Citation Nr: 21040630 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 13-08 077 DATE: July 6, 2021 ORDER Prior to February 9, 2018, entitlement to a disability rating higher than 0 percent for the service-connected right lower extremity radiculopathy, is denied. Since February 9, 2018, entitlement to a disability rating higher than 10 percent for the service-connected right lower extremity radiculopathy, is denied. Prior to February 9, 2018, entitlement to a disability rating higher than 0 percent for the service-connected left lower extremity radiculopathy, is denied. Since February 9, 2018, entitlement to a disability rating higher than 10 percent for the service-connected left lower extremity radiculopathy, is denied. Prior to February 9, 2018, entitlement to a disability rating of 10 percent, but not higher, for the service-connected left knee instability is granted. From February 9, 2018, to February 7, 2021, entitlement to a disability rating higher than 10 percent for the service-connected left knee instability is denied. Since February 7, 2021, entitlement to a disability rating of 20 percent, but not higher, for the service-connected left knee instability is granted. REMANDED Entitlement to an increased disability rating for the service-connected cervical spine (neck) disability, currently rated at 10 percent prior to February 9, 2018, and 20 percent since February 9, 2018, is remanded. Entitlement to an increased disability rating for the service-connected thoracolumbar spine (low back) disability, currently rated at 10 percent prior to February 9, 2018, and 20 percent since February 9, 2018, is remanded. Entitlement to an increased disability rating for limitation of motion associated with the service-connected left knee disability, currently rated at 10 percent is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to February 9, 2018, the service-connected right lower extremity radiculopathy was manifested by no neurological abnormality. 2. Since February 9, 2018, the service-connected right lower extremity radiculopathy is manifested by mild incomplete paralysis of the sciatic nerve. 3. Prior to February 9, 2018, the service-connected left lower extremity radiculopathy was manifested by no neurological abnormality. 4. Since February 9, 2018, the service-connected left lower extremity radiculopathy is manifested by mild incomplete paralysis of the sciatic nerve. 5. For the entire period prior to February 7, 2021, the service-connected left knee instability is manifested by slight lateral instability or recurrent subluxation. 6. Since February 7, 2021, the service-connected left knee instability is manifested by a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace. CONCLUSIONS OF LAW 1. Prior to February 9, 2018, the criteria for a disability rating higher than 0 percent for the service-connected right lower extremity radiculopathy were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 2. Since February 9, 2018, the criteria for a disability rating higher than 10 percent for the service-connected right lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 3. Prior to February 9, 2018, the criteria for a disability rating higher than 0 percent for the service-connected left lower extremity radiculopathy were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 4. Since February 9, 2018, the criteria for a disability rating higher than 10 percent for the service-connected left lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 5. Prior to February 9, 2018, the criteria for a disability rating of 10 percent for the service-connected left knee instability were met; the criteria for a rating higher than 10 percent were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 6. From February 9, 2018, to February 7, 2021, the criteria for a disability rating higher than 10 percent for the service-connected left knee instability were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 7. Since February 7, 2021, the criteria for a disability rating of 20 percent are met; the criteria for a rating higher than 20 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from January 29, 1974, to January 16, 1980, and from January 2, 1985, to June 30, 1999. This appeal comes before the Board of Veterans' Appeals (Board) from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In August 2017, the Veteran presented testimony at a Board hearing, chaired via videoconference by the undersigned Veterans Law Judge and accepted such hearing in lieu of an in-person hearing before a Member of the Board. See 38 C.F.R. § 20.700(e). At the Board hearing, the Veteran was informed of the basis for the RO's denial of his claims and he was informed of the information and evidence necessary to substantiate each claim. 