 U.S.C. § 5110(b)(3). The effective date statute and its implementing regulations require that the evidence demonstrate that at least some portion of the increase in disability occurred within the one-year period prior to the date of the claimant's claim for increase to receive the benefit of an earlier effective date. See Gaston v. Shinseki, 605 F.3d 979, 984 (Fed.Cir.2010) (stating that section 5110(b)(2), now section 5110(b)(3), requires that "an increase in a veteran's service connected disability must have occurred during the one year prior to the date of the veteran's claim... to receive the benefit of an earlier effective date"). The Veteran's lumbar spine disability currently has a staged rating, with a 10 percent rating from April 24, 2012, and a 20 percent rating from October 18, 2019, under DC 5242, with the appeal period from October 13, 2014, the date of claim for a rating increase. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this diagnostic code was not changed. Disabilities of the spine are rated under the General Rating Formula for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Rating Formula). Under the General Rating Formula for Diseases and Injuries of the Spine applied by DC 5242, the disability is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. A 20 percent rating requires thoracolumbar spine forward flexion greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the thoracolumbar spine warrants a 50 percent evaluation, and unfavorable ankylosis of the entire spine is rated 100 percent disabling. 38 C.F.R. § 4.71a. The IVDS Rating Formula provides a 20 percent rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, normal extension is zero to 30 degrees, normal left and right lateral flexion is zero to 30 degrees, and normal left and right lateral rotation is zero to 30 degrees. 38 C.F.R. § 4.71a, DC 5237, Note 2. Further, all measured ranges of motion should be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, general rating formula, Note 4. Ankylosis is a condition in which an entire spinal segment is immobile and fixed in position. Unfavorable ankylosis exists where the fixation is in flexion or extension, and the ankylosis results in difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; and/or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) is considered favorable ankylosis. 38 C.F.R. § 4.71a, general rating formula, Note 5. In a January 2015 VA examination report, the examiner noted that the Veteran did not report flare-ups of the thoracolumbar spine, but the Veteran did report back pain with lifting, or prolonged standing or walking. Flexion was to 80 degrees, and extension, right and left lateral flexion and rotation were each to 15 degrees with diminished flexibility and pain on each range of motion. There was evidence of pain with weight bearing, but no localized tenderness or pain on palpation of joints and/or soft tissue of the thoracolumbar spine. There was no additional loss of function or range of motion with repetitive use testing. There was no guarding or muscle spasm of the thoracolumbar spine, muscle strength was normal, and the Veteran did not have muscle atrophy. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy, and there was no ankylosis of the spine. The examiner reported that the Veteran did not have IVDS, the Veteran reported regular use of the cane, and the examiner noted that the Veteran's thoracolumbar spine disability impacted his ability to work as the Veteran is unable to do work that involves heavy lifting or prolonged standing. An October 2019 disability benefits questionnaire (DBQ) indicated that the Veteran reported flare-ups of his lumbar spine disability, stating that he suffers from sharp pain in the lower back if he is bent over, or getting out of the car. He stated that he cannot run, jump, play sports, or do any prolonged standing, sitting, or walking. Flexion was to 70 degrees, extension to 10 degrees, right and left lateral flexion both to 25 degrees, and right and left lateral rotation both to 30 degrees. Pain was noted with each range of motion, and there was evidence of pain with weight bearing, but there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. No additional loss of function or range of motion was noted after 3 repetitions, the examiner noted that the examination was not conducted during a flare-up, but she indicated that pain significantly limited functional ability with flare-ups. The examiner described the additional loss during a flare-up in terms of range of motion with flexion to 35 degrees, extension to 5 degrees, right and left lateral flexion to 10 degrees, and right and left lateral rotation to 15 degrees. The Veteran did not report guarding or muscle spasm of the thoracolumbar spine, but reported disturbance of locomotion, interference with sitting and standing, and less movement than normal due to ankylosis, limitation or blocking, adhesions, etc. Muscle