Citation Nr: 21051744 Decision Date: 08/23/21 Archive Date: 08/23/21 DOCKET NO. 12-23 618 DATE: August 23, 2021 ORDER An increased rating for a right knee disability based on limitation of extension of 30 percent, effective December 8, 2009, prior to September 22, 2020, is granted. An increased rating for a right knee disability based on limitation of extension in excess of 50 percent since September 22, 2020, is denied. A separate or increased rating for a right knee disability based on limitation of flexion, to include effective since September 22, 2020, is denied. A separate or increased rating for a right knee disability based on medial and lateral menisci conditions (meniscus tears) of 20 percent, effective since December 8, 2009, to include an increase from 10 percent since February 19, 2019, is granted. A separate increased rating for a right knee disability based on instability of 10 percent, effective since December 8, 2009, is granted. A temporary total rating based on convalescence for a right knee arthroscopic surgery on June 29, 2010, is denied. A temporary total rating based on convalescence for a right knee arthroscopic surgery on June 6, 2013, is denied. An increased rating for a left knee disability based on limitation of extension in excess of 20 percent prior to September 22, 2020, and in excess of 50 percent thereafter, is denied. A separate or increased rating for a left knee disability based on limitation of flexion prior to September 22, 2020, and in excess of 10 percent thereafter, is denied. An increased rating for a left knee disability based on medial and lateral menisci conditions (tears) of 20 percent, effective from February 19, 2019, through December 11, 2019, is granted. An increased rating for a left knee disability based on medial and lateral menisci conditions in excess of 10 percent since December 12, 2019, is denied. A temporary total rating based on convalescence for a left knee arthroscopic surgery on December 12, 2019, is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the appeal period prior to September 22, 2020, the Veteran's right knee disability including quadriceps muscle atrophy resulted in painful or limited motion due to pain, weakness, and other factors, with extension limited to 20 degrees during episodes of increased symptoms. 2. Since September 22, 2020, the Veteran's right knee is assigned the maximum rating for extension limited to 45 degrees during episodes of increased symptoms. 3. Throughout the appeal period, the Veteran's right knee disability resulted in painful or limited motion due to pain and other factors, but with flexion to greater than 45 degrees even during episodes of increased symptoms. 4. A separate or increased rating for a right knee disability based on medial and lateral menisci conditions (meniscus tears) of 20 percent, effective since December 8, 2009, and including since February 19, 2019, is granted. 5. Throughout the appeal period, the Veteran's right knee had a torn meniscus (medial and/or lateral menisci); although he had partial meniscectomies in 2010 and 2013 he had additional or continued tears, with nonoverlapping symptoms of frequent pain without movement, locking, and swelling or effusion into the joint. 6. Throughout the appeal period, the Veteran's right knee disability has resulted in frequent buckling or giving way (without a brace), but without objective instability, ligament sprain or tear, or laxity on testing, and the use of a brace and cane at times; with non-overlapping symptoms consistent with mild recurrent instability. 7. The Veteran's right knee disability has not manifested by ankylosis, tibia or fibula impairment, or acquired genu recurvatum. 8. The Veteran's right knee surgical scars are not painful or unstable, do not measure at least 144 square inches (929 square cm), and do not result in disabling effects. 9. Effective since September 22, 2020, the Veteran's right knee disability has a 50 percent rating for limited extension, 20 percent for a torn meniscus, and 10 percent for instability; which combine to the maximum allowable rating of 60 percent. 10. The Veteran did not have convalescence for one month or more, or severe postoperative residuals, after his June 2010 and June 2013 right knee surgeries. 11. Throughout the appeal period prior to September 22, 2020, the Veteran's left knee disability resulted in painful or limited motion due to pain and other factors, with extension limited to 15 degrees during episodes of increased symptoms. 12. Since September 22, 2020, the Veteran's left knee is assigned the maximum rating for extension limited to 45 degrees during episodes of increased symptoms. 13. Throughout the appeal period, to include since September 22, 2020, the Veteran's left knee disability resulted in painful or limited motion due to pain and other factors, but with flexion to greater than 45 degrees even during episodes of increased symptoms. 14. Resolving reasonable doubt in the Veteran's favor, from February 19, 2019, until his December 12, 2019, surgery (to include prior to February 19, 2019,) the Veteran's left knee had torn medial and lateral menisci with nonoverlapping symptoms of frequent pain without movement, locking, and effusion into the joint. 15. On December 12, 2019, the Veteran had a left knee arthroscopic surgery including a partial medial meniscectomy, and he continued to have post-surgical symptoms; with no post-surgical evidence of another torn meniscus. 16. The Veteran has had occasional right knee buckling or giving way, but without objective instability, ligament sprain or tear or laxity (except for in 2019), and the use of a brace and cane at times; but symptoms are contemplated by other ratings. 17. The Veteran's left knee disability has not manifested by ankylosis, tibia or fibula impairment, or acquired genu recurvatum. 18. The Veteran's left knee surgical scars are not painful or unstable, do not measure at least 144 square inches (929 square cm), and do not result in disabling effects. 19. Effective since September 22, 2020, the Veteran's left knee disability has a 50 percent rating for limited extension, 10 percent for limited flexion, and 10 percent for a meniscal condition; which combine to the maximum allowable rating of 60 percent. 20. After his December 12, 2019, left knee arthroscopic surgery, the Veteran did not have convalescence for one month or more, or severe postoperative residuals. CONCLUSIONS OF LAW 1. The criteria for an increased rating for a right knee disability based on limitation of extension of 30 percent, effective December 8, 2009, prior to September 22, 2020, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 2. The criteria for an increased rating for a right knee disability based on limitation of extension in excess of 50 percent since September 22, 2020, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 3. The criteria for an increased or separate compensable rating for the right knee disability based on limitation of flexion, to include since September 22, 2020, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 4. The criteria for a separate or increased rating for the right knee based on based on medial and lateral menisci (meniscus tears) of 20 percent, effective since December 8, 2009, and including since February 19, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5258 & 5259. 5. The criteria for a separate increased rating for the right knee based on recurrent instability of 10 percent, effective since December 8, 2009, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.14, 4.71a, Diagnostic Code 5257. 6. The criteria for a temporary total rating based on convalescence after a right knee arthroscopic surgery on June 29, 2010, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.30. 7. The criteria for a temporary total rating based on convalescence after a right knee arthroscopic surgery on June 6, 2013, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.30. 8. The criteria for an increased rating for a left knee disability based on limitation of extension in excess of 20 percent prior to September 22, 2020, and in excess of 50 percent thereafter, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 9. The criteria for an increased rating for a left knee disability based on limitation of flexion of compensable prior to September 22, 2020, and in excess of 10 percent thereafter, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 10. The criteria for an increased rating for the left knee based on based on medial and lateral menisci conditions of 20 percent, effective February 19, 2019, through December 11, 2019, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5258 & 5259. 11. The criteria for an increased rating for the left knee based on based on medial and lateral menisci conditions in excess of 10 percent since December 12, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5258 & 5259. 12. The criteria for a temporary total rating based on convalescence after a left knee arthroscopic surgery on December 12, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.30. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Air Force from October 1976 to March 1978. The Veteran perfected an appeal to the Board of Veterans' Appeals (Board) for the ratings for his bilateral knee disabilities in August 2012. Multiple rating decisions have been issued since his December 8, 2009 claim, as summarized below. In May 2019, the Veteran testified before the undersigned Veteran's Law Judge. In April 2020, the Board remanded this matter for additional development and consideration, along with issues of service connection for lumbar spine and cervical spine conditions. The two service connection issues were granted in full in an October 2020 rating decision; therefore, they are no longer before the Board. Historically, the Veteran was awarded service connection for a bilateral knee condition as a single noncompensable disability, effective since March 1978. A March 2010 rating decision recharacterized the disability as chondromalacia patella and assigned a 10 percent rating for each knee, effective December 8, 2009. A November 2017 rating decision again recharacterized the right knee disability by adding "degenerative joint disease and muscle atrophy"; and also increased the disability ratings for each knee from 10 to 20 percent, effective December 8, 2009. After the April 2020 Board remand, an October 2020 rating decision granted service connection for medial and lateral menisci conditions of both knees, rated at 10 percent for each knee; and surgical scars for each knee, rated noncompensable (0 percent); all effective February 19, 2019. The Veteran has not challenged the noncompensable rating for his surgical scarring; however, he continues to seek a higher rating for impairment from his bilateral knee disabilities themselves. An April 2021 rating decision granted an increase to 50 percent for each knee based on limitation of extension, and granted a separate rating for each knee based on limitation of flexion, rated 10 percent for the left knee but 0 percent (noncompensable) for right knee, all effective since September 22, 2020. As noted in the prior Board remand, rating decisions in July 2019 and February 2020 denied service connection for two genetic conditions which the Veteran has asserted are related to or resulted in his knee disabilities: hypophosphatasia and Ehlers-Danlos syndrome. The Board declines to expand the scope of the current appeal to include consideration of these conditions, as the Board will not entangle these service connection issues (which were previously denied twice) with the increased rating issues that are now on appeal. However, if it is not possible to separate the effects of those or other nonservice-connected conditions from the effects of the service-connected bilateral knee disabilities, reasonable doubt will be resolved in the Veteran's favor to attribute them to the service-connected disability. The April 2020 Board remand also noted that the Veteran has undergone two operations on his right knee for a torn meniscus and one operation on his left knee for a torn meniscus since his December 8, 2009, claim. Rating decisions in August 2011 and September 2014 denied a temporary total rating based on convalescence for right knee surgeries on June 29, 2010, and June 6, 2013, in part because they were not for the specific service-connected disability. The medical evidence reflects that these arthroscopic surgeries included a partial meniscectomy, and the Veteran also had a left knee arthroscopic surgery including a partial meniscectomy on December 12, 2019. The Board requested medical opinions because there were conflicting opinions regarding whether the Veteran's right knee torn meniscus was related to his service-connected right knee conditions, and no opinion addressed the left knee torn meniscus. An October 2020 rating decision granted service connection and 10 percent ratings for right and left knee meniscal impairment, effective since September 19, 2019, but did not address the remainder of the period since the December 8, 2009, claim, to include a higher rating for pre-surgical symptoms or a temporary total rating based on surgical convalescence under 38 C.F.R. § 4.30. VA has a duty to maximize benefits to the Veteran, to include addressing a temporary total rating; thus, those matters are also before the Board. Additionally, evidence obtained upon remand includes an October 2019 VA treatment record where the Veteran reported being disabled since 2017 due to his bilateral knee disabilities. This raises the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). This issue is under the Board's current jurisdiction as part and parcel of the appeal for the ratings for the underlying bilateral knee disabilities. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Harper v. Wilkie, 30 Vet. App. 356 (2018). Increased Ratings VA's schedular percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. A separate or higher rating may be assigned based on non-overlapping conditions and symptoms, if the compensable criteria under applicable diagnostic codes are met, including with consideration of additional functional loss after repetitive use or flare-ups for musculoskeletal conditions based on range of motion. See 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.71a; Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009); Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016). Pain itself does not constitute functional loss, and painful motion must result in functional loss to constitute limited motion for a rating under diagnostic codes based on limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be awarded if there are decreases or increases in symptomatology that meet the criteria for a different rating for a distinct period during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). If an increase in disability level was factually ascertainable within one year prior to receipt of the increased rating claim, then the effective date will be the date on which that increase is shown to have occurred; otherwise, the effective date will be the date of receipt of the claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Knee disabilities in particular are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. Although the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. The Veteran has had similar complaints and findings for both knees throughout the appeal period, with the right knee generally being worse than the left knee. As noted in his December 2009 claim increase, the Veteran reported that his right knee was his main concern, but his left knee was starting to do the same things as the right knee. To avoid unnecessary repetition, the Veteran's general complaints and potentially applicable legal criteria for both knees are summarized first, followed by application of the diagnostic criteria to each knee to determine the ratings. History and Complaints for Both Knees The evidence reflects service-connected right knee diagnoses of chondromalacia, arthritis, quadriceps muscle atrophy due to disuse, and meniscal tears, with surgeries for meniscectomies and chondroplasty in June 2010 and June 2013. Service-connected left knee diagnoses are chondromalacia, arthritis, and meniscal tears, with a surgery for meniscectomy and chondroplasty in December 2019. There is lay and medical evidence relevant to bilateral knee arthritis with chondromalacia patella, painful and limited motion, impaired meniscus before and after surgery, potential instability, and arthroscopic surgeries. For the right knee, there is also evidence of right quadriceps muscle atrophy due to disuse. Throughout the appeal period, the Veteran has described frequent bilateral knee pain to varying degrees. He had tenderness to palpation around the patella, joint line tenderness, stiffness, painful and limited motion, crepitus or a grinding sensation, and swelling or effusions at times. The Veteran described bilateral knee flareups of increased pain or difficulty with activities or repeated use over time, including both flexion and extension activities. He reported difficulty squatting, kneeling, standing up from a sitting position, prolonged sitting or driving for more than 30 minutes, and walking up steps or stairs, and being unable to run. The Veteran also described sensations of locking and weakness or instability, giving way, or buckling in both knees. He has had an antalgic gait or limp at times, he had mild right quadriceps atrophy since at least January 2010 with reduced strength at times, and he has used a knee braces and cane at times since February 2010. The Veteran has also taken multiple oral medications for pain in the knees and other areas, and he received Hyalgan and steroid injections and several types of therapy for the knees. He had arthroscopic surgeries including meniscectomies in June 2010 and June 2013 (for the right knee) and December 2019 (for the left knee). Although the Veteran had symptoms or manifestations to differing degrees in each knee, and which varied over time as explained below, these manifestations are generally consistent in lay and medical evidence. See, e.g., Veteran statements in December 2009, July and August 2010, May 2011, May 2014, and May 2019 Board hearing; lay statement from business partner since 2008 in August 2010; VA treatment records since January 2010; private treatment records in 2010 and 2013; VA examinations in January 2010, March 2012, October 2017, and October 2020; Social Security Administration (SSA) reports from September to December 2010. Legal Criteria In rating the knees, a separate rating may be assigned under a code for meniscal impairment pre- or post-surgery (DCs 5258 and 5259), for limitation of motion (DCs 5003 or 5260 and 5261), and for stability or subluxation (DC 5257), if there are non-overlapping symptoms that are not compensated by the assigned rating. The criteria for rating knee disabilities, including knee replacements, were recently amended, effective February 7, 2021. The Board will consider both sets of criteria, as the Veteran is entitled to application of the criteria that are most favorable to his pending claim; however, an award based on the amended regulations may not be made effective before the effective date of the change. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under either version of the rating criteria (pre- and post-February 7, 2021), DC 5003 for degenerative arthritis provides for a 10 percent rating for each major joint (including the knee joint) or group of minor joints when there is limitation of motion of the joint that is noncompensable under the appropriate DC. If there is no limitation of motion, ratings of 10 or 20 percent are available if there is x-ray evidence of two or more major joints or two or more minor joint groups, requiring occasional incapacitating exacerbations for a 20 percent rating. 38 C.F.R. § 4.71a. Similarly, if there is no arthritis, where there is noncompensable limitation of motion for a specific joint, 38 C.F.R. § 4.59 provides for a minimum compensable rating for actually painful joints in conjunction with a diagnostic code based on limitation of motion. Sowers v. McDonald, 27 Vet. App. 472, 479 (2016); Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). Where there is painful or limited motion with both flexion and extension, but the compensable criteria are not met for flexion (DC 5260) or extension (DC 5261), only one minimum rating of 10 percent should be assigned. Separate ratings also may not be assigned for painful or noncompensable limitation of motion using DC 5003 or section 4.59 in connection with 5260, and for compensable limitation of extension under DC 5261. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Normal knee range of motion is from 0 degrees of flexion to 140 degrees of extension. 38 C.F.R. § 4.71, Plate I. Under DC 5260, a 10 percent rating is assigned for limitation of flexion of the leg to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Id. Under DC 5261, a 10 percent rating is assigned for limitation of extension of the leg to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A maximum 50 percent rating is assigned for extension limited to 45 degrees. Id. The April 2020 Board remand directed that new VA examinations be obtained to address, in part, any additional degree of limitation during periods of increased symptoms due to pain or other factors during flareups or repeated use over time. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). An October 2020 VA examination provided such an estimate or opinion, as well as other directed information, and resulted in partial increased ratings based on limited extension for both knees. To the extent prior examinations since the Veteran's December 2009 claim did not contain an estimate as to additional loss during periods of increased symptoms, the evidence is sufficient and another remand is not warranted. 38 C.F.R. § 3.159. Overall, the guidance on how to evaluate loss during periods of flareups and repeated use over time is not particularly clear. Thus, the Board finds that any additional loss must be quantifiable and must result in limitation of motion beyond that contemplated by the measured levels to warrant a higher rating. Additionally, due to the rule regarding stabilization, increased impairment due to flareups or repeated use must be of such length as to establish that the overall impairment is more severe than currently rated. The degrees of disability and ratings specified in diagnostic codes are considered adequate to compensate for considerable loss of working time from exacerbations proportionate to the severity of the disability. In this case, other than as discussed for each knee below, the Veteran's descriptions do not show that knee flareups or repeated use over time additionally limited function in a quantifiable way, or that they were of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings. VA examiners prior to 2020 did not give an estimate as to additional loss of motion or function during flareups or after repeated use over time, although the Veteran reported frequent flareups of pain with reduced motion or impairment of various activities, particularly involving weightbearing. However, VA and private treatment records include varying measurements of motion that contemplate the Veteran's complaints of pain and other contributing factors to varying degrees, which would be consistent with him seeking treatment and range of motion being measured during episodes of increased symptoms, i.e., flareups or repeated use over time. Accordingly, the available evidence and measurements are sufficient to determine any additional loss during such periods. As discussed below, the lay and medical evidence do not support a greater degree of functional loss or limitation than noted below to warrant other separate or higher ratings for either knee. As noted above, pain alone is not sufficient to constitute limitation of motion without resulting additional functional loss, and painful motion alone does not constitute limited motion for the purposes of rating under the codes pertaining to limitation of motion for a particular disability, as opposed to assigning a minimum rating under DC 5003 or section 4.59. Other than as discussed below, the Veteran's reports of exacerbations during flareups or after repeated use are not quantifiable or of sufficient duration to warrant a higher rating without violating the spirit of Mitchell, 38 C.F.R. § 4.1, and the rule regarding stabilization of ratings. A remand to obtain a retroactive opinion to estimate any additional degree of limitation during such periods would have no reasonable possibility of assisting in substantiating the claim. Therefore, the lack of any such opinion prior to 2020 is not prejudicial to the claims and a remand is not required. 38 C.F.R. § 3.159. Under both versions of the rating criteria, DC 5258 addresses a dislocated (torn) semilunar cartilage (meniscus), and assigns a 20 percent rating if there are frequent episodes of "locking," pain, and effusion into the joint. Under DC 5259, symptomatic removal of the meniscus is rated at 10 percent. 38 C.F.R. § 4.71a. Under the criteria effective prior to February 7, 2021, DC 5257 provides that recurrent subluxation or lateral instability will be assigned a 10 percent rating where it is mild, a 20 percent rating where it is moderate, or a maximum 30 percent rating where it is severe. 38 C.F.R. § 4.71a (2020). Under the criteria effective since February 7, 2021, DC 5257 provides that recurrent subluxation or instability will be assigned a 10 percent rating 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. A 20 percent rating will be assigned if there is 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 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. A 30 percent rating requires an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Id. There are also new criteria for patellar instability under DC 5257. A 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. at Note (1). 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). Id. at Note (2). A temporary total rating may be assigned based on convalescence if treatment of a service-connected disability results in: (a) surgery necessitating at least one month of convalescence; or (b) surgery with severe postoperative residuals such as incompletely healed surgical wounds, stumps of recent amputations, therapeutic immobilization of one major joint or more, application of a body cast, or the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or (c) immobilization by cast, without surgery, of a major joint. 38 C.F.R. § 4.30. The total rating will be effective from the date of hospital admission or outpatient treatment, and will continue for a period of one, two, or three months from the first day of the month following the hospital discharge or outpatient release (with a possible extension beyond an initial three months), followed by a schedular evaluation under the appropriate code. Id. 1. , 2., 3., 4., 5., 6., and 7. Increased ratings for a right knee disability, to include limitation of extension, limitation of flexion, meniscal impairment, instability, and temporary total ratings for surgical convalescence The Veteran contends that he is entitled to higher compensation for his right knee disability based on pain and other symptoms with resulting functional impairment since his December 2009 claim, including temporary total ratings based on convalescence after arthroscopic surgeries on June 29, 2010, and June 6, 2013. Arthritis and Limitation of Motion The Veteran has right knee arthritis with painful and limited motion. He has been assigned a rating based on limitation of extension of 20 percent effective since December 8, 2009, then 50 percent effective since September 22, 2020. There is also a noncompensable rating for limitation of flexion as of September 22, 2020. As explained below, a higher rating of 30 percent based on limited extension is warranted and granted for the full period prior to September 22, 2020; however, a separate compensable rating based on limitation of flexion is not warranted. Prior to September 22, 2020, the Veteran generally had extension measured to full range (0 degrees) or limitation of less than 15 degrees, with or without pain, as well as hyperextension or more than full extension noted at times. See, e.g., private treatment records in August 2010, September 2010, and July 2013; VA treatment records in December 2011, September 2012, January 2013, April 2013, June 2013 through September 2013 (monthly), March 2016, September 2016, November 2016, June 2017, March 2018, February 2019, January 2020, February 2020, and May 2020; VA examinations in January 2010 and March 2012; Social Security Administration (SSA) evaluation in December 2010. However, the Veteran's right knee extension was further limited to 20 degrees in VA treatment records in June 2010 (prior to his June 29, 2010, arthroscopic surgery) and July 2010 (within one month after the surgery). He continued to have right knee pain. These findings support a 30 percent rating under DC 5261. Previously, in February and April 2010, VA treatment records noted a three-month history of worsening right knee pain, which the Veteran rated as 9 out of 10 at worst at the end of the day, stating that his pain medications were not effective. This is generally consistent with an onset of worsening pain around the date of his December 2009 claim, when he stated that his right knee was the main concern. Additionally, during the January 2010 VA examination, the Veteran had right knee extension limited to 10 degrees and to 12 degrees after three repetitions. This examiner noted that there would be less function with use primarily due to pain. An August 2010 VA treatment record and the October 2017 VA examination measured extension limited to 15 degrees, with no change after repetitive testing. These findings would support a 20 percent rating under DC 5261, but no estimate of additional loss during flareups or with repeated use over time was given. Accordingly, resolving reasonable doubt in the Veteran's favor, the worsened degree of limited extension measured prior to the June 2010 surgery (and again during recovery in July 2010) is consistent with a higher degree of impairment due to pain or other factors during flareups or with repeated use over time throughout the appeal period from December 8, 2009, prior to September 22, 2020. Extension limited to 20 degrees warrants a 30 percent rating, and a partial increase is granted. There was no factually ascertainable increase during the one year prior to the December 8, 2009, to warrant an earlier date for the 30 percent rating. See 38 C.F.R. § 3.400(o). Instead, as noted above, the Veteran reported a three-month history of worsening pain in February and April 2010, or around December 2009. Additionally, in October 2015, the AOJ found no existing VA medical records from January 2009 through