38 C.F.R. § 3.103. He was provided additional time following the hearing to submit private medical records. A transcript of the hearing is associated with the claims file. In September 2017, the Board remanded this appeal for additional evidentiary development. The appeal has since been returned to the Board for further appellate action. The issue of TDIU entitlement was not separately appealed but is being considered here as a component of the increased rating claim(s) in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009) (where there is evidence of unemployability raised by the record during a rating appeal period, the TDIU is an element of an initial rating or increased rating). Increased Rating Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). The rating must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). The Schedule of Ratings for Neurological and Convulsive Disorders governs disability rating for specific neurological diseases and their residuals, which may be rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function. Consider especially psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc., referring to the appropriate bodily system of the schedule. With partial loss of use of one or more extremities from neurological lesions, rate by comparison with the mild, moderate, severe, or complete paralysis of peripheral nerves. Regarding the peripheral nerves, the term incomplete paralysis indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. 38 C.F.R. § 4.124a. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. See nerve involved for diagnostic code number and rating. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code number and rating. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to an increased disability rating for the service-connected bilateral lower extremity radiculopathy, each currently rated 0 percent prior to February 9, 2018, and 10 percent since February 9, 2018. The current appeal arises from an increased rating claim received at VA on August 18, 2010. In a January 2019 rating decision, separate ratings for neurological impairment of the right lower extremity and left lower extremity were assigned. Ratings of 10 percent were assigned for each lower extremity under Diagnostic Code 8520, effective February 9, 2018. Under Diagnostic Code 8520, an 80 percent rating is available for complete paralysis of the sciatic nerve such that the foot dangles and drops, there is no active movement possible of muscles below the knee, flexion of the knee is weakened or (very rarely) lost; a 60 percent rating is available for incomplete paralysis of the sciatic nerve that is severe, with marked muscular atrophy; a 40 percent rating is available for incomplete paralysis of the sciatic nerve that is moderately severe; a 20 percent rating is available for incomplete paralysis of the sciatic nerve that is moderate; a 10 percent rating is available for incomplete paralysis of the sciatic nerve that is mild. 38 C.F.R. § 4.124a, Diagnostic Code 8520. A VA examination in September 2010 reveals the Veteran was in no acute distress. He reported no bowel or bladder changes. He had 5/5 strength in the lower extremities. His sensation was intact to light touch over the L2-S1 dermatomes bilaterally. He had excellent dorsalis pedis pulses bilaterally. He had a negative Babinski's sign bilaterally, and negative clonus bilaterally. He had a negative straight leg raise bilaterally. His deep tendon reflexes were 1+, equal and symmetric bilaterally. He walked with a non-antalgic gait. His gait was symmetric and equal (Record 09/11/2010). A March 7, 2013, orthopedic consult reveals a mildly antalgic gait (Record 03/18/2013). An August 20, 2013, VA primary care note reveals the Veteran's denial of numbness and tingling (Record 01/03/2019 at 66). A September 13, 2013, neurological consult reveals the Veteran's denial of tingling, numbness, or pin prick sensation of the extremities (Record 01/03/2019 at 62). An October 24, 2013, VA orthopedic note reveals a normal gait (Record 01/03/2019 at 59). A private evaluation of the knee in March 2017 reveals a slightly antalgic gait, without an assistive device. Sensation and pulses were normal (Record 11/07/2017). A VA examination of the back in February 2018 reveals the Veteran's complaint of intermittent bilateral lower extremity radiculopathy, left greater than right. It will last for minutes. He used a TENS unit and back brace. He could walk 100 yards, sit for 1 hour, stand for 10 minutes, lift 15 pounds, and perform limited bending. Flares consisted of increased pain with prolonged walking or heaving lifting. Lower extremity muscle strength was full without atrophy. Reflexes were normal and sensation was normal. Radiculopathy was assessed as mild intermittent pain, bilaterally, and mild paresthesias/dysesthesias. There were no other neurological abnormalities. The examiner diagnosed bilateral lower extremity radiculopathy (Record 02/09/2018). After a review of all of the evidence, the Board finds that the criteria for higher ratings are not met for either lower extremity. For the period prior to February 9, 2018, the evidence does not substantiate the presence of any significant lower extremity symptomatology that can be associated