strength was normal, the Veteran did not have muscle atrophy, radicular pain or other signs or symptoms due to radiculopathy, ankylosis, or IVDS. There was no objective evidence of pain on non-weight bearing, and passive range of motion was the same as with active range of motion. The Board finds that the evidence is at least evenly balanced that the Veteran's low back disability symptomatology more nearly approximates that contemplated by a 40 percent rating under the general rating formula. While the October 2019 examiner described additional loss during a flare-up as limited to 35 degrees forward flexion, and 5 degrees extension, the DBQ was not administered during a flare-up. Therefore, it is reasonable to conclude, considering the examiner's description of additional loss during a flare-up, and the Veteran's competent and credible reports of being unable to do any heavy lifting or prolonged standing, sitting, or walking due to his lumbar spine disability, that his lumbar spine range of motion is more severely limited during a flare-up than is evidenced by the DBQ. The October 2019 examiner also indicated that the Veteran experienced pain with weight bearing, and the Veteran reported sharp pain when bent over or getting out of a car. Considering these contentions in light of the evidence of record and the applicable law, the orthopedic manifestations of the Veteran's low back disability are best evaluated as 40 percent disabling from October 18, 2019, the earliest date as of which it is ascertainable that an increase in disability occurred. However, a rating greater than 40 percent is not warranted for any period on appeal. While the Veteran's range of motion of the thoracolumbar spine is limited, the VA examination report and DBQ indicate that the Veteran has motion in all relevant directions, and his thoracolumbar spine is not fixed in flexion or extension. The examiners also reported that the Veteran did not have signs or symptoms due to ankylosis. The Veteran's lumbar spine disability thus does not more nearly approximate unfavorable ankylosis, therefore, a rating higher than 40 percent is not warranted. Additionally, the previously discussed examination report and DBQ indicate that the Veteran does not suffer from IVDS or incapacitating episodes, thus a higher rating under the Formula for Rating IVDS is not warranted. For the foregoing reasons, a rating of 40 percent, but no higher, is warranted for the Veteran's lumbar spine disability from October 18, 2019, the earliest date from which it is ascertainable that an increase in disability occurred. 2. Hip, Femur, and Thigh Disabilities The Veteran's left and right thigh limitation of flexion are each rated noncompensable under DC 5003-5252, his left thigh impairment is rated 10 percent disabling, and his right thigh impairment is rated noncompensable, both under DC 5003-5253, his left femur disability is rated 20 percent disabling, and his right hip degenerative joint disease is rated 10 percent disabling, both under DC 5003-5251. Hyphenated DCs are used when a rating under one code requires use of an additional DC to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, these diagnostic codes were not changed. Under DC 5251, a 10 percent rating is the maximum rating assignable for limitation of extension to 5 degrees. DC 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is for flexion of the thigh that is limited to 10 degrees. 38 C.F.R. § 4.71a. Under DC 5253, impairment of the thigh, the criteria for a 10 percent rating is the inability to cross the legs or external rotation limited to 15 degrees. The criterion for the next higher rating, 20 percent, is adduction limited to 10 degrees. Normal range of motion of the hip is from 0 to 125 degrees of flexion and 0 to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II. An August 2012 VA examination report indicates that the Veteran has a history of left tibia osteomyelitis. The Veteran reported using a cane for ambulation, the condition did not affect motion of a joint, and there were no flare-ups of bone or joint disease. A January 2015 VA examination report indicates that the Veteran did not experience flare-ups of his bilateral degenerative joint disease of the hips, but the Veteran reported pain with walking and prolonged standing. Left hip flexion was to 60 degrees, extension to 5 degrees, abduction to 25 degrees, adduction to 10 degrees, external rotation to 30 degrees, and internal rotation to 20 degrees. The Veteran reported diminished flexibility, but adduction was not limited such that the Veteran could not cross his legs. Pain was noted with each range of motion which caused functional loss, and there was evidence of pain with weight bearing. Right hip flexion was to 80 degrees, extension to 5 degrees, abduction to 30 degrees, adduction to 15 degrees, external rotation to 30 degrees, and internal rotation to 20 degrees. The examiner noted