January 2010, and there are no measurements of record to support a higher degree of limitation within the one year prior to December 2009. Thus, December 8, 2009, is the earliest date an increase may be awarded. Id. Since September 22, 2020, the Veteran has a maximum 50 percent rating for limitation of extension to 45 degrees or less. A higher rating is not available. Additionally, there was no factually ascertainable increase to the 50 percent level prior to September 22, 2020. Id. This rating was based on the date of a VA treatment record where the Veteran reported that it was hard for him to stand anymore due to his knees, combined with measurements in an October 2020 VA examination. During the examination, right knee extension was limited to 25 degrees with pain, and the examiner estimated an additional loss to 35 degrees with repeated over time and to 50 degrees during flareups due to pain and other factors. Prior to September 22, 2020, the Veteran retained right knee extension to at least 20 degrees, with full extension or hyperextension at times, as noted above. There is no suggestion that the Veteran's impairment more nearly approximated limitation to 30 degrees or 45 degrees of extension, as required for a 40 or 50 percent rating. Although a September 2010 private record noted severe pain with terminal knee extension (TKE) from 30 to 0 degrees, the same record noted range of motion to 0 degrees of extension; therefore, there was no resulting functional loss due to pain. Additionally, as summarized above, several objective measurements close in time to this record (June, July, and August 2010) showed extension to 15 or 20 degrees, which reflects the degree of functional loss in addition to pain alone. Because pain without resulting functional loss is not sufficient for a higher rating, the September 2010 notation does not support a rating higher than 30 percent for this period. Concerning flexion, although the Veteran has had limited flexion or painful motion with flexion at times, he has not met the criteria for a compensable rating under DC 5260 as required for a separate rating, as is there no suggestion that his flexion was limited to 45 degrees at lower. Furthermore, the Veteran has at least a minimum rating for right knee painful or limited motion since his December 2009 claim, and he is already in receipt of the maximum rating of 20 percent available under DC 5003. Therefore, his rating for limited extension contemplates his painful or limited motion due to arthritis under DC 5003 or under section 4.59. Throughout the appeal period, the Veteran's right knee flexion ranged from 90 to 140 degrees or full range, even when considering additional limitation due to increased pain or other contributing factors during flareups or after repeated use over time. The October 2020 VA examiner measured flexion to 100 degrees, and gave an estimate of additional loss to 90 degrees during flareups. This is generally consistent with the Veteran's lay descriptions throughout the appeal period, as well as the varying levels of measure limitation, and it is well above the level required for a compensable rating. See, e.g., VA treatment records in February 2010, April 2010, June 2010, July 2010, August 2010, October 2010, May 2011, December 2011, September 2012, January 2013, April 2013, June 2013 through September 2013 (monthly), March 2016, November 2016, June 2017, March 2018, February 2019, December 2019, January 2020, and February 2020; private treatment records in August 2010 and September 2010; SSA evaluation in December 2010; VA examinations in January 2010, March 2012, October 2017, and October 2020. Therefore, a separate compensable rating based on limited flexion may not be assigned under DC 5260 (or DC 5003), either before or after September 22, 2020. As summarized above, the available medical evidence is sufficient to determine any additional loss, or the evidence does not suggest an additionally quantifiable loss of motion, during periods of increased symptoms due to flareups or repeated use over time. The lay and medical evidence reflects significant flexion and extension to above the 30 percent level prior to September 22, 2020, despite increased pain or other factors, and the Veteran is already at the maximum rating thereafter. Thus, these factors did not result in a greater degree of functional loss or limitation than noted above to warrant a separate or even higher rating. Additionally, although the evidence reflects that the Veteran has used various pain medications and received steroid injections for his right knee at times, there is no suggestion that they reduced his symptoms to an extent to warrant a higher or separate rating when discounting their ameliorative effects. In particular, there is no suggestion that flexion would decrease to 45 degrees or below or extension would decrease to less than 20 degrees prior to September 22, 2020, without medications. As noted above, for VA treatment in 2010, the Veteran reported that this pain medications were not effective and he had pain of 9 out of 10, which is part of the reason for finding a higher degree of limited extension during that period to meet the 30 percent rating criteria with limitation to 20 degrees. In summary, an increase to 30 percent for limited extension prior to September 22, 2020, is granted. However, a higher rating than 50 percent for limited extension since September 22, 2020, and a compensable rating based on flexion, are denied. Meniscal Impairment The Veteran has been assigned a 10 percent rating for right knee medial and lateral menisci conditions, effective since February 19, 2019, based on symptomatic removal of the meniscus (DC 5259). The October 2020 rating decision indicates that this rating was assigned as of the date of an MRI that showed the meniscal condition. However, that MRI noted "continued" degenerative tearing of the meniscus, and there are numerous records of prior meniscal tears and symptoms. As discussed below, resolving reasonable doubt in the Veteran's favor, the evidence warrants a higher 20 percent rating based on non-overlapping symptoms of meniscus tears under DC 5258, effective since December 8, 2009. This includes the period since February 19, 2019. Throughout the appeal period, the medical evidence shows that the Veteran's right knee had at least one torn meniscus. Although he had partial meniscectomies in 2010 and 2013, he had additional or continued tears after the surgeries. He also had nonoverlapping symptoms of frequent pain without movement (including tenderness to palpation and medial and/or lateral joint line pain), locking, and swelling or effusion into the joint. The Veteran's pain with movement is already contemplated by his rating based on limited extension, and a separate rating on this basis would constitute impermissible pyramiding. However, as noted above, DC 5258 provides for a higher rating where the identified non-overlapping symptoms are present based on a torn meniscus. DC 5259 addresses a condition that is symptomatic post-removal of the meniscus, or post-meniscectomy. In this case, the Board finds that DC 5258 is the most appropriate code to contemplate the Veteran's diagnosis, non-overlapping symptoms, severity, and functional impairment for his right knee. Specifically, in a December 2009 statement for his claim, the Veteran described right knee pain and locking up when he tries to bend down. During a January 2010 VA examination, he reported knee pain and swelling that had progressively worsened since service, and that his right knee locked once every 2 to 3 months. His described his pain as constant at a moderate level with severe flareups once a day for several hours. There were no effusions found and a McMurray test for meniscal impairment was negative. A February 2010 VA primary care visit also had a negative meniscal test. However, a February 2010 VA physical therapy consult noted the Veteran's report that his right knee would collapse and then locks straight, and his right knee locked in extension frequently. A test for meniscal impairment was positive, and the provider noted a possible meniscal tear. A March 2010 MRI of the right knee showed a complex tear of the posterior horn of the medial meniscus associated with a moderate-sized knee effusion. In June 2010, the Veteran had a partial medial meniscectomy (and other procedures). After the June 2010 surgery, VA treatment records in July, August, and October 2010 noted minimal effusion and continued right knee pain. A December 2010 SSA evaluation noted the Veteran's complaints of pain and swelling in the right knee, and that he believed his June 2010 surgery worsened these symptoms. On examination, his right knee had 1+ effusion. A May 2011 VA physical therapy record noted right knee pain post-surgery and that the Veteran had fallen in February 2011 while carrying a heavy door, but a McMurray's test was negative. An August 2011 MRI of the right knee included findings of "postsurgical changes versus residual oblique tear of posterior horn medial meniscus." A March 2012 VA examination noted a right knee meniscal tear with frequent joint pain and no meniscectomy, but a June 2010 partial medial meniscectomy. A September 2012 VA treatment record noted right knee medial joint line tenderness, but found no signs of meniscal tear on examination. A December 2012 record noted that the Veteran continued to have pain after his arthroscopy, and he had some relief from an injection in the past. He had mild crepitus, diffuse tenderness to palpation, and some medial joint line tenderness on examination. A January 2013 MRI of the right knee showed a stable oblique tear of the medial meniscus. A January 2013 treatment record noted the MRI results and similar findings on examination, and that the Veteran had tried injections and medications and wanted to try another arthroscopy for his right knee. In June 2013, the Veteran had another right knee partial medial meniscectomy (and other procedures). After this surgery, treatment records in June 2013 noted moderate effusion and swelling due to fluid retained from the surgery, then limping and increased swelling and pain. A July 2013 VA treatment record noted that the January 2013 MRI had confirmed an oblique tear of the posterior horn of the medial meniscus, and the operative report showed a right knee partial