with the service-connected low back disability. Findings were essentially normal. In September 2010, the Veteran reported numbness and weakness in his left buttock, but this was not associated by the examiner to sciatic neuropathy. Examination of the lower extremities was pertinently negative. The Veteran denied symptomatology such as numbness and tingling repeatedly after that examination. Accordingly, the Board finds that, to the extent the Veteran had any symptomatology prior to February 2018, it did not rise to the level of mild incomplete paralysis of the sciatic nerve. Since February the February 9, 2018, examination, the evidence does not substantiate incomplete paralysis that is more than mild. The February 2018 examination report is probative and persuasive evidence that the Veteran's symptomatology, consisting of intermittent pain, paresthesias and/or dysesthesias, was not moderate or severe, but was mild, as found by the examiner. Accordingly, the Board finds that moderate incomplete paralysis is not shown. As this report is the first positive finding for radiculopathy, and as it does not identify the date of onset, the date of the report represents the earliest date as of which it is factually ascertainable based on all evidence of record that an increase in disability had occurred. 38 C.F.R. § 3.400(o). In sum, the Board finds that prior to February 9, 2018, the service-connected left and right lower extremity radiculopathy were manifested by no neurological abnormality; and since February 9, 2018, the disabilities are manifested by mild incomplete paralysis of the sciatic nerve. In light of these findings of fact, the Board concludes that a disability rating higher than 0 percent is not warranted prior to February 9, 2018, for either extremity; and a rating higher than 10 percent is not warranted since that date, for either extremity. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to an increased disability rating for the service-connected left knee instability, currently rated 0 percent prior to February 9, 2018, and 10 percent since February 9, 2018. In a May 2000 rating decision, VA granted service connection for a left knee disability and assigned a disability rating under Diagnostic Code 5259, effective July 16, 1999. The current appeal arises from an increased rating claim received at VA on August 18, 2010. In a January 2019 rating decision, a separate rating for instability was assigned at 10 percent under Diagnostic Code 5257, effective February 9, 2018. For reasons discussed in the remand below, the Board has found the medical evidence regarding limitation of motion to be inadequate. As Diagnostic Code 5257 does not address limitation of motion, a remand for this matter is not necessary. During the course of this appeal, the criteria for Diagnostic Code 5257 rating lateral instability of the knee changed effective February 7, 2021. 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). However, the Board must consider the application of prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Effective February 7, 2021, under Diagnostic Code 5257, other impairment of the knee can be rated on the basis of either recurrent subluxation or lateral instability, or on the basis of patellar instability. Where a rating is assigned on the basis of recurrent subluxation or lateral instability, a rating of 30 percent if there is an 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 rating of 20 percent is assigned with 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 rating of 10 percent for a 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. Where a rating is assigned on the basis of patellar instability, a rating of 30 percent is assigned where there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A rating of 20 percent is assigned with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A rating of 10 percent is assigned with 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. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 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). Prior to February 7, 2021, recurrent subluxation or lateral instability are assigned a rating of 30 percent where these symptoms are severe; a rating of 20 percent where such symptoms are moderate; or a rating of 10 percent where such symptoms are slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (prior to 2021). Lateral: denoting a position farther from the median plan or midline of the body or structure. See Dorland's Illustrated Medical Dictionary 1022 (31st ed. 2007). Diagnostic Code 5257 does not require "objective" medical evidence of lateral instability for a rating to be assigned. When weighing evidence to determine whether there is lateral instability, the Board cannot find objective medical evidence is automatically more probative than lay evidence. English v. Wilkie, 30 Vet. App. 347 (2018). Under Diagnostic Code 5258, a rating of 20 percent is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, symptomatic removal