Citation Nr: 21042414 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 14-38 802 DATE: July 13, 2021 ORDER Entitlement to an increased disability rating in excess of 10 percent for the service-connected residuals, right knee injury with post-traumatic arthritis, is denied. Entitlement to a higher disability rating for the service-connected right knee instability with anterior cruciate ligament tear, in excess of the currently-assigned 10 percent from March 31, 2016 and 20 percent from February 7, 2021 to the present, is denied. FINDINGS OF FACT 1. The Veteran's right knee disability is manifested by arthritis, established by X-ray findings, with painful and limited right knee motion, however, there is no evidence of the right leg flexion limited to 45 degrees, or extension limited to 10 degrees, including additional estimated loss of range of motion during flare-ups, throughout the appeal period. 2. The preponderance of the evidence of record suggests that there was no subluxation or lateral instability prior to March 31, 2016; and there was no moderate subluxation or lateral instability from March 31, 2016 to February 7, 2021, or severe subluxation or lateral instability thereafter. Additionally, the Veteran has unrepaired complete ligament tear in the right knee causing persistent instability, and a medical provider prescribed an assistive device (e.g., cane(s), crutch(es), walker) but not a bracing for ambulation. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for the service-connected residuals, right knee injury with post-traumatic arthritis have not been met. 38 U.S.C. §§ 1155, 5110, 5107; 38 C.F.R. §§ 4.1, 4.27, 4.3, 4.40, 4.45, 4.59, 4.7, 4.71a, Diagnostic Code 5003, 5010. 2. The criteria for a higher disability rating for the service-connected right knee instability with anterior cruciate ligament tear, in excess of the currently-assigned 10 percent from March 31, 2016 and 20 percent from February 7, 2021 to the present, have not been met. 38 U.S.C. §§ 1155, 5110, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.31, 4.40, 4.45, 4.59, 4.7, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from April 1971 to April 1979. This matter comes before the Board of Veterans' Appeals ("Board") on appeal from a September 2011 rating decision of the Department of Veterans Affairs ("VA") Regional Office ("RO"). In a December 2016 decision, the Board denied ratings in excess of 10 percent for post-traumatic arthritis of the right knee; and in excess of 10 percent for the right knee instability. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims ("Court"). In an October 2017 order, the Court granted a joint motion for remand ("JMR"), vacating the Board's December 2016 decision and remanding the case for further action consistent with instructions outlined by the parties in the JMR. Subsequently, the Board remanded this case in November 2017, January 2019, October 2020, and March 2021 for additional development. Recently, after the last Board's remand, in an April 2021 rating decision, the RO increased the disability rating to 20 percent for the right knee instability with anterior cruciate ligament tear, with an effective date of February 7, 2021. Since this award constitutes a partial grant of the benefit sought, the RO issued a supplemental statement of the case in April 2021, continuing 10 percent rating for the service-connected residuals, right knee injury with post-traumatic arthritis; and denying rating in excess of 10 percent prior to February 7, 2021 and in excess of 20 percent thereafter for the service-connected right knee instability with anterior cruciate ligament tear, and returned the matter to the Board for appellate consideration. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a claimant is presumed to be seeking the maximum benefit allowed by law). In the March 2021 remand, the Board directed the RO to obtain an addendum medical opinion on the current severity of the Veteran's service-connected right knee disability. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board finds that the RO substantially complied with the directives set forth in the March 2021 remand, and medical opinion obtained in March 2021 is consistent with and responsive to the remand directives, and adequate for deciding the issue on appeal. See Stegall, 11 Vet. App. at 271; see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only "substantial" rather than strict or exact compliance with the Board's remand directives is required under Stegall). Following issuance of the most recent supplemental statement of the case for the issue on appeal in April 2021, additional evidence was associated with the record. The additional evidence, which consists of medical records, is not pertinent to the issue on appeal, instead it is relevant to a different issue that is not on appeal. Accordingly, a remand for issuance of an additional supplemental statement of the case is not necessary, and the Board may proceed with appellate consideration. See 38 C.F.R. § 20.1305(c). 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 resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating is assigned if the disability picture more nearly approximates the criteria for the higher rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when assigning disability rating. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); 38 C.F.R. § 4.1. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the period of claim on appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45, 4.59. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court specified additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. In addition, assignment of a disability rating should consider limitation of functional ability during flare-ups or when a joint is used repeatedly over a period of time. See DeLuca 8 Vet. App. 202. Specifically, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court stated that flare-ups must be considered in providing an estimate of additional functional loss based on range of motion. Based on range of motion generally knee disabilities are rated pursuant to 38 C.F.R. § 4.71a, diagnostic code 5260 and/or 5261. Pursuant to diagnostic code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a maximum of 30 percent is assigned when flexion is limited to 15 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. Pursuant to diagnostic code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension of the leg is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is assigned when extension is limited to 30 degrees; and a maximum of 50 percent rating is assigned when extension is limited to 45 degrees. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71. Normal extension and flexion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71. The Board must consider whether the Veteran is entitled to separate ratings under diagnostic code 5260 (limitation of flexion of the leg) and diagnostic code 5261 (limitation of extension of the leg). VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). 