medial meniscectomy. There was no pain with the McMurray's test (or a negative result) for the right knee. A July 2013 private treatment record found a minimal right knee effusion and swelling, but no pain with McMurray's test (or a negative result). In September 2014, a VA examiner opinion reviewed the claims file and noted that the Veteran had significant and prolonged knee pain and effusions in service. The examiner opined that it is not actually known when the right knee meniscal tear occurred, but a meniscal tear could not be ruled out during service because no MRI was done. The examiner further opined that by the time the Veteran presented for VA treatment in 2010 with much more right knee pain, he had significant quadriceps atrophy so his knee condition was chronic, "not something that had just occurred with a new meniscal tear. There was in fact no history of any interval trauma to suggest an acute tear." The examiner noted that the June 2010 surgery included a partial medial meniscectomy, and the June 2013 was "a probable complete medial meniscectomy." Despite this notation, records (including shortly after the surgery as noted above) note that this was a partial medial meniscectomy. In September 2016, x-rays for both knees showed trace knee effusion. A November 2016 VA orthopedic record noted no popping, locking, and clicking, but a January 2017 record noted complaints of right knee catching and locking. A July 2017 VA physical therapy record noted right knee pain and a trace effusion, with no significant change since April 2016. An October 2017 VA examination noted the history of a right knee meniscal tear with frequent pain and two surgeries, although the examiner did not find or note locking or effusion. A June 2018 VA treatment record noted that walking a lot increased the Veteran's knee pain, and his right knee right would catch on the outside (lateral side) with weightbearing. His daily pain had increased from 2 to 5 out of 10. In January 2019, X-rays for right knee pain showed no effusion, but meniscal chondrocalcinosis. A February 2019 MRI of the right knee showed chondrocalcinosis with a small joint effusion and a loose body, and a degenerative tear at the medial meniscus anterior horn that was noted to be suspected as chronic. A February 2019 VA orthopedic consult noted that the Veteran reported pain and swelling in the right knee at times, and he had a slight effusion on examination. The Veteran denied having recent locking of the right knee. A subsequent treatment record in February 2019 noted that he lacked full extension probably due to the meniscal tear and loose body. The provider stated that the Veteran may benefit from a medial off-loader brace for his right knee, which was ordered, but ultimately he would probably need a total knee replacement. A September 2019 VA orthopedic record noted that a total knee replacement may be detrimental due to the Veteran's connective tissue hyperelasticity due to his genetic hypophosphatasia (HPP) and Ehlers Danlos syndrome. A December 2019 VA orthopedic record noted that the Veteran wanted to discuss the February 2019 MRI results for his right knee, stating that his right knee was worsening, and after he recovered from his recent left knee surgery, he may be referred for consideration of another right knee arthroscopy. A December 2019 VA orthopedic record noted the 2019 MRI results and that the Veteran was having worsening right knee pain, and he may be considered for another arthroscopic surgery after his left knee healed from recent surgery. A January 2020 record again noted a possibility of another right knee surgery. An October 2020 VA examination noted current right knee symptoms including pain on the outside of the knee and under the kneecaps, as well as locking of the knee joints. There was also a history of recurrent effusion including intermittent swelling in the right knee joint associated with weightbearing activities. The examiner noted the Veteran's history of meniscal tear, two surgeries, ongoing degenerative changes or tear of the medial meniscus shown in the February 2019 MRI (as also noted in an April 2019 letter from a VA rheumatologist). The examiner noted that there were frequent episodes of joint pain and locking. VA treatment records in November 2020 and March 2021 found no knee effusions. In light of the above, there are some notations of no locking or effusions for the right knee, as well as some findings of no clinical signs of meniscal impairment. Nevertheless, overall, the weight of the evidence reflects recurring meniscus tears and symptoms including frequent pain, as well as locking and effusions at times, that are not otherwise compensated by the assigned ratings throughout the appeal period. Accordingly, the Veteran has sufficient non-overlapping right knee symptoms due to a meniscal tear or tears, pre- and post-surgeries in 2010 and 2013, to warrant a 20 percent rating under DC 5258 since his December 8, 2009, claim. There is no factually ascertainable increase to this level within the one year prior to the Veteran's claim. Instead, the Veteran's statements in 2009 and 2010, as summarized above, as well as the 2014 VA examiner's opinion, reflect that his meniscus tear and related complaints were chronic and longstanding. Thus, an effective date prior to December 8, 2009, is not warranted. 38 C.F.R. § 3.400(o). Instability There is no current rating for recurrent subluxation or instability of the right knee under DC 5257. The Veteran has consistently denied a history of recurrent subluxation or dislocation, and there is also no medical evidence to suggest such impairment. However, he has given competent and credible descriptions of a frequent feeling or sensation of weakness, giving way, collapsing, buckling, or instability of the right knee, particularly when bending his knee or walking, causing him to fall at times throughout the appeal period. See, e.g., statements for claim in December 2009, July 2010, May 2019 Board hearing; VA treatment records since February 2010; private treatment records in 2010 and 2013; SSA evaluations in 2010 and 2011; VA examinations since January 2010. Although there is conflicting evidence as to the underlying cause of these sensations, resolving reasonable doubt in the Veteran's favor, the evidence supports a separate 10 percent rating for right knee instability since December 8, 2009. VA treatment records and examinations noted the Veteran's subjective reports as to these sensations relevant to instability. However, they consistently found objectively stable or intact ligaments (including in x-rays and MRIs) and normal or negative results for joint stability tests (including posterior and anterior drawer, Lachman's, varus and valgus stress). There was right quadriceps muscle atrophy and loss of strength or weakness due to not using the right knee as a result of pain. His muscle strength generally measured 4 out of 5 of the right knee. Several times, the Veteran was provided physical therapy and advised that he needed to strengthen his quadriceps muscle to help with his right knee buckling and instability. For example, the January 2010 VA examination noted moderate subjective reports of instability in the right knee, but negative Lachman's test and no objective lateral instability. An April 2010 orthopedic consult noted reports of the Veteran falling several times in the past four months from his right knee giving way, that he had appreciable lower quadriceps atrophy or muscle wasting and motor or muscle strength of 4-, 4, or 4+ out of 5, all ligaments were intact, and physical therapy was advised after his surgery to increase the strength of his right lower extremity. An August 2010 private physical therapy record explained that the Veteran continued to have a lot of weakness in the right leg after his surgery, and the provider opined that the "giving out" was greatly due to weakness and atrophy in the quadriceps muscle. When his knee is weightbearing at terminal extension, his proprioception and stability at that position are poor and the leg gives out. An October 2012 VA examination for muscles as to the right quadriceps noted that the Veteran was first made aware of his muscle atrophy when it was pointed out by a physical therapist in 2010. The examiner stated that the condition involved Muscle Group XIV, which affected knee extension and had consistent weakness. A July 2013 private physical therapy record after the second right knee surgery noted right quadriceps atrophy, and trace ligamentous laxity on varus/valgus stressing of the right knee, but negative Lachman's test for instability. The provider recommended continued strengthening as pain allows, and opined that to a reasonable degree of medical certainty the Veteran's buckling of the right knee could be related to his medial meniscus tear and grade 3-4 chondromalacia, but also hs persistent right quadriceps atrophy would contribute to the buckling. An October 2020 VA examination noted that the Veteran had a "hyperlax" patella and stated that his right knee was unstable and had given out a number of occasions, and the knee "wants to hyperextend backwards when it gives out." This examiner noted no history of lateral instability and all joint stability tests were again normal. The examiner stated that the Veteran developed weakness and atrophy in the right quadriceps muscle over time because of lack of use of his right knee joint due to the pain, and this led to further problems of instability in the right knee and a tendency for the right knee to hyperextend during weightbearing. This type of right knee instability was much greater than his left knee instability. Other medical records had similar subjective reports of buckling, giving way, or a feeling of instability and hyperextension of the knee, but objective findings of intact ligaments and no laxity or instability (anterior, medial, or lateral). See, e.g., VA treatment records in March 2010 (MRI showed intact ligaments), June 2010 through October 2010 (monthly), May 2011, August 2011 (MRI showed mild to moderate quadriceps tendinosis, no high grade or full thickness tear, all ligaments intact), December 2011, February 2020, and May 2020; private treatment record in September 2010; VA examinations in March 2012 and October 2017. In addition to the above, VA treatment records reflect that the Veteran