that each range of motion contributed to diminished flexibility, and pain was noted on examination which caused functional loss. There was evidence of pain with weight bearing, but no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The examination report indicated that there was no additional loss of function or range of motion with repetitive use testing in either the left or right hip, muscle strength was normal, there was no muscle atrophy, and no ankylosis was noted in either hip. The examiner noted that the Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy, and the Veteran reported regular use of a cane. The examiner indicated that the Veteran's hip disabilities impacted the Veteran's ability to work as he would be unable to do work that involves prolonged standing or walking. An October 2019 DBQ reflected that the Veteran reported that his bilateral hip pain has remained the same since onset, but indicated that he suffers from flare-ups, stating that the throbbing and pain is worse on the left hip if he uses it too much. Right hip flexion was to 105 degrees, extension to 20 degrees, abduction, and adduction to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees. The examiner noted that adduction was not limited such that the Veteran could not cross his legs, but the Veteran was unable to do deep squats or lunges. Pain was noted on each range of motion, there was evidence of pain with weight bearing, but no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or objective evidence of crepitus. Left hip flexion was to 105 degrees, extension to 10 degrees, abduction, and adduction each to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees. Adduction was not limited such that the Veteran could not cross his legs, but range of motion contributed to a functional loss, as he could not perform deep squats or lunges. Pain was noted with each range of motion, there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, no objective evidence of crepitus, but there was evidence of pain with weight bearing. There was no additional functional loss or loss of range of motion, only predicted increased symptoms of pain with repetitive use. The examination was not conducted during a flare up, but the examiner indicated that both right and left hip pain significantly limited functional ability with flare-ups, but stated no further range of motion loss was anticipated during flare-ups, thus no estimate is warranted. The examination report indicated that less movement than normal and pain in both the left and right hip interferes with locomotion, sitting, and standing. Muscle strength in both hips was normal, there was no muscle atrophy, no ankylosis, and the Veteran did not have malunion or nonunion of the femur, flail hip joint, or leg length discrepancy. The Veteran reported regular use of a cane for his left hip and leg conditions. There was no objective evidence of pain in either hip with non-weight bearing, and passive range of motion of both hips was the same as with active range of motion. Based on the foregoing, an initial compensable rating for the Veteran's left and right hip limitation of flexion is not warranted. While the VA examination and DBQ reflect that the Veteran has consistently reported suffering from bilateral hip pain, they also indicate that the Veteran's range of motion with flexion is between 80 to 105 degrees on the right hip, and 60 to 105 degrees on the left hip. Additionally, while the Veteran reported flare-ups, particularly in the left hip, the October 2019 examiner reported that no additional loss of range of motion was anticipated with flare-ups. Thus, the Veteran's right and left hip limitation of motion does not more nearly approximate flexion of the thigh limited to 45 degrees, therefore a higher, compensable rating is not warranted under DC 5252. The Veteran's right thigh impairment symptomatology does not more nearly approximate inability to cross the legs or external rotation limited to 15 degrees as contemplated by a 10 percent disability rating under DC 5253. The January 2015 examiner noted external rotation to 30 degrees, and the October 2019 examiner noted right hip external rotation to 60 degrees, with both examiners indicating that the Veteran did not have an inability to cross his legs. Additionally, while the examination was not administered during a flare-up, the October 2019 examiner indicated no further range of motion loss was anticipated during flare-ups. As the Veteran's right thigh impairment symptomatology does not more nearly approximate an inability to cross his legs or external rotation limited to 15 degrees, a compensable disability rating under DC 5253 is not warranted. However, a higher initial 20 percent rating is warranted for the Veteran's left thigh impairment. While the October 2019 DBQ reflects left hip external rotation to 60 degrees with adduction not so limited such that the Veteran could not cross his legs, his January 2015 VA examination report indicates that his left hip adduction was to 10 degrees. Additionally, both the VA examination and DBQ indicate that the Veteran had pain with each range of motion, including with weight bearing. The evidence is at least evenly balanced as to whether the Veteran's left hip impairment symptomatology more nearly approximates adduction limited to 10 degrees. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, a higher 20 percent rating is warranted for his left hip impairment under DC 5253. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. This is the highest available schedular rating under DC 5253. As for the Veteran's claims for an increased rating for left femur disability, currently rated 20 percent disabling, and right hip disability, currently rated 10 percent disabling, both under DC 5003-5251, the Board notes that the highest available rating under DC 5251 is 10 percent, and the highest available rating under DC 5003 is 20 percent. As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (the Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if "§ 3.321(b) (1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board" (quoting Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). As both the Veteran's left femur and right hip disabilities are currently rated at or above the highest available rating under DC 5251 and the record does not indicate that referral for an extraschedular rating is warranted, further discussion as to whether a higher rating is warranted under DC 5251 is unnecessary. As previously noted, the RO has assigned separate ratings for limitation of extension, flexion, and impairment of the thigh for the Veteran's bilateral hip and thigh disabilities. Thus, the Veteran is in receipt of three separate ratings for disabilities related to his hips and thighs. The Board is cognizant of the fact that the assignment of multiple ratings based on the same symptoms or manifestations constitutes prohibited pyramiding. 38 C.F.R. § 4.14. However, here, the Board finds that the assignment of separate ratings based on limitation of extension, flexion, and impairment of the right hip under DCs 5251, 5252, and 5253 would not amount to pyramiding under 38 C.F.R. § 4.14. In this regard, separate ratings under different diagnostic codes may be assigned where "none of the symptomatology for any of [the] conditions is duplicative of, or overlapping with the symptomatology of the other... conditions." Esteban v. Brown, 6 Vet. App. 259 (1994). Here, this key consideration has been met in that limitation of extension, flexion, and adduction concern excursions of movements in different planes, and these limitations therefore constitute different bases for rating the hip. 38 C.F.R. § 4.45. If these limitations are demonstrated, they must be rated separately to adequately compensate for functional loss associated with the service connected hip and thigh disabilities. Cf. VAOPGCPREC 9-2004 (providing that separate ratings may be assigned for disability of the same joint where Veteran has both limitation of flexion and limitation of extension of same leg); see also Yonek v. Shinseki, 722 F.3d 1355 (2013) (finding separate ratings are not warranted for limitation of motion in different planes of the shoulder because they are not warranted under the applicable diagnostic codes, but that diagnostic codes addressing joints other than the shoulder assign different codes to limitation of motion in different planes, or to limitation of motion in different directions within a single plane, for example, DCs 5252 and 5253 with regard to the thigh). In addition, a higher 20 percent rating under DC 5003 is not warranted for the right hip disability, as there is no X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. As for other potentially applicable diagnostic codes pertaining to the hip, the record does not contain evidence of ankylosis of the left or right hip, or evidence that his left and right hip disabilities more nearly approximate pathology such as femur malunion, fracture, or hip flail joint; therefore, ratings under DCs 5250, 5254, or 5255 are not appropriate. 38 C.F.R. § 4.71a. 3. Knees The Veteran's right knee disability is rated 10 percent disabling under DC 5260 for limitation of flexion of the leg, and his left knee total joint replacement is rated 10 percent from October 13, 2014, 100 percent from December 2, 2016, and 30 percent from February 1, 2018, under DC 5055. As previously discussed, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021, and both the former and new rating criteria from February 7, 2021. DC 5055 has been revised. However, the Board finds that the earlier version of DC 5055 is more favorable to the Veteran, and thus will be applied. DC 5055, which pertains to a knee replacement, provides for a 100 percent rating for one year following implantation of prosthesis and a minimum 30 percent rating following that one-year period. 