of the semilunar cartilage is assigned a rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5259. A VA examination of the knee in September 2010 reveals the Veteran's complaint of knee pain. The Veteran stated that he used a cane on an intermittent basis, which was minimally helpful. He could walk for 15 minutes, up to 1-2 blocks at a time. He had flares on a-monthly basis associated with navigating stairs and sitting for long periods of time. The Veteran had arthroscopy in 1999 and 2007. He has had physical therapy, injections, and medication treatment. He was in no acute distress. There was a positive patellar grind. He had a negative McMurray's sign, negative Lachman's sign and posterior drawer. He had no varus or valgus instability on examination; however, he did have pain over the medial aspect of his knee on palpation. He had negative pivot shift sign. It was found conceivable that his pain would limit function; however, it was difficult to quantify loss of function with any medical certainty (Record 09/11/2010). An October 24, 2013, VA orthopedic note reveals complaint of chronic left knee pain. The Veteran had a normal gait. No swelling or palpable effusion was noted. There was normal alignment. Skin color and temperature were normal. There was minimal patellar tenderness to palpation. There was no ligamental laxity with valgus/varus stress. The examiner noted positive patellofemoral crepitus and grinding with flexion and extension. No locking was found. The knee was positive to medial/lateral joint line tenderness. McMurry's test was negative as was anterior and posterior drawer. Motor strength was 5/5 in flexion and extension. The impression was left knee pain/osteoarthritis (Record 01/03/2019 at 59). A March 7, 2013, orthopedic consult reveals complaint of knee pain. On examination, the Veteran had trace effusion of the left knee. He had a valgus posture on standing, a mildly antalgic gait and no instability. There was no locking. The diagnosis was symptomatic arthritis (Record 03/18/2013). A September 2013 MRI of the knee reveals (1) a complete chronic tear of the anterior cruciate ligament; (2) maceration of the posterior horn of the lateral meniscus; (3) a complex tear of the anterior horn of the lateral meniscus; (4) extensive chondromalacia of the lateral compartment; (5) chondrocalcinosis of the lateral compartment of the knee; (6) chondromalacia of the patellofemoral compartment; (7) joint effusion; (8) small free bone fragment anterior to the tibia; (9) small free bone fragment with in the Baker's cyst; (10) a multiloculated cyst along the course of the popliteus tendon which may be a synovial cyst and possible ganglion cyst; (11) and dystrophic calcification surrounding the popliteus tendon (Record 01/03/2019 at 65). A private evaluation of the knee in March 2017 reveals the Veteran's complaint of instability. He had issues with stairs and hills. He walked with a slightly antalgic gait, without an assistive device. Sensation and pulses were normal. There was no instability with varus or valgus stress at 0 to 30 degrees. The extensor was intact. There was a mild gross valgus deformity. There was no effusion of the knee joint (Record 11/07/2017). A VA examination of the knee in February 2018 reveals the Veteran's complaint of occasional swelling of the knee. Sometimes his knee felt unstable. He could walk 100 yards, but not run. He avoided squatting and stairs whenever possible. Flares were associated with prolonged walking, and they consisted of increased pain. Muscle strength was full without atrophy. The examiner assessed slight lateral instability. However, testing for anterior instability, posterior instability, medial instability, and lateral instability were all normal. The examiner described mild daily pain associated with the meniscal injury. There was no joint effusion. The Veteran regularly used a brace. The functional impact was limited walking and squatting. The meniscal condition resulted in mild daily pain. The examiner diagnosed status-post cartilaginous/ligament injury with tricompartmental arthritis (Record 09/13/2010). In December 2018, the Veteran was provided a knee orthosis for support and stabilization of the knee during stance and ambulation (Record 01/03/2019 at 126). After a review of all of the evidence, the Board finds that, prior to February 9, 2018, the criteria for a disability rating of 10 percent are met; from February 9, 2018, to February 7, 2021, the criteria for a rating higher than 10 percent are not met; and, since February 7, 2021, the criteria for a rating of 20 percent are met. The amended criteria for lateral instability, effective February 7, 2021, provide a rating of 20 percent with 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. Here, the evidence establishes a failed knee repair. The Veteran is status-post meniscectomy and two other arthroscopies, described as "clean out" operations (Record 09/19/2017 at 45). He has been given a knee brace by VA (Record 09/19/2017 at 