was provided various braces (a genutrain sleeve or soft brace, a hard or hinged brace, and a medial off-loader brace) for his right knee from February 2010 forward, and he also used a cane from June 2017 forward. These were noted to be used, at least in part, to prevent hyperextension, buckling, giving way, or instability of the right knee. Knee arthritis and nonservice-connected hypophosphatemia, low back problems, and lack of sensation of feet were also noted a reasons for a brace or cane at times. See, e.g., VA treatment records in February 2010, September 2010, December 2011, July 2013, June 2017, March 2018, April 2018, June 2018, February 2019, March 2018, September 2019, December 2019, May 2020, and October 2020; report for SSA claim in November 2010; VA examinations in March 2012, October 2012, October 2017, and October 2020. As noted above, the criteria under DC 5257 in effect prior to February 7, 2021, address recurrent lateral instability. They do not give specific definitions of mild, moderate, or severe conditions. Instead, the Board must make the determination based on consideration of all evidence. Medical evidence is not automatically more probative than lay evidence, but it may outweigh lay evidence. Considering all lay and medical evidence, the evidence supports a 10 percent rating based on recurrent lateral instability, effective since December 8, 2009, under this code version. Specifically, the Veteran is competent to report his observable sensations, and his reports are credible because they are consistent throughout the appeal period. However, he is not competent to identify the underlying basis for such sensations or whether they are due to lateral instability or another cause because the knee is very complex and requires medical expertise to interpret the evidence and tests. As summarized above, the medical evidence reflects that the Veteran's sensations of instability and falling at times were due, in part, to quadriceps muscle weakness with resulting hyperextension of the patella, chondromalacia, and/or a torn meniscus. There were no objective findings of lateral or other instability on repeated testing, and no ligament tears. Although there was a notation of trace ligamentous laxity in July 2013, this was not shown at other times; instead, MRIs showed intact lateral and other ligaments. Accordingly, the medical evidence is the most probative as to the underlying basis for the Veteran's sensations of instability, and it does not establish recurrent lateral instability. However, as the evidence clearly shows frequent buckling, giving way, and falling, the Board resolves reasonable doubt in the Veteran's favor and finds that a 10 percent rating for mild instability is warranted under the old version of DC 5257 to account for the portion of such sensations or impairment that are not contemplated by the assigned ratings for limitation of extension and torn meniscus throughout the appeal period. A higher rating is not warranted because the ratings otherwise fairly compensate him. Under the criteria effective since February 7, 2021, a rating under DC 5257 for recurrent instability expressly contemplates the claimant being prescribed an assistive device such as a cane, crutches, and/or a walker. However, those criteria require a sprain, incomplete ligament tear, or complete ligament tear for a rating, which is not shown in this case. Thus, a higher rating is not warranted on this basis. The new criteria for patellar instability under DC 5257 require a diagnosed condition involving the patellofemoral complex, which includes the quadriceps tendon, the patella, and the patellar tendon. A rating in excess of 10 percent requires recurrent instability after surgical repair. In this case, the Veteran's right knee surgeries in 2010 and 2013 involved chondroplasty of the patella (in addition to partial medial meniscectomies), and he continued to have recurrent instability and hyperextension of the knee after those surgeries. Additionally, he was prescribed a brace since February 2010; although he used a cane since June 2017, there is no indication that the cane (as opposed to various braces) was prescribed by a medical provider. Thus, the criteria for a 20 percent rating are met. However, such a rating may only be made effective since February 7, 2021. As explained below, the Veteran's ratings effective since September 22, 2020, already combine to the maximum allowable of 60 percent without violating the amputation rule. Therefore, this higher rating may not be assigned in this case as a matter of law. Other Rating Considerations Throughout the appeal period, there is no argument or indication of right knee ankylosis (DC 5256), tibia or fibula impairment (DC 5262), or genu recurvatum (DC 5263) to warrant a separate rating or discussion of those diagnostic codes. Finally, the Veteran's right knee surgical scars from the 2010 and 2013 are service-connected as noncompensable, effective February 19, 2019. Although the rating criteria for scars were amended effective August 13, 2018, during the course of this appeal, they are essentially the same as relevant to this Veteran's case, and neither version is more favorable. The evidence consistently shows that the right knee scars are not painful or unstable, there is no suggestion that they are "deep" scars or are associated with underlying soft tissue damage, and they do not measure at least 144 square inches (929 square cm). There is also no suggestion of disabling effects due to the scarring itself. Therefore, a separate compensable rating is not warranted on this basis. See 38 C.F.R. § 4.118, DCs 7801 to 7805 (2017 & 2020). In light of the Board's determinations of entitlement to increased ratings for the right knee, effective since September 22, 2020, the Veteran has ratings of 50 percent for limitation of extension under DC 5261, 20 percent for a torn meniscus under DC 5258, and 10 percent for instability under DC 5257. These ratings combine to 64 percent, which rounds down to 60 percent. 38 C.F.R. § 4.25. This is the maximum allowed for knee impairment under the amputation rule. See 38 C.F.R. §§ 4.68 (the combined rating for a disability shall not exceed the rating for amputation at the elective level of the extremity, were amputation to be performed) & 4.71a, DC 5164 (amputation of the lower extremity not improvable by prosthesis controlled by natural knee action will be rated 60 percent). Accordingly, the Veteran may not be assigned a higher rating or paid more than 60 percent compensation for his right knee, effective since September 22, 2020, as this would violate the amputation rule. Id. However, as he is entitled to the indicated separate and increased ratings for portions of the appeal period prior to September 22, 2020, and the earlier ratings do not combine to higher than 60 percent, they should remain in effect for compensation for those prior periods. Temporary Total Ratings The Veteran has asserted that he should be awarded a temporary total rating for his right knee surgeries under either 38 C.F.R. § 4.30 or § 4.29. See, e.g., June 2014 statement for claim. As relevant to this case, section 4.30 is for surgery requiring convalescence of one month or more or with severe postoperative residuals, as discussed further below; section 4.29 is for inpatient hospital treatment or observation for 21 days or more, which is not applicable to this case. As discussed below, although the Veteran had right knee arthroscopic surgeries in June 2010 and June 2013, the evidence does not reflect a level of convalescence after those surgeries to warrant a temporary total disability rating on this basis. Concerning the June 29, 2010 surgery, a June 22, 2010, VA pre-operative orthopedic visit noted retropatellar mechanical complaints. Examination showed mild muscle atrophy at the right thigh (quadriceps), active range of motion from 20 degrees of extension to 120 degrees of flexion, muscle strength of 4 out of 5 in the quadriceps and hamstrings, patellofemoral crepitance, and tenderness to palpation over the medial joint line. The provider noted that an MRI documented a medial meniscus tear and patellar chondromalacia, and the surgery was recommended. The June 29, 2010, brief operative report noted a principal postoperative diagnosis of right knee medial meniscal tear plus grade 2-3 chondromalacia medial and anterior compartment of knee; and reflected that the surgeon performed arthroscopic surgery, partial medial meniscectomy (PMM), and chondroplasty. Within one month after the June 2010 surgery, a July 13, 2010, VA treatment record noted that the Veteran had been weightbearing at home with some giving out of the knee, anterior and medial knee pain, and his right leg felt week. He decreased extension to 20 degrees and flexion to 125 degrees, minimal effusion, strength of 4 out of 5 in the hamstrings and quadriceps, and his surgical portals were healed. The orthopedic surgeon summarized that the Veteran was doing well status post-surgery. The provider recommended continued use of NSAIDs and to begin physical therapy and follow up in four weeks for a possible steroid injection. A July 26, 2010, VA treatment record noted that the Veteran had pain and was concerned that his right knee still "goes out. The provider reinforced the importance of physical therapy to increase muscle strength for a stable knee. More than one month after the surgery, an August 13, 2010, private physical therapy record noted that the right knee was still as sore as it was prior to surgery, and the Veteran had been told that he would be able to return to work a couple weeks after surgier, but that was not yet possible because kneeling made his knee sore. Passive range of motion was from 5 to 140 degrees, strength was 4 or 4+ out of 5. All tests for stability or other findings were negative, although meniscal tests (McMurray's and Apley's) were not conducted. The provider stated that the right knee was moving well, but he continued to have a lot of weakness in the leg. The provider felt that the giving way was greatly due to weakness and atrophy in the quadriceps, and atrophy was still very obvious but could improve with therapy. An August 17, 2010, VA orthopedic surgery follow up record noted similar complaints six weeks after the surgery, and active range of motion was slightly improved to 15 degrees of extension