38 C.F.R. § 4.71a, DC 5055. Where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is warranted. Id. Where there are intermediate degrees of residual weakness, pain or limitation of motion, the rating criteria provide that the disability is to be rated by analogy to DCs 5256, 5261 or 5262. Id. The Board has also considered other potentially relevant diagnostic codes. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Under DC 5010, applicable to traumatic arthritis, traumatic arthritis is rated as degenerative arthritis under DC 5003. Degenerative or traumatic arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 5003, 5010. With any form of arthritis, painful motion is an important factor. 38 C.F.R. § 4.59. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). DC 5256 assigns a 30 percent evaluation for knee ankylosis with a favorable angle in full extension, or in slight flexion between 0 and 10 degrees; a 40 percent rating for knee ankylosis in flexion between 10 and 20 degrees; a 50 percent rating for knee ankylosis in flexion between 20 and 45 degrees; and a 60 percent rating for extremely unfavorable knee ankylosis in flexion at an angle of 45 degrees or more. DC 5257, under the earlier version of the regulation, assigns a 10 percent evaluation for slight recurrent subluxation or lateral instability; a 20 percent evaluation for moderate recurrent subluxation or lateral instability; and a 30 percent evaluation for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. § 4.2, 4.6. Under the revised version of DC 5257, for recurrent subluxation or lateral instability, a 30 percent rating is assigned for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is assigned 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. 38 C.F.R. § 4.71a, DC 5257 (2021). In cases of patellar instability, a 30 percent rating is warranted for 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 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. Under Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Per Note (2): 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). 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). Under DC 5258, a 20 percent evaluation is assigned for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under DC 5259, a 10 percent evaluation is assigned for removal of semilunar cartilage which is symptomatic. 38 C.F.R. § 4.71a. Under DC 5260, limitation of flexion of the leg is noncompensable where flexion is limited to 60 degrees. A 10 percent evaluation is warranted where flexion is limited to 45 degrees; a 20 percent evaluation is warranted where flexion is limited to 30 degrees; and a 30 percent evaluation is warranted where flexion is limited to 15 percent. 38 C.F.R. § 4.71a. Under DC 5261, limitation of extension of the leg, a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a. VA General Counsel provided guidance in VAOPGCPREC 23-97 (July 1997) that a veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating must be based upon additional disability. When a knee disorder is already rated under DC 5257, the Veteran must also have limitation of motion under DC 5260 or 5261 in order to obtain a separate rating for arthritis. If the Veteran does not at least meet the criteria for a zero percent rating under either of those codes, there is no additional disability for which a rating may be assigned. In VAOPGCPREC 9-98, General Counsel also clarified, if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. Given the findings of osteoarthritis, the General Counsel stated that the availability of a separate evaluation under DC 5003 in light of sections 4.40, 4.45, 4.59 must be considered. See Lichtenfels v. Derwinski, 1 Vet. App. 484. Absent x-ray findings of arthritis, limitation of motion should be considered under DCs 5260 and 5261. The claimant's painful motion may add to the actual limitation of motion so as to warrant a rating under DCs 5260 or 5261. In addition, the VA General Counsel has held that separate ratings may be assigned under DC 5260 and DC 5261 for disability of the same joint. VAOPGCPREC 9-2004. Id. Specifically, where a Veteran has both a limitation of flexion and a limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. The limitation of flexion and extension must be compensable in both planes in order to warrant separate ratings. Id. There is no prohibition of separate evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5257 or 5261 and a meniscal Diagnostic Code, i.e., Diagnostic Codes 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). A January 2015 VA examination report reflects that the Veteran did not report flare-ups which impact the function of his knees or lower leg, but he reported bilateral knee pain with walking, standing, or bending at the knees. Left knee flexion was to 80 degrees, and extension to 0 degrees. The examiner noted pain that caused functional loss with