19). Accordingly, effective February 7, 2021, the criteria for a rating of 20 percent are met. While the Veteran reported using a cane intermittently to the September 2010 examiner, the evidence does not establish a prescription for a cane, crutches, or a walker in combination with bracing. Indeed, the Veteran indicated to the examiner that it was only minimally helpful. A prescription for one of these assistive devices is required for a 30 percent rating under the current criteria. A November 21, 2018, VA primary care note states that the Veteran does not use a cane or a walker (Record 01/03/2019 at 4). The Veteran does not contend that he requires crutches or that they have been prescribed. The former criteria can also be considered during this period. However, consistent with the determination of the VA examiner, the Veteran's lateral instability is slight, and is not moderate or severe. For the period from February 9, 2018, to February 7, 2021, the former criteria apply. Again, the finding of the February 2018 VA examiner was of slight lateral instability. The examiner also had the choice of "Moderate" and "Severe" but chose "Slight." This is persuasive evidence as it is consistent with the other clinical findings in the examination report of mild pain, occasional swelling, and occasionally (sometimes) feeling unstable. It is also consistent with the normal results of testing for joint stability. Accordingly, the Board finds that a rating higher than 10 percent is not warranted. For the period prior to February 9, 2018, the Board finds that a rating of 10 percent is warranted. The evidence establishes that the Veteran's left knee has been symptomatic regarding instability for the entire period of the claim. The effective date was established as of the date of the February 2018 VA examination which found slight lateral instability. While tests for instability have largely been negative, the Veteran has described instability well prior to the February 2018 examination. The March 2017 private evaluation notes the Veteran's complaint of instability. On the March 2013 VA Form 9, the Veteran described instability and stated that his stability is dependent on the strength of his muscles. He also stated that his spousea licensed physical therapistfound a measurable difference between his right and left leg musculature. Moreover, the Veteran's use of a knee brace extends at least to the July 2011 Notice of Disagreement, in which the Veteran recounted his daily need for a brace. It is difficult to find that a condition requiring the need for bracing is not at least slight. Accordingly, the Board resolves all reasonable doubt in favor of the claim and finds that, prior to February 9, 2018, a rating of 10 percent is warranted. However, in light of the consistently normal tests for lateral instability prior to that date, the Board concludes that a rating higher than 10 percent is not warranted. The Board has considered whether any additional ratings are warranted. The Veteran is already rated for limitation of motion of the knee. That issue is remanded below. While he has dislocated meniscus, Diagnostic Code 5258 requires frequent episodes of locking, pain, and effusion into the joint. There is mixed evidence regarding effusion; however, the evidence does not substantiate frequent locking. Therefore, a rating under that code is not appropriate. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of the semilunar cartilage. However, the word "symptomatic" is broad and necessarily includes any symptomatology, including lateral instability. Therefore, a separate rating under that code is precluded as pyramiding. 38 C.F.R. § 4.14. The rating of 10 percent is the maximum rating under that code. In sum, the Board finds that, prior to February 9, 2018, and from February 9, 2018 February 7, 2021, the service-connected left knee instability is manifested by mild lateral instability or recurrent subluxation. Since February 2, 2021, the service-connected left knee instability is manifested by a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace. In light of these findings of fact, the Board concludes that, prior to February 9, 2018, a rating of 10 percent, but not higher, is warranted; from February 9, 2018, to February 7, 2021, a rating higher than 10 percent is not warranted; and since February 7, 2021, a rating of 20 percent, but not higher, is warranted. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, to the extent of denial of still higher ratings, the preponderance of the evidence is against the claim. Therefore, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. REASONS FOR REMAND Entitlement to an increased disability rating for the service-connected neck disability, currently rated at 10 percent prior to February 9, 2018, and 20 percent since February 9, 2018. Entitlement to an increased disability rating for the service-connected low back disability, currently rated at 10 percent prior to February 9, 2018, and 20 percent since February 9, 2018. Entitlement to TDIU. The Veteran had multiple examinations of the neck, left knee, and low back. In September 2010, the examiner noted flares of neck, knee, and low back symptoms, but did not comment on additional limitation of motion during symptom flares. The examiner also did not discuss additional limitation of motion after repeated use over a period of time. Each report indicates that the examination was conducted immediately after repetitive use over a period of time, and that pain, weakness, fatigability, and/or incoordination significantly limited functional ability with repeated use over a period of time, but in each report, the examiner declined to estimate loss of range of motion after repeated use over a period of time, simply stating: "CANNOT DETERMINE FROM EXAM OR HX." If the examination was conducted immediately after repetitive use over a period of time, the range of motion reported on the examination should represent this value. The examiner's response to the second question is inconsistent with his response to the first question. The February 2018 VA examiner also declined to estimate loss of range of motion during neck, low back, and knee flares, in each case stating that the Veteran was not presently having a flare. When veterans are not examined during flares or immediately after repeated use over time, VA examiners must provide an estimate of such functional limitation in terms of degrees of motion. If such estimation is not possible without resort to speculation, examiners must give an explanation as to why this is so, beyond merely noting that objective examination in such conditions has not been performed. In such a case, there is necessarily a lack of objective testing and observation, and an estimation therefore must be based on statements by the veteran or other treatment records. If such an estimation is impossible, it must be clear that the impossibility is predicated on a lack of knowledge among the medical community at large and not the insufficient knowledge of the specific examiner. Sharp v. Shulkin, 29 Vet. App. 26, 35-36 (2017). Here, the examiner did not give a proper estimation of the Veteran's functional loss during symptom flares or after repeated use over a period of time in terms of degrees of motion lost. The examiner's explanations for this lack of necessary information did not indicate whether he actually asked the Veteran for information on these questions. The Veteran has provided several written descriptions of his functional loss. See August 18, 2010, VA Form 21-4138 (Statement in Support of Claim), September 24, 2010, Statement in Support of Claim, July 11, 2011, Notice of Disagreement, March 18, 2013, VA Form 9 (Appeal to Board of Veterans' Appeals), August 18, 2017, Board hearing transcript. Unlike a medical professional, the Board is not competent to interpret the Veteran's descriptions to provide an estimate of additional limitation of motion during flares and after repeated use over a period of time. The Board finds that these examination reports are inadequate to consider the neck and low back claims, which are based on range of motion, and are inadequate to consider the limitation of motion component of the left knee disability. The separate issue of TDIU entitlement is inextricably intertwined and the proposed development will encompass that issue. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). These matters are REMANDED for the following action: 1. Schedule an appropriate VA examination to determine the manifestations and functional impairment caused by the service-connected neck, low back, and knee limitation of motion disabilities. The relevant documents in the claims file should be made available to the VA examiner. Range of motion should be reported with active and passive motion, and with weight-bearing and non-weight-bearing. Where relevant (knee), comparison should be made to equivalent joints on the nonservice-connected extremity. Symptomatology, including range of motion during flares should be documented. If the examination is not conducted during a flare, an estimate of range of motion should be provided. The Veteran's description of his range of motion during flares should be considered and recorded. Symptomatology, including range of motion after repeated use over a period of time should be documented. If the examination is not conducted after repeated use over a period of time, an estimate of range of motion should be provided. The Veteran's description of his range of motion after repeated use over a period of time should be considered and recorded. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, the examiner is asked to please provide complete explanations stating why this is so. In so doing, the examiner is asked to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that the examiner has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Readjudicate the remanded claims. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Cramp 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.