and 130 degrees of flexion. The orthopedic surgeon stated that the Veteran had pain from knee osteoarthritis, a steroid injection was given, and he recommended a possible total knee arthroplasty in the future. A September 7, 2010, private physical therapy record noted right knee pain and that the knee still felt weak, but the Veteran was beginning to see progress in therapy, in that the quadriceps was getting stronger but there was still pain with extending the knee the last few degrees. The Veteran reported pain on average of 3 out of 10, but 8 out of 10 at worst when his knee gives out. Passive range of motion was 0 to 140 degrees, and strength was 4+ out of 5. Tests for stability and other findings were again all negative, with the meniscus not being tested. The provider again noted that if the Veteran's leg did not get stronger he would remain very susceptible to the knee giving out when carrying heavy items. A September 23, 2010, VA physical therapy record noted that the Veteran had degenerative joint disease and was post-surgery for a meniscectomy. He complained of quadriceps atrophy and "giving out," although knee tests were stable. A knee brace was ordered, and he was discharged from physical therapy. An October 2010 VA orthopedic clinic record then noted that the Veteran was having lateral knee pain with weightbearing, but no evidence of significant lateral meniscus tear or osteoarthritis on intraoperative evaluation. He was also having right leg weakness and pain over the quadriceps tendon. He reported minimal improvement from the knee injection at the last orthopedic visit. Range of motion and other physical examination findings were similar to the prior record. In addition to medical records, the Veteran asserted in July 2010 that a temporary total rating should be awarded because his post-operative condition was more severe than 10 percent due to his limited range of motion, particularly extension limited to 20 degrees, and instability. He has been awarded 30 percent for his extension, and these impairments due to not qualify for a temporary total rating. In an August 25, 2010, statement for his claim, the Veteran asserted that he was told that he could returned to work after two weeks, and he went back to work on August 9, 2010, but was unable to perform required duties including kneeling or carrying heavy materials due to severe pain when he returned home. The Veteran discussed this with his physical therapist and was told it was too early to return to work. He reported temporary relief after the cortisone shot on August 17, but he now had pain again and difficulty performing work duties. The Veteran's business partner for two years (or since 2008) also submitted a statement in August 2008, indicating that he had witnessed similar symptoms of the right knee buckling and the Veteran almost falling before and after the surgery. In summary, the Veteran continued to have right knee pain, limited range of motion, and giving way or a sensation of instability after his 2010 surgery. However, there is no indication that his continuing right knee symptoms were related to this surgery, as opposed to longstanding complaints and quadriceps atrophy, or that he required convalescence for one month or more or had severe residuals. Instead, he was noted be doing well within the first month of recovery, despite the need for additional treatment and a possible surgery in the future. To the extent the Veteran's symptoms after the surgery warrant higher than the currently assigned rating, they are covered by the analysis under applicable diagnostic codes. Treatment records reflect that the June 6, 2013, right knee arthroscopic surgery was a partial medial meniscectomy and synovectomy and chondroplasty of the patella with chondromalacia rated grade 3-4. However, a September 2014 VA opinion noted that this surgery appeared to be a probable complete medial meniscectomy. A June 11, 2013 VA treatment record noted moderate effusion or swelling due to fluid retained from the arthroscopy that becomes prominent on knee flexion. Range of motion was from 0 to 90 degrees, and the provider stated that the fluid may absorb on its own. A June 18, 2013, follow up two weeks after surgery noted that the Veteran was limping and had increased swelling and pain, which increased from 5 to 9 with ambulation. He had swelling around the knee, but range of motion was within normal limits. Two sutures were removed, and the provider reviewed post-operative activities and advised the Veteran to return in two weeks. A June 18, 2013, letter from the VA orthopedic surgery clinic noted that the Veteran should not work form June 6, 2013, through July 7, 2013, due to surgery (or for one month). A June 27, 2013, VA physical therapy record noted the Veteran's longstanding knee pain and history of two arthroscopic surgeries on the right knee, and that his right knee buckles and feels weak and he has pain with increased activity and at night. The Veteran was ambulating with a single-point cane and wearing sleeve braces on both knees. He reported that physical therapy in the past was helpful, and his goal was to strengthen the right leg to decrease right knee buckling. A July 18, 2013, private treatment record noted that the Veteran had been having continued swelling and pain over his right knee since his surgery. He had been doing physical therapy and strengthening through a chiropractor, but naproxen (an NSAID) was not helping. He reported that he had been on pain medications including morphine most recently up to twice and a day, which he had been on for four years, and his prior injections had not provided longstanding relief. Examination showed that the right knee portal sites were healing, there was minimal right knee effusion and swelling, asymmetry of the quadriceps muscle on the right, trace ligamentous laxity on varus/valgus stressing on the right, negative Lachman's test, normal alignment, pain with resisted (or active) terminal extension on the right, and crepitus in the patellofemoral joint with range of motion testing. There was no pain with McMurray's testing (for the meniscus) on the right. The provider noted the results of a January 2013 MRI that showed a medial meniscus tear and osteoarthritis, and the June 2013 surgery report. The provider recommended continued exercises and strengthening as pain allows and medications. He stated that to a reasonable degree of medical certainty the right knee buckling could be related to the findings of a medial meniscus tear and grade 3-4 chondromalacia, although persistent right quad atrophy would also contribute. In summary, as in 2010, the Veteran continued to have right knee pain, limited range of motion, and giving way or buckling due to pain or weakness after his 2013 surgery. However, there is no indication that his continuing right knee symptoms were related to this surgery, as opposed to longstanding complaints and quadriceps atrophy, or that he required convalescence for one month or more or had severe residuals. Instead, he was given a work note for one month after surgery, sutures were removed approximately two weeks after surgery, and providers noted that his complaints were related to his prior right knee conditions. Overall, the preponderance of the evidence is against a temporary total rating for the Veteran's June 2010 or June 2013 right knee surgeries under 38 C.F.R. § 4.30. Conclusion In summary, the Veteran's right knee disability warrants staged ratings, with separate or increased ratings noted above, which are partial grants of the appeal. Otherwise, the Veteran's right knee manifestations were relatively stable during the staged periods on appeal, and any increases in severity were not sufficient to meet the criteria for a higher or separate rating. The preponderance of the evidence is against a higher or separate rating under any reasonably raised theory, and there is no reasonable doubt to be resolved in his favor. The appeal is otherwise denied. 8. , 9., 10., 11., and 12. Increased ratings for a left knee disability, to include limitation of extension, limitation of flexion, meniscal impairment, instability, and a temporary total rating for surgical convalescence The Veteran contends that he is entitled to higher compensation for his left knee disability based on pain and other symptoms with resulting functional impairment since his December 2009 claim. The record also raises consideration of a temporary total rating based on convalescence after a December 12, 2019, surgery. Arthritis and Limitation of Motion The Veteran has left knee arthritis with painful and limited motion. He has been assigned a rating based on limitation of extension of 20 percent effective since December 8, 2009, then 50 percent effective since September 22, 2020. There is also a 10 percent rating for limitation of flexion as of September 22, 2020. As explained below, higher or separate ratings for left knee limited extension or limited flexion are not warranted for any of the staged periods on appeal. Prior to September 22, 2020, the Veteran generally had left knee extension measured to full range (0 degrees) or limitation of less than 15 degrees, with or without pain, as well as hyperextension or more than full extension at times. See, e.g., private treatment records in August 2010, September 2010, and July 2013; VA treatment records in December 2015, March 2016, September 2016, November 2016, February 2017, March 2018, February 2019, March 2019, September 2019, December 2019, January 2020, February 2020, and May 2020; VA examinations in January 2010 and March 2012; SSA evaluation in December 2010. During the January 2010 VA examination, the Veteran had left knee extension limited to 11 degrees and to 10 degrees after three repetitions. This examiner noted that there would be less function with use primarily due to pain. The October 2017 VA examination measured extension limited to 15 degrees, with no change after repetitive testing. This would be consistent with additional limitation. Although no estimate was given as to any additional loss during flareups or with repeated use over time prior to the 2020 VA examination, in contrast to the Veteran's right knee, there was no further limitation of extension shown in treatment records. Significantly, he reported in his December 2009 claim and at other times that his right knee