flexion and extension, there was evidence of pain with weight bearing, and objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, with the Veteran indicating tenderness at the medial joint line. Right knee flexion was to 90 degrees, extension to 0 degrees, and the examiner noted diminished flexibility, and pain with flexion that did not result in functional loss. There was evidence of pain with weight bearing, and tenderness at the medial joint line. No additional functional loss or range of motion was reported with repetitive use in either knee, muscle strength was normal, the Veteran did not have muscle atrophy, and there was no ankylosis in either knee. The examiner noted no history of recurrent subluxation, lateral instability, or recurrent effusion, there was no joint instability in either knee as reflected by testing, the Veteran did not have, and had never had a meniscus condition, recurrent patellar dislocation, or any tibial or fibular impairment. The Veteran reported regular use of a cane, and there was no objective evidence of crepitus. September 2016 private treatment records indicate the Veteran suffered from multidirectional tear of the lateral meniscus with radial and horizontal/oblique components involving the posterior horn and posterior body of the left knee. A March 2017 VA examination report reflects that the Veteran reported flare-ups of his left tibia and or fibula fracture, with the Veteran stating that he cannot tolerate stair climbing for his job, and cannot fully bend his left knee. Right knee range of motion was normal, with flexion to 140 degrees, and extension to 0 degrees. There was no pain noted, no pain with weight bearing, and no evidence of crepitus. Left knee flexion was to 100 degrees, extension to 0 degrees, and the Veteran reported that he is unable to ride motorcycles, squat, climb, hike, or hunt without assistive devices. There was evidence of pain with flexion, with weight bearing, and evidence of lateral sub-patellar pain on palpation, but no evidence of crepitus. There was no additional functional loss or range of motion with repetitive use testing in either knee, but the examiner noted that pain, weakness, fatigue, lack of endurance, and incoordination significantly limited functional ability with repeated use over a period of time in the left knee, but could not describe the additional loss in terms of range of motion. While the examination was not conducted during a flare-up, the examiner noted that pain, fatigue, weakness, lack of endurance, and incoordination limited the Veteran's functional ability with flare-ups, but was unable to describe the functional loss in terms of range of motion. The examiner also noted that the Veteran suffered from left knee swelling, deformity, disturbance of locomotion, interference with sitting, and interference with standing. There was no reduction in muscle strength, muscle atrophy, or ankylosis in either knee, and no history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that the Veteran had leg length discrepancy with the right leg measuring 33 cm, and the left leg measuring 32.5 cm. The examiner reported that the initial injury caused loss of the tibia and femoral shaft with resultant, life-long, discrepancy that was unable to be corrected by total knee replacement surgery performed in December 2016. The examination report indicated that the Veteran has never had a meniscus condition, but underwent total knee joint replacement with intermediate degrees of residual weakness, pain, or limitation of motion. The Veteran reported occasional use of a wheelchair and walker, and constant use of a cane for locomotion. The examiner noted that there was evidence of pain in the left knee on passive range of motion testing, and when the joint was used in non-weight bearing. An October 2019 DBQ indicated that the Veteran's knee and leg disabilities have worsened since their onset, with the Veteran reporting that he experiences bilateral knee pain and loss of range of motion. The Veteran reported flare-ups, stating that the pain worsens if he uses his knees too much or moves too quickly. He stated that he is unable to run, jump, play sports, or do any prolonged standing, sitting, or walking. Right knee flexion was to 120 degrees, and extension to 0 degrees. Pain was noted with extension and flexion, but there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, but there was evidence of pain with weight bearing. There was no objective evidence of crepitus. Left knee flexion was to 90 degrees, and extension to 0 degrees, with pain noted with both flexion and extension. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or objective evidence of crepitus, but there was evidence of pain with weight bearing. The examiner noted that pain significantly limited functional ability with repeated use over a period of time, describing it in terms of range of motion with flexion to 100 degrees, and extension to 0 degrees in the right knee, flexion to 70 degrees, and extension to 0 degrees in the left knee. While the examination was not conducted during a flare-up, the examiner stated that pain significantly limited functional ability with flare-ups, describing such limitation in terms of range of motion with right knee flexion to 100 degrees, extension to 0 degrees, left knee flexion to 70 degrees, and extension to 0 degrees. The examiner also noted that less movement than normal and pain interferes with locomotion, sitting, and standing in both knees. There was no muscle strength reduction, muscle atrophy, or ankylosis noted in either knee, and no history of recurrent subluxation, lateral instability, or recurrent effusion in either knee. No joint instability was noted, and the examiner indicated that the Veteran has not had, and has never had recurrent patellar dislocation, "shin splints" stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The examination report also indicated that the Veteran had not had a meniscus condition, but reflected a total left knee joint replacement, with intermediate degrees of residual weakness, pain, or limitation of motion. There was no objective evidence of pain in either knee on non-weight bearing, and passive range of motion was the same as with active range of motion. Based on the foregoing, the Board finds that a rating higher than 10 percent for the Veteran's right knee disability is not warranted at any point during the appeal period. In this case, the DBQ and examination reports of record show that the Veteran was able to perform range of motion of the right knee for flexion anywhere from 90 degrees to 140 degrees to include with repetitive use testing. Additionally, the October 2019 examiner reported right knee flexion to 100 degrees due to limitations in range of motion during flare-ups. Accordingly, the 10 percent rating contemplates the Veteran's symptoms as a 20 percent rating would require flexion limited to 30 degrees. Although functional loss due to pain and/or lack of endurance was noted during these examinations and DBQ, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's symptoms most closely approximate the criteria for a 10 percent rating. In this regard, the weight of the evidence shows that even considering the indications of functional loss, the Veteran's symptoms were not shown to be so disabling to actually, or effectively, result in limitation of flexion to 30 degrees or less. Moreover, the examination reports and DBQ show that the Veteran did not have ankylosis of the either knee. Thus, a rating higher than 10 percent is not warranted under DC 5260 or 5256. Additionally, the examination reports and DBQ indicate that the Veteran was able to perform range of motion of the right knee for extension to 0 degrees to include with repetitive use testing. Accordingly, a separate rating under DC 5261 is not warranted as a compensable rating would require extension limited to 5 degrees. The examination reports and DBQ reflect that the Veteran's right knee disability has not at any time during the period on appeal more nearly approximated recurrent subluxation or lateral instability, recurrent patellar dislocation, or symptomatic removal of semilunar cartilage, thus separate ratings under DCs 5257, 5258, and 5259 are not warranted. For the foregoing reasons, the preponderance of the evidence reflects the symptoms of the Veteran's right knee disability do not include or more nearly approximate the criteria for a rating higher than 10 percent. The benefit of the doubt doctrine is therefore not for application, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. As for the Veteran's left knee limitation of flexion, for the period from October 13, 2014, to December 1, 2016, the Board finds that an initial rating higher than 10 percent is not warranted under DC 5260. While the Veteran reported suffering from knee pain with walking, standing, and bending at the knees, the left knee flexion was noted to 80 degrees by the January 2015 examiner. The January 2015 examination report also indicated that while there was evidence of pain with weight bearing, and tenderness at the medial joint line, the Veteran did not report flare-ups, and no additional functional loss or range of motion was reported with repetitive use in the left knee. The Veteran's left knee limitation of flexion symptomatology thus does not more nearly approximate flexion limited to 30 degrees as contemplated by a 30 percent rating under DC 5260 for the period from October 13, 2014, to December 1, 2016. The evidence of record also does not reflect that the Veteran's left knee disability more nearly approximates extension limited to 15 degrees during the period from October 13, 2014, to December 1, 2016. The previously discussed January 2015 VA examination report reflects that the Veteran's left knee limitation of extension measured to 0 including with repetitive