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. Id. A number of other diagnostic codes also potentially apply to knee ratings. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on ankylosis of knee (Diagnostic Code 5256), instability and recurrent subluxation (Diagnostic Code 5257), meniscal conditions (Diagnostic Codes 5258, 5259), impairment of tibia and fibula (Diagnostic Code 5262), and genu recurvatum (Diagnostic Code 5263). 38 C.F.R. § 4.71a, Diagnostic Code 5256, 5257, 5258, 5259, 5262, 5263. Additionally, if arthritis is established by X-ray findings, and limitation of motion of the joint(s) is non-compensable or in the absence of limitation of motion, disability rating can also be considered under specific diagnostic codes 5003 and 5010 for arthritis for each major joint or group of minor joints. See 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010. Also, under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; and joints that are actually painful, unstable, or malaligned due to healed injury should be entitled to at least the minimum compensable rating for the joint. However, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). 1. Entitlement to an increased disability rating in excess of 10 percent for the service-connected residuals, right knee injury with post-traumatic arthritis. The Veteran contends that he is entitled to a higher rating for his knee disability because it has increased in severity. The Veteran submitted a claim for increased rating for his service-connected right knee disability in June 2011, which is the start of rating period for issues on appeal. Previously, in a June 1982 rating decision, the RO assigned a noncompensable rating for residuals, right knee injury under diagnostic code 5257. 38 C.F.R. § 4.71a, Diagnostic Code 5257. In a December 2001 rating decision, the RO increased the disability rating to 10 percent under diagnostic code 5257-5010 because the Veteran had increased symptoms with painful or limited motion, and degenerative joint disease was diagnosed. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; additional code is shown after the hyphen. See 38 C.F.R. § 4.27. Therefore, the RO rated residuals, right knee injury as post-traumatic arthritis under diagnostic code 5010 because the Veteran was receiving service connection for right knee disability based on an in-service injury. Currently, the service-connected residuals, right knee injury with post-traumatic arthritis is rated as 10 percent under Diagnostic Code 5260-5010. The Board notes that, effective February 7, 2021, certain parts of 38 C.F.R. § 4.71a, which provides the ratings schedule for disabilities of the musculoskeletal system, were revised. 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). 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. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied from February 7, 2021. The Board notes that the diagnostic code 5010 was amended effective February 7, 2021. The regulatory changes reworded diagnostic code 5010 from "Arthritis, due to trauma, substantiated by X-ray findings" to "Post-traumatic arthritis". Prior to the regulatory change, diagnostic code 5010 directed that the disability (arthritis due to trauma) be rated as degenerative arthritis under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2020). As of February 7, 2021, under the amended criteria, diagnostic code 5010 directs that the disability (post-traumatic arthritis) be rated as limitation of motion, dislocation, or other specified instability under the affected joint. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2021). If there are 2 or more joints affected, each rating is to be combined in accordance with 38 C.F.R. § 4.25. Id. Consequently, the Board will consider the old diagnostic code 5010 prior to February 7, 2021, and new and old both criteria thereafter. The regulatory changes reworded the diagnostic code 5003 from "Arthritis, degenerative (hypertrophic or osteoarthritis)" to "Degenerative arthritis, other than post-traumatic", but did not change the actual criteria for rating disabilities under the diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2021). Under diagnostic code 5003 (under both old and new criteria) degenerative arthritis, when established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020, 2021). 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 diagnostic code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 20 percent evaluation is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Id. A 10 percent evaluation is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups. Id. Turning to the medical evidence of record from the beginning of the rating period, the Board notes that a June 2011 VA treatment record indicated that the Veteran reported right knee pain. During physical examination, the clinician noted pain, limited mobility, and stiffness in the right knee. During the July 2011 VA compensation and pension examination (C&P examination), the Veteran reported that the pain was constant and worsen with walking. Joint symptoms included giving way, pain, crepitus, and swelling. There was no instability, stiffness, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking episodes, or effusions. Gait was normal and no patellar or meniscus abnormalities were noted. Range of motion ("ROM") testing showed flexion to 115 degrees and extension to 0 degrees. There was objective evidence of pain with active and repetitive motion, but there was no additional limitation after three repetitions of ROM. There was no joint ankylosis. The examiner noted a June 2011 X-ray showed moderate narrowing of the right medial tibial femoral compartment, mild degenerative change in the patellofemoral compartments with minimal degenerative change in the lateral tibial femoral compartment. The Veteran lost three weeks of work during the past 12 months. A September 2011 VA physical therapy note indicated right knee pain. Physical examination revealed an antalgic gait. ROM testing showed flexion to 110 degrees and extension to 0 degrees. A medial/lateral stress test showed no instability with varus/valgus stress testing at 0 and 30 degrees flexion. Lachman's test showed minimal anterior laxity right lower extremity. McMurray test was positive for medial/lateral meniscal tear right lower extremity. Tenderness to palpation at medical lateral joint lines right knee. The examiner was concerned with 3+ pitting edema of the lower extremities and was unsure about the cause. An October 2011 VA orthopedic consult note reflected that the Veteran's knee problem had worsened recently. He had pain on stairs and pain when walking despite the use of naproxen. Gait was slightly antalgic on the right. The right knee was aligned in neutral with active motion from 0 to 115 degrees. There was no swelling, inflammation, or tenderness of the right knee and the Veteran had a good dorsal pedal pulse. Lachman's test was 3+ with soft end point. The clinician noted that the June 2011 radiographs showed osteoarthritis in all compartments, most obvious in the medial compartment with narrowing and dense reactive bone formation. The July 2011 MRI films of the knee confirmed these findings, and there was absent anterior cruciate ligament ("ACL"). An October 2011 primary care clinic note indicated right knee pain. The examiner noted the findings of the July 2011 MRI, which showed "degenerative tear of the medial meniscus; small horizontal tear involving the junction of the posterior horn and body of the lateral meniscus; tricompartmental osteoarthritis changes, more prominent in the medical joint compartment; nonvisualization of the ACL, likely torn; mild prepatellar soft tissue edema; and high-grade medial joint compartment chondromalacia." During the June 2014 VA C&P examination, the examiner noted the diagnosis of right knee traumatic arthritis and meniscal tear. The Veteran reported pain of 7 to 8 out of 10, which was the same for the previous year. The Veteran reported flare-ups 2 to 3 times per month. Right knee flexion was to 120 degrees, with pain beginning at 120 degrees. Right knee extension was to 0 degrees, with pain beginning at 10 degrees. The Veteran was able to perform three repetitions with no additional loss of ROM. Functional loss was described as incoordination, impaired ability to execute skilled movements smoothly, swelling, and disturbance of locomotion. There was no tenderness or pain to palpation for joint line or soft tissue of the right knee. Muscle strength and stability testing was normal. There was no history of recurrent patellar subluxation or dislocation. The Veteran had not had a meniscectomy or other knee surgery. The Veteran had difficulty walking distances and had to walk slowly while doing his job as an airplane inspector. The Veteran did not use any assistive devices. The examiner found that the right knee meniscal tear was not caused by the service-connected degenerative arthritis, and the meniscal tear might be responsible for premature development of osteoarthritis of the knee. The Veteran underwent another right knee VA C&P examination in March 2016, in which the Veteran reported that his right knee frequently swelled up, usually when he accidentally twisted the knee while walking; the swelling took one to three days to go back to baseline with rest and ice packs. The knee frequently clicked during walking, however, the Veteran reported that it did not lock. He also reported that he had never had intraarticular injections or any type of knee surgery. He did not use a cane, walker, or any assistive device for right knee. Flare-ups occurred when he walked for more than 10 minutes, stood still for more than 15 minutes, squatted, pivoted, and sat for a long time with his knee bent. He also reported the cold weather increased his knee pain. The physical examination showed flexion limited to 110 degrees and extension limited to 0 degrees. Pain was noted on examination, which caused functional loss. There was moderate tenderness over the medial and superomedial aspects of the right knee. There was objective evidence of crepitus. After three repetitions, flexion was 0 to 100 degrees and extension 100 to 0 degrees. Factors that caused functional loss included pain, weakness, lack of endurance, and incoordination. Muscle strength testing of the right knee was 4/5 on flexion and 5/5 on extension. The examiner noted that the reduction in muscle strength was entirely due to the diagnosed right knee disabilities. The Veteran did not have muscle atrophy or ankylosis. The examiner also noted that there was a history of slight lateral instability and recurrent effusion. Instability tests showed 1+ (0-5 millimeters) of anterior, medial, and lateral instability. The examiner noted the Veteran had a meniscus condition described as meniscal tear, frequent episodes of joint pain and effusion. After reviewing the claims file, the examiner stated that the Veteran's degenerative disease of the right knee had progressed from a mild degree in 2001 to a severe degree in 2016 on top of the development of meniscal and ACL tear as well as a popliteal cyst. During the December 2017 VA C&P examination, the examiner noted diagnosis of right knee meniscal tear, anterior cruciate ligament tear, osteoarthritis, chondromalacia of the knee (high grade), popliteal cyst. The Veteran reported that he had flare-ups with severe pain and swelling. He further stated that he was unable to run and tried to avoid lifting heavy items, prolonged walking, prolonged standing, climbing more than a few steps at a time, repetitive bending, squatting, and kneeling. However, he stated that fortunately his job involved lot of desk work, and he did not have to do stressful activity as he had when he worked as an aircraft mechanic. The examiner noted right knee flexion from 0 to 110 degrees and extension 110 to 0 degrees. The examiner stated that he was unable to determine whether pain, weakness, fatigability, or incoordination would significantly limit functional ability with flare-ups since he would need to resort to speculation in this hypothetical situation. The examiner noted 5/5 muscle strength during both flexion and extension, and there was no muscle atrophy. The examiner did not find ankylosis, subluxation or lateral instability of the right knee. The examiner noted meniscal tear but no pain on passive range of motion testing on flexion and extension of the right knee. There was also no evidence of pain when the right knee was assessed in non-weight bearing flexion and extension. (active flexion and extension of the right knee). There were no abnormalities noted on examination of the opposing (contralateral) left knee joint. The examiner further stated that as a result of the severity of the Veteran's right knee condition, with meniscus and ACL tears, degenerative arthritis and high-grade chondromalacia, chronic edema, and pain with range of motion and weightbearing, an orthopedic reevaluation for possible right knee arthroscopic surgical repairs versus a total knee arthroplasty would be considered. However, there was a much higher surgical risk than typical because of the Veteran's impaired cardiopulmonary status, hypertension, diabetes, heavy weight, and other medical conditions. Since during the December 2017 VA examination, the examiner did not address functional loss during flare-ups, the Board remanded the matter again in January 2019 and directed the examiner to discuss additional function loss during flare-ups. Hence, another VA examination was scheduled in May 2019, during which the examiner noted right knee ROM as 0 to 105 degrees on flexion and 105 to 0 degrees on extension. The examiner stated that the Veteran's history, physical examination and review of available medical records support a worsening of functional ability with flare-ups, therefore, it was more likely than not (far greater than 50% probability) that pain, weakness, fatigability or incoordination would potentially and significantly limit the Veteran's functional ability with flare-ups. The examiner further explained that no loss of extension was anticipated. However, a loss of range of up to 10 degree of flexion was