use testing. Therefore, entitlement to a separate 10 percent rating for the period from October 13, 2014, to December 1, 2016 is not warranted for left knee limitation of extension under DC 5261. The January 2015 examination report reflects that the Veteran's left knee disability has not at any time during the period on appeal more nearly approximated recurrent subluxation or lateral instability, or removal of semilunar cartilage which is symptomatic, thus separate ratings under DCs 5257, and 5259 are not warranted for the period from October 13, 2014, to December 1, 2016. However, the while the Veteran's January 2015 examination report indicates that the Veteran did not have, and had never had a meniscus condition, recurrent patellar dislocation, any tibial or fibular impairment, or symptomatic removal of semilunar cartilage, his September 2016 private treatment records reflect multidirectional tear of the lateral meniscus. Therefore, the evidence is at least evenly balanced that for the period from October 13, 2014, to December 1, 2016, the Veteran's left knee disability more nearly approximated dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Therefore, a separate 20 percent rating is warranted under DC 5258 for the period from October 13, 2014, to December 1, 2016, for left knee meniscal tear. For the period from February 1, 2018, the evidence is at least evenly balanced as to whether the Veteran's left knee disability symptomatology more nearly approximates that contemplated by a 60 percent rating under DC 5055. As previously noted, DC 5055 provides for a 100 percent rating for one year following implantation of prosthesis and a minimum 30 percent rating following that one-year 100 percent rating period following implantation of prosthesis. However, where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is warranted. Id. While the October 2019 examiner described intermediate degrees of residual weakness, pain, or limitation of motion due to the Veteran's left knee disability, the examiner also noted pain with both flexion and extension. Additionally, while the examiner reported normal muscle strength, no muscle atrophy, and no ankylosis in the left knee, the Veteran has stated that his left knee pain worsens if he uses it too much, or moves too quickly. He also stated that he is unable to run, jump, play sports, or do any prolonged standing, sitting, or walking. The Veteran is competent to report the functional limitations due to his left knee pain and the Board has no reason to doubt his credibility. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, a 60 percent rating is warranted under DC 5055 from February 1, 2018. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. A 60 percent rating is the maximum rating under DC 5055. If a veteran is receiving the maximum disability rating allowable for a particular disorder, the Board does not have to consider whether he is entitled to a higher disability rating because of functional loss under §§ 4.40 and 4.45. Spencer v. West, 13 Vet. App. 376, 382 (2000). The Board notes that the previously discussed DBQ shows that the Veteran did not have ankylosis of the left knee at any time during the period on appeal. Thus, a separate rating under DC 5256 is not warranted. Moreover, from February 1, 2018, there is no evidence that the Veteran is currently symptomatic due to his previously noted multidirectional tear of the lateral meniscus. The evidence of record also does not indicate that the Veteran's current left knee disability symptomatology included dislocation of semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint, and the October 2019 DBQ reflected no recurrent patellar dislocation. Therefore, separate ratings under DCs 5258 and 5259 are not warranted. As for a separate compensable rating for left knee instability under either the former or revised version of DC 5257 from February 1, 2018, the October 2019 examiner reported no lateral instability, and the Board notes that any symptoms of instability are contemplated by the 60 percent rating that includes weakness. Tedesco v. Wilkie, 31 Vet. App. 360, 367, n. 5 (2019) (declining to reach the question of whether the Board committed legal error when it found that a separate rating for instability under DC 5257 could be granted in addition to a rating for knee replacement under DC 5055 because to allow such a rating would constitute improper pyramiding). As to consideration of referral for an extraschedular rating, the Veteran has not contended, and the evidence does not reflect, that he has experienced symptoms outside of those listed in the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (the Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if "§ 3.321(b) (1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board" (quoting Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). Jenna Brant Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.