anticipated with a very mild flare-up, but 20 to 45 degrees loss of flexion was anticipated for a much more severe flare-up, until the flare-up subsides (usually after several hours for a mild flareup, but could be as long as 1-2 days for a more severe flareup). The examiner did not find right knee subluxation and lateral instability. The examiner noted mild prepatellar soft tissue edema. The examiner also noted occasional use of cane as an assistive device. The examiner concluded that the Veteran had severe chondromalacia of the right knee and tricompartmental degenerative arthritis. The Veteran also had mild instability at times because of the old ACL tear, and had mild edema of the right knee, which appeared to be chronic in nature based upon prior C&P evaluation of the knee in 2017 and MRI examination in 2016. The Board remanded the matter again in October 2020 and directed the examiner to provide a retrospective opinion based on medical and lay evidence. Therefore, another VA medical opinion was obtained in October 2020, in which the examiner reiterated the comments of the previous VA examiners from 2016 and 2017 and the findings of 2011 and 2016 MRI reports, and stated that the Veteran had mild instability of the right knee, moderate loss of range of motion of the right knee, which was most likely severe when he had a flare-up with increased pain and increased edema of the knee. However, the greatest functional impairment was loss of mobility, including walking more than a short distances or standing for more than a few minutes because of the severe degenerative changes of the right knee, which included high-grade chondromalacia, torn medial and lateral menisci, and tricompartmental degenerative arthritis of the knee that had progressively become more severe and more painful. The examiner further stated that the Veteran likely would benefit considerably from a right total knee replacement, but the orthopedic surgeons were hesitant because of the high risk involved due to the Veteran's diabetes, hypertension, cardiopulmonary condition, being extremely overweight, and his other medical conditions. Subsequently, in March 2021, the Board remanded the matter again and instructed the examiner to provide a retrospective medical opinion that adequately assesses the severity of the Veteran's right knee disability from June 22, 2011 (the date of increased rating claim) to May 20, 2019 (the date of the most recent in-person examination). Specifically, the Board directed the examiner to address all previous VA examinations of the right knee since June 2011. Consequently, another VA medical opinion was obtained in March 2021, in which the examiner stated that any examiner, including himself is unable to estimate the degrees of additional range of motion loss during flare-ups or after repeated use without resorting to speculation. He further elaborated that the need to speculate was not caused by a deficiency in the state of general medical knowledge (i.e. no one could respond precisely, given medical science and the known facts) or deficiency in the medical record. Even then, one must use his/her expertise to analyze the Veteran's statements as to loss of range with repeated use or during a flare-up at each interval, relying on one's overall medical knowledge if the Veteran had not been examined during the actual flare-up. The examiner further stated that he could provide estimates based upon his professional education and experience over many years, as requested, but it would be untruthful to state that speculation is not involved, since a certain amount of speculation is always involved in these statements when the impairments in range of motion are not directly observed. In providing a retrospective opinion, as requested by the Board in the March 2021 remand, the examiner addressed the previous VA examinations one by one. For the July 2011 VA examination, the examiner noted documented right knee pain, swelling, and loss of range of motion. The examiner noted that the Veteran was able to stand up to one hour and walk for 1/4 mile. The Veteran had normal gait but did not need assistive devices or aids. There was crepitus of the right knee. There was 0 to115 degrees of range of motion of the right knee, compared to 0 to 130 degrees of range of motion of the left knee. There was evidence of pain following repetitive motion, but no additional limitations after only three repetitions. The June 2011 X-ray of the right knee demonstrated moderate narrowing of the right medial tibial femoral compartment. There was mild degenerative change in the patellofemoral compartments with minimal degenerative change in the lateral tibial femoral compartment. No fracture or dislocation or bone destruction was seen, and the impression was degenerative changes. The examiner noted that there was estimated 0 to 10 degree of additional loss of flexion after repeated use and during flare-ups, and the most severe loss could result in approximately 0 to 105 degree of flexion. Then examiner noted that the July 2011 MRI demonstrated high-grade chondromalacia and meniscus tears, which were medically known to develop in conjunction with the degenerative arthritis of the knee and are most likely (greater than 50% probability) a progression of the Veteran's service-connected condition and likely contributed to the loss of range of motion of the right knee. The impression of the July 2011 MRI was "complex degenerative tear of the medial meniscus, small horizontal tear involving the junction of the posterior horn and body of the lateral meniscus, tricompartmental osteoarthritis changes, more prominent in the medial joint compartment, nonvisualization of the ACL (likely torn), mild prepatellar soft tissue edema, and high-grade medial joint compartment chondromalacia." For the June 2014 VA examination, the examiner noted that there was pain on movement of the right knee, swelling, and disturbance of locomotion, and documented 0 to 120 degree of flexion of the right knee, which was very close to the measurement that had been taken 3 years earlier. The examiner stated that the Veteran underwent another MRI in March 2016, and overall, there was no significant interval change. The examiner noted that the March 2016 MRI showed no acute tear in the medial collateral ligament and lateral collateral ligament complex. The lateral meniscus showed stable horizontal abnormal signal at the posterior horn and body. There was abnormal morphology and signal of the medial meniscus compatible with complex tear. The anterior cruciate was not seen. The posterior cruciate ligament showed no acute tear. The medial and lateral patellar retinaculum showed no acute tear. Evaluation of extensor mechanism revealed a normal quadriceps and patellar tendon. Evaluation of the osseous structures demonstrated tricompartmental osteophytes and significant narrowing of the medial joint compartment. The articular cartilage was lost in the medial joint compartment. There was no significant suprapatellar effusion. There was mild prepatellar soft tissue swelling, and a popliteal cyst. The visualized muscles of the knee were normal in appearance. The impression was stable complex degenerative tear of the medial meniscus, stable lateral meniscal tear, tricompartmental osteoarthritis changes, more prominent in the medial joint compartments, mild prepatellar soft tissue edema, high-grade medial joint compartment chondromalacia, ACL tear, and Popliteal cyst. The examiner stated that ROM during March 2016 examination was 0 to 110 degrees of right knee flexion, and 0 to 100 degrees of right knee flexion with repetitive use. The examiner stated that in the next right knee VA examination in December 2017, 0 to 110 degree of right knee flexion was noted. The examiner explained that in both examinations additional functional loss was estimated after repeated use and during flare-ups, with additional loss of 0 to 10 degrees of flexion was estimated. The most severe loss could result in approximately 0 to 100 degrees of flexion. Loss of range of motion of the right knee during the interval between the two examination could be extrapolated to be 0 to 112.5 degrees of flexion, and as much as 0 to 102.5 degree of flexion with repeated use over time and during a flare-up. For the May 2019 VA examination, the examiner noted the right knee flexion of 0 to 105 degrees was documented, and right knee flexion of 0 to 95 degrees for repeated use over time and during flare-ups was anticipated. Loss of range of motion of the right knee during the interval between December 2017 and May 2019 examination could be extrapolated to be 0 to 107.5 degree flexion, and 0 to 97.5 degree flexion with repeated use over time and during a flare-up. As discussed above, before regulatory change, diagnostic code 5010 instructed to rate post-traumatic arthritis as degenerative arthritis under diagnostic code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2020). After the February 7, 2021 regulatory change, diagnostic code 5010 instructs to rate post-traumatic arthritis as limitation of motion, dislocation, or other specified instability under the affected joint. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2021). If there are 2 or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Id. The Board notes that X-rays have shown degenerative arthritis in the Veteran's right knee. Since the Veteran's had painful and limited motion throughout the appeal period, the arthritis in the right knee would be rated under range of motion throughout the appeal period, including the period before and after the regulatory change. However, the Board finds that older criteria seem to be more favorable to the Veteran because the older diagnostic code 5003 warrants at least 10 percent rating if limitation of motion is non-compensable. The Board notes the diagnostic codes 5260 and 5261 for limited range of motion were not amended under the recent regulatory change and are the same throughout the appeal period. The lay and medical evidence throughout the appeal period does not warrant a separate rating or higher rating in excess of 10 percent under diagnostic codes 5260 and 5261 for limited range of motion because there is no evidence of flexion limited to 45 degrees, and extension limited to 10 degrees, with additional estimated loss of range of motion during flare-ups in VA treatment records, including July 2011, June 2014, March 2016, December 2017 and May 2019 in-person VA examinations. The worse limitation of motion was noted in May 2019 VA examination as 0 to 105 degrees for flexion and 105 to 0 degrees for extension of the right knee, with additional estimated loss of range of motion of 20 to 45 degrees for flexion during severe flare-ups but not for extension. Since the limitation of motion for both flexion and extension of the right leg is non-compensable throughout the appeal period, at least 10 percent rating is warranted for right knee post-traumatic arthritis under the old diagnostic code 5003, and the Veteran is already receiving this rating since December 2000. 38 C.F.R. § 4.71a, Diagnostic Code 5003, 5010 (2020). And a separate or higher rating in excess of 10 percent for limited range of motion is not warranted because as discussed above the range of motion is not even compensable throughout the appeal period. The Board also notes that the Veteran demonstrated painful motion throughout the appeal period. Since the Veteran is already in receipt of 10 percent disability rating for right knee disability for post-traumatic arthritis from December 28, 2000 under diagnostic code 5010, a separate compensable evaluation under 38 C.F.R. § 4.59 for painful motion would be inappropriate. See 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5010. For the above described reasons, the Board finds that the preponderance of the evidence weighs against the assigment of a disability rating in excess of 10 percent for the service-connected residuals, right knee injury with post-traumatic arthritis for the entire rating period from June 2011 to the present. 2. A higher disability rating for the service-connected right knee instability with anterior cruciate ligament tear, in excess of the currently-assigned 10 percent from March 31, 2016 and 20 percent from February 7, 2021 to the present. As noted above, the Veteran submitted a claim for increased rating for his service-connected right knee disability in June 2011, which is the start of rating period for issues on appeal. As discussed above, the Veteran is receiving a 10 percent separate rating for the service-connected residuals, right knee injury with post-traumatic arthritis since December 28, 2000. After the Board's February 2016 remand, the Veteran was afforded another in-person examination for his right knee disability, in which the VA examiner noted slight lateral instability. Therefore, in an April 2016 rating decision, the RO assigned a separate rating for the service-connected right knee disability based on noted instability with an evaluation of 10 percent from March 31, 2016, the date of VA examination. Subsequent to the Board's March 2021 remand, an addendum medical opinion was obtained in March 2021, after which, in an April 2021 rating decision, the RO increased the rating to 20 percent for the service-connected right knee instability with anterior cruciate ligament tear with an effective date of February 7, 2021 under diagnostic code 5257. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). The Board notes that, effective February 7, 2021, certain parts of 38 C.F.R. § 4.71a, which provides the ratings schedule for disabilities of the musculoskeletal system, were revised. 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). 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. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The Board also notes that the diagnostic code 5257 for knee impairment was amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). "Slight" is defined as "small of its kind or in amount." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed July 7, 2021). "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. Within the context of the old version of diagnostic code 5257, which established a successive, tiered rating structure, "severe" represented the highest or most extreme level of disability. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). As of February 7, 2021, diagnostic code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). The first is for recurrent subluxation or instability and second for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. See 38 C.F.R. § 4.31; see also 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). "Persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed July 7, 2021). Under these new criteria, a 30 percent rating is assigned with 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. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. Id. 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 or bracing for ambulation. Id. Regarding patellar instability, 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 warrants a 30 percent rating, which is the highest allowable rating for patellar instability. Id. 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 warrants a 20 percent rating. Id. 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 warrants a 10 percent rating. Id. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1) (2021). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability does not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id. at Note (2). Rating for the right knee instability from June 22, 2011 to March 31, 2016: For rating of the right knee instability from the beginning of appeal period, the Board notes that a June 2011 VA treatment record indicated that the Veteran reported right knee pain. During physical examination, the clinician noted pain, limited mobility, and stiffness in the right knee, but did not note any recurrent subluxation or lateral instability. During the July 2011 VA examination, the Veteran reported that the pain was constant and worsen with walking. Joint symptoms included giving way, pain, crepitus, and swelling. There was no instability, stiffness, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking episodes, or effusions. No patellar or meniscus abnormalities were noted. There was no joint ankylosis. The examiner noted a June 2011 X-ray showed moderate narrowing of the right medial tibial femoral compartment, mild degenerative change in the patellofemoral compartments with minimal degenerative change in the lateral tibial femoral compartment. A September 2011 VA physical therapy note indicated right knee pain. Physical examination revealed an antalgic gait. ROM testing showed flexion to 110 degrees and extension to 0 degrees. A medial/lateral stress test showed no instability with varus/valgus stress testing at 0 and 30 degrees flexion. Lachman's test showed minimal anterior laxity right lower extremity. McMurray test was positive for medial/lateral meniscal tear right lower extremity. An October 2011 VA orthopedic consult note reflected that the Veteran's knee problem had worsened recently. He had pain on stairs and pain when walking despite the use of naproxen. Gait was slightly antalgic on the right. The right knee was aligned in neutral with active motion from 0 to 115 degrees. There was no swelling, inflammation or tenderness of the right knee and the Veteran had a good dorsal pedal pulse. Lachman's test was 3+ with soft end point. The clinician noted that June 2011 radiographs showed osteoarthritis in all compartments, most obvious in the medial compartment with narrowing and dense reactive bone formation. Also, the July 2011 MRI films of the knee confirmed these findings, and there was absent anterior cruciate ligament ("ACL"). The clinician did not note any lateral instability or recurrent subluxation. In an October 2011 VA treatment record, the clinician noted the July 2011 MRI findings, which showed "degenerative tear of the medial meniscus; small horizontal tear involving the junction of the posterior horn and body of the lateral meniscus; tricompartmental osteoarthritis changes, more prominent in the medial joint compartment; nonvisualization of the ACL, likely torn; mild prepatellar soft tissue edema; and high-grade medial joint compartment chondromalacia." During the June 2014 VA examination, the examiner noted the diagnosis of the right knee traumatic arthritis and meniscal tear. The Veteran reported pain of 7 to 8 out of 10, which was the same for the previous year. Functional loss was described as incoordination, swelling, pain on movement, and disturbance of locomotion. There was no tenderness or pain to palpation for joint line or soft tissue of the right knee. Muscle strength and stability testing was normal. There was no history of recurrent patellar subluxation or dislocation. The joint stability test was normal. The Veteran had not had a meniscectomy or other knee surgery. The Veteran had difficulty walking distances and had to walk slowly while doing his job as an airplane inspector. The Veteran did not use any assistive devices. The examiner found that the right knee meniscal tear was not caused by the service-connected degenerative arthritis, and the meniscal tear may be responsible for premature development of osteoarthritis of the knee. The Veteran underwent another right knee VA examination in March 2016, in which the Veteran reported that his right knee frequently swelled up, usually when he accidentally twisted the knee while walking; the swelling took one to three days to go back to baseline with rest and ice packs. Pain was noted on examination, which caused functional loss. The examiner noted moderate tenderness over the medial and superomedial aspects of the right knee. There was objective evidence of crepitus. There was a history of slight lateral instability and recurrent effusion noted by the examiner. Instability tests showed 1+ (0-5 millimeters) of anterior, medial, and lateral instability. The examiner noted the Veteran had a meniscus condition described as meniscal tear, frequent episodes of joint pain and effusion. The examiner noted that the lateral instability of the right knee was "slight." The Board notes that the first time right knee instability was noted by a VA examiner during the March 2016 VA examination. As noted above, a slight lateral instability warrants a 10 percent rating under diagnostic code 5257, which was effective before February 7, 2021. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). Consequently, the RO granted a separate 10 percent rating for the right knee instability with an effective date of March 31, 2016 based on notation in the March 2016 VA examination. Objective medical evidence is not required to establish lateral knee instability under diagnostic code 5257, thus objective medical evidence cannot be categorically found more probative than lay evidence with respect to this diagnostic code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). In this regard, the Board notes that during the July 2011 VA examination, the Veteran stated that his knee "gives away". However, overall, the lay and medical evidence indicates that there was no recurrent subluxation or lateral instability at least prior to March 2016. Particularly in an October 2020 remand, the Board directed the VA examiner to address signs of recurrent subluxation or lateral instability at any time prior to March 31, 2016. Consequently, in the October 2020 medical opinion, the examiner explained that during the May 2019 physical examination, he detected mild anterior instability on the right knee but no lateral instability. He further explained that he did not detect evidence of anterior or lateral instability during the previous examination in December 2017. Regarding notation of "slight instability" during the March 2016 examination, the October 2020 examiner explained that in the March 2016 examination no subluxation was documented but Dr. Perez-Rivas, an internist/cardiologist, checked the boxes for slight medial/lateral instability. Range of motion of the right knee at that time was 0 to 110 degrees. On an earlier orthopedic surgery examination in October 2011, the Veteran had 0 to 115 degrees range of motion. At that time the Veteran had 3+ anterior instability (rather than 1+ detected in 2017 and in 2019). There was no mention of lateral instability. Diminished anterior instability over the years could be due to the gradual formation of scar tissue, degenerative changes, etc., which diminished the extent of anterior instability. The examiner further explained that the July 2011 right knee MRI noted "the medial collateral ligament and lateral collateral ligament complex show no acute tear...nonvisualization of the ACL, likely torn..." The March 2016 right knee MRI report noted "Findings: comparison is made with prior MRI of July 2011. Overall, no significant interval changes. The medial collateral ligament and lateral collateral ligament complex show no acute tear. The lateral meniscus shows stable horizontal abnormal signal at the posterior horn and body. There is abnormal morphology and signal of the medial meniscus compatible with complex tear. The anterior cruciate is not seen. The posterior cruciate ligament shows no acute tear...ACL tear..." The examiner elaborated that the two MRI findings were consistent with the anterior instability that was noted in the orthopedic surgeon's and the physiatrist's notes, but there were no tears that were consistent with medial or lateral instability, which was not noted on the orthopedic surgeon's and the physiatrist's notes. This is analogous to a subtle murmur being detected by an internist/cardiologist, but not by an orthopedic surgeon or a physiatrist - in this instance the cardiologist is more likely accurate, whereas on the knee exam the orthopedic surgeon and the physiatrist are more likely to be accurate. The examiner further explained that the orthopedic surgeon did not detect lateral instability of the right knee prior to the internist/cardiologist's evaluation in March 2016. After March 2016, the physiatrist examined the Veteran twice, December 2017 and May 2019, and did not detect lateral instability of the right knee. The mild lateral instability noted by the internist/cardiologist was most likely in error. The examiner then stated that the July 2011 VA examination report which notes the Veteran's affirmative response to the right knee "giving way" was most likely due to the torn ACL that was detected on the MRI examinations in July 2011 and March 2016. Based on above analysis, the Board finds that the preponderance of the evidence shows that there was no subluxation or lateral instability prior to March 2016. Therefore, a compensable rating for right knee instability is not warranted prior to March 31, 2016 under diagnostic code 5257 effective prior to February 7, 2021. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). Rating for the right knee instability from March 31, 2016 to February 7, 2021: As noted above, during the March 2016 VA examination, the examiner noted slight right knee instability, therefore, the RO granted a 10 percent rating for the right knee instability with an effective date of March 31, 2021, which is the date of examination. Subsequently, the Veteran underwent another VA examination in December 2017, in which the examiner noted the diagnosis of right knee meniscal tear, anterior cruciate ligament tear, osteoarthritis, chondromalacia of the knee (high grade), popliteal cyst. The Veteran reported that he had flare-ups with severe pain and swelling that are activity related. He further stated that he was unable to run and tried to avoid lifting heavy items, prolonged walking, prolonged standing, climbing more than a few steps at a time, repetitive bending, squatting, and kneeling. The examiner noted 5/5 muscle strength during both flexion and extension, and there was no muscle atrophy. The examiner did not find ankylosis, subluxation or lateral instability of the right knee. There were no abnormalities noted on examination of the opposing (contralateral) left knee joint. During the May 2019 VA examination, the Veteran stated that he was able to straighten his right leg during severe flare-ups, however, loss of motion was severe during flare-ups. The examiner explained that the Veteran's history, physical examination and review of available medical records support a worsening of functional ability with flare-ups, and therefore it is more likely than not (far greater than 50% probability) that pain, weakness, fatigability or incoordination would potentially and significantly limit the Veteran's functional ability with flare-ups. No loss of extension was anticipated. However, a loss of range of up to 10 degrees of flexion was anticipated with a very mild flareup, but 20 to 45 degrees loss of flexion was anticipated for a much more severe flareup, until the flare-up subsides (usually after several hours for a mild flareup, but could be as long as 1-2 days for a more severe flareup). The examiner did not find right knee subluxation and lateral instability. The examiner noted mild prepatellar soft tissue edema. The examiner also noted occasional use of cane as assistive device. The examiner concluded that the Veteran had severe chondromalacia of the right knee and tricompartmental degenerative arthritis. The Veteran also had mild instability at times because of the old ACL tear, and had mild edema of the right knee, which appeared to be chronic in nature based upon prior C&P evaluation of the knee in 2017 and MRI examination in 2016. During the October 2020 VA examination, the examiner stated that the Veteran had mild instability of the right knee, moderate loss of range of motion of the right knee, which was most likely severe when he had a flare-up with increased pain and increased edema of the knee. However, the greatest functional impairment was loss of mobility i.e. walking more than a short distances or standing for more than a few minutes because of the severe degenerative changes of the right knee, which included high-grade chondromalacia, torn medial and lateral menisci, and tricompartmental degenerative arthritis of the knee that had progressively become more severe and more painful. Based on VA examinations, including December 2017, May 2019 and October 2020 examinations, and the Veteran's reports of symptoms, the Board finds that the preponderance of evidence suggests that there was no moderate subluxation or lateral instability from March 31, 2016 to February 7, 2021, therefore, a rating in excess of 10 percent for the service-connected right knee instability with anterior cruciate ligament tear is not warranted under diagnostic code 5257, which was effective prior to February 7, 2021. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). Rating for the right knee instability from February 7, 2021 to the present: As noted above the diagnostic code 5257 was amended with an effective date of February 7, 2021. Therefore, the Board remanded the matter again in March 2021 and instructed the examiner to provide an opinion regarding ACL tear and if it causes instability or if it requires an assistive device prescribed by a medical provider as provided in newly amended diagnostic code 5257. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). Regarding ACL tear and assistive device, in the March 2021 medical opinion, the VA examiner stated that the ACL was not visualized in the July 2011 and March 2016 right knee MRI examinations. However, both MRIs were consistent with a complete ACL tear. The examiner explained that the tear was not repaired because the Veteran had a very high surgical risk. The ACL tear causes mild persistent anterior instability of the right knee. The ACL tear on its own would likely require a prescription from a medical provider for an assistive device (e.g., a cane, or possibly a walker), but probably not bracing for ambulation. However, when in conjunction with high-grade chondromalacia of the knee with meniscus tearing and tricompartmental degenerative arthritis, which are medically known to continue to progress, the Veteran has a severe right knee impairment that necessitates assistive devices. The examiner further stated that in 2020 the Veteran was prescribed a roller walker with a seat to enable him to ambulate short distances, rest, ambulate a little further, rest, and ambulate more, etc. Based on the March 2021 VA opinion, in an April 2021 rating decision, the RO increased the rating to 20 percent for the right knee instability under newly amended diagnostic code 5257. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). The Board finds the assigned rating is consistent with current version of diagnostic code 5257, which warrants a 20 percent rating for 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), or a walker) or bracing for ambulation. Id. A higher rating of 30 percent is not warranted under new criteria because the evidence of record shows that the Veteran has unrepaired complete ligament tear in the right knee causing persistent instability, and a medical provider prescribed an assistive device (e.g., cane(s), crutch(es), walker) but not a bracing for ambulation. As noted by the examiner in March 2021 that the Veteran probably requires an assistive device (e.g., a cane, or possibly a walker), but not bracing for ambulation. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). Also, the examiner noted that in 2020 the Veteran was prescribed a roller walker with a seat to enable him to ambulate, however, there is no evidence showing that a bracing was prescribed for ambulation. The Board finds that a higher rating of 30 percent from February 7, 2021 is also not warranted for patellar instability under new criteria because no surgical repair has been performed for right knee condition. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). The Board also finds that a higher rating of 30 percent from February 7, 2021 is also not warranted under the old criteria because the preponderance of the evidence is against the finding that the Veteran has severe recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). Consequently, based on the above analysis the Board finds that the preponderance of the evidence is against an assignment of disability rating in excess of 20 percent for service-connected right knee instability with anterior cruciate ligament tear, from February 7, 2021 to the present. The Board has also considered the other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107, 118 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The Board notes that only two diagnostic codes 5257 and 5262 for knee disabilities were amended in the recent regulatory change for musculoskeletal system. However, the remaining diagnostic codes relating to knee and leg disabilities, including 5256, 5258, 5259, 5260, 5261, and 5263 were not amended. The Board finds that throughout the appeal period, the Veteran's right knee disability did not demonstrate knee ankylosis; or dislocated semilunar cartilage in the right knee manifested by frequent episodes of "locking," pain, and effusion into the joint; or symptomatic residuals related to removal of semilunar cartilage. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259. Therefore, a separate or higher rating is not available under these diagnostic codes. The lay and medical evidence throughout the appeal period does not warrant a separate rating or higher rating under diagnostic codes 5260 and 5261 for limited range of motion because there is no evidence of flexion limited to 45 degrees, and extension limited to 10 degrees, including additional estimated loss of range of motion during flare-ups, noted in VA treatment records or examinations, including July 2011, June 2014, March 2016, December 2017 and May 2019 in-person VA examinations. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The worse limitation of motion was noted in May 2019 VA examination as 0 to 105 degrees for flexion and 105 to 0 degrees for extension of the right knee, with additional estimated loss of range of motion of 20 to 45 degrees for flexion but not for extension during severe flare-ups. Therefore, a separate or increased rating is not warranted for the right knee disability under diagnostic code 5260 and 5261 for limited range of motion even during flare-ups. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Also, a separate or higher rating in not warranted under diagnostic code 5262 under old or new criterial because the evidence of record does not show any tibia or fibula impairment in the right leg. 38 C.F.R. § 4.71a, Diagnostic Code 5262 (2020, 2021). The Board further finds that diagnostic code 5263 for genu recurvatum is not applicable to the right knee disability as the medical evidence does not show that the Veteran has had that condition in the right knee during the course of the appeal period. 38 C.F.R. § 4.71a, Diagnostic Code 5263. Consequently, entitlement to a higher disability rating for the service-connected right knee instability with anterior cruciate ligament tear, in excess of the currently-assigned 10 percent from March 31, 2016 and 20 percent from February 7, 2021 to the present, is denied. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tariq, Nadeem, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.