was worse than his left knee. As noted above, he also identified his right knee as having worsening pain in February 2010 and April 2010. Accordingly, there is no lay or medical evidence to support an increase to the 30 percent or higher level based on limited left knee extension for this period. Since September 22, 2020, the Veteran has a maximum 50 percent rating for limitation of extension to 45 degrees or less. A higher rating is not available. Additionally, there was no factually ascertainable increase to the 50 percent level prior to September 22, 2020. Id. This rating was based on the date of a VA treatment record where the Veteran reported that it was hard for him to stand anymore due to his knees, combined with measurements in an October 2020 VA examination. During the examination, left knee extension was limited to 20 degrees, and the examiner estimated an additional loss to 30 degrees with repeated over time and to 40 degrees during flareups due to pain and other factors. Prior to September 22, 2020, the Veteran retained left knee extension to at least 15 degrees, with full extension or hyperextension at times, as noted above. There is no suggestion that the Veteran's impairment more nearly approximated limitation to 20, 30, or 45 degrees of extension, as required for a 30, 40, or 50 percent rating. Concerning flexion, although the Veteran has had limited flexion or painful motion with flexion at times, he did not met the criteria for a compensable rating under DC 5260 as required for a separate rating, to include prior to September 22, 2020, as there was no suggestion that his flexion was limited to 45 degrees at lower. Furthermore, the Veteran has at least a minimum rating for left knee painful or limited motion since his December 2009 claim, and he is already in receipt of the maximum rating of 20 percent under DC 5003. Therefore, his rating for limited extension contemplates his painful or limited motion under DC 5003 or under section 4.59, and a separate rating may not be assigned on this basis for flexion. Throughout the appeal period, including since September 22, 2020, the Veteran's left knee flexion ranged from 100 to 140 degrees or full range, even when considering additional limitation due to increased pain or other contributing factors during flareups or after repeated use over time. The October 2020 VA examiner measured left knee flexion to 120 degrees, and gave an estimate of additional loss to 110 degrees after repeated use over time and 100 degrees during flareups. This is generally consistent with the Veteran's lay descriptions throughout the appeal period, as well as the varying levels of measured limitation, and it is well above the level required for a compensable rating. See, e.g., VA treatment records in January 2013, December 2015, March 2016, September 2016, November 2016, February 2017, June 2017, March 2018, February 2019, March 2019, September 2019, December 2019, January 2020, February 2020; private treatment records in August 2010, September 2010, and July 2013; SSA evaluation in December 2010; VA examinations in January 2010, March 2012, October 2017, and October 2020. As summarized above, the available medical evidence is sufficient to determine any additional loss, or the evidence does not suggest an additionally quantifiable loss of motion, during periods of increased symptoms due to flareups or repeated use over time. The lay and medical evidence reflects significant flexion to above the compensable level, as well as extension to above the 20 percent level prior to September 22, 2020, despite increased pain or other factors. Thus, these factors did not result in a greater degree of functional loss or limitation than noted above to warrant a separate or higher rating during the staged periods. Although the evidence reflects that the Veteran has used various pain medications and received steroid injections for his left knee at times, there is no suggestion that they reduced his symptoms to an extent to warrant a higher or separate rating when discounting their ameliorative effects. In particular, there is no suggestion that flexion would decrease to 45 degrees or below, or extension would be limited further than 15 degrees prior to September 22, 2020, without medications. In summary, higher ratings for left knee extension and flexion are denied. Meniscal Impairment The Veteran has been assigned a 10 percent rating for left knee medial and lateral menisci conditions, effective since February 19, 2019, based on symptomatic removal of the meniscus (DC 5259). The October 2020 rating decision indicates that this rating was assigned as of the date of an MRI that showed the meniscal condition. However, the left knee surgery was not until December 12, 2019. As discussed below, resolving reasonable doubt in the Veteran's favor, the evidence warrants a higher 20 percent rating based on non-overlapping symptoms of a torn meniscus under DC 5258, effective from February 19, 2019, through December 11, 2019. The medical evidence shows a left knee torn meniscus at an unspecified date after the February 2019 MRI. The Veteran also had nonoverlapping symptoms of frequent pain without movement (including tenderness to palpation and medial and/or lateral joint line pain), locking, and swelling or effusion into the joint. To avoid unnecessary confusion, the rating is granted as an increase since the current effective date assigned by the AOJ for the 10 percent rating under DC 5259. The Veteran's pain with movement is already contemplated by his rating based on limited extension, and a separate rating on this basis would be impermissible pyramiding. However, as noted above, DC 5258 provides for a higher rating where the identified non-overlapping symptoms are present based on a torn meniscus. DC 5259 addresses a condition that is symptomatic post-removal of the meniscus, or post-meniscectomy. In contrast to the right knee, there is no indication of another meniscus tear after the left knee partial meniscectomy on December 12, 2019. Thus, a 10 percent rating under DC 5259 is appropriate since that date. Specifically, the Veteran indicated in a December 2009 statement for his claim that his right knee was the main concern, although his left knee was starting to do the same things, and he described right knee locking. In the January 2010 VA examination, the Veteran reported right knee locking, but he expressly denied left knee locking. A McMurray's test for meniscal impairment was negative. In an April 2010 VA orthopedic record, the Veteran reported that his left knee sometimes locks. A March 2010 MRI of the right knee had shown a meniscal tear, but there was no diagnosis or mention of a possible left knee meniscal tear in April 2010 or in subsequent treatment records or examinations until February 2019. Although there was occasional locking, there was also no indication of frequent locking or other meniscal symptoms. For example, a December 2015 VA orthopedic record noted one episode of apparent left knee locking a couple months earlier, which had not occurred since then. There was no left knee effusion or joint line pain on examination. A March 2016 VA orthopedic record noted a recent MRI on the left knee, as well as a recent EMG with no evidence of a neurologic issue, and that the MRI showed some patellofemoral chondromalacia. On examination, there was no effusion, but diffuse tenderness to palpation. The provider noted prior treatment and that the Veteran still complained of knee pain out of proportion to his imaging findings. The Veteran had x-rays of both knees in September 2016 for knee pain, compared to a November 2015 series for the left knee. Findings were a trace knee effusion, mild to moderate narrowing of the patellofemoral joint space, chondrocalcinosis consistent with calcium pyrophosphate deposition, two ossific densities overlying the medial compartment that may be loose bodies, and an enthesophyte at the insertion of the quadriceps tendon, with no significant change since 2015. In September 2016 and November 2016, VA orthopedic records reflected bilateral knee pain and occasional buckling, but no popping, locking, or clicking, and no effusion on examination. The impression was patellofemoral syndrome and chondromalacia, with notations that MRIs and surgical reports (for the right knee) showed grade 3 to 4 degenerative changes (chondromalacia as noted previously). In January 2017, a VA orthopedic record noted continued knee pain primarily on the left knee at the medial aspect and catching and locking. Examination of the left knee showed trace effusion and medial and lateral joint line tenderness. The impression was left knee pain with possible loose body, and an MRI was ordered. An April 2017 VA rheumatology record noted the Veteran's complaints of chronic pain and episodic swelling in the knees since age 17, which had gradually worsened over years, and lately he was seeing an orthopedist regularly for the knees. He was being seen for pseudogout, and on examination, there was trace effusion. The provider reviewed prior x-rays and labs, and also included the report results of a February 2017 MRI for a history of left knee pain rule out loose bodies, with comparison to a February 2016 MRI and September 2016 x-rays. Findings and impressions included a moderate joint effusion near the lateral meniscus similar to the prior study in 2016, no evidence of a loose body, mild or moderate tendinosis, likely degenerative changes in the medial meniscus with no evidence of a discrete tear, degenerative changes and grade 2 or 3 chondromalacia. The rheumatologist diagnosed chronic pain and episodic swelling in the knees likely secondary to calcium pyrophosphate deposition (CPPD) and osteoarthritis, noting that radiologic images (MRI and x-rays) of both knees showed CPPD and degenerative joint disease findings. Other differential diagnosis included gout. A February 11, 2019, VA orthopedic consult for both knees noted that the had been seen in February 2017 for the same complaints for his left knee, and he had swelling in multiple joints including the knees. He had several prior x-rays and MRIs of the left knee without much mechanical findings, and he had recently been diagnosed with calcium pyrophosphate deposition disease. The Veteran reported that the prior week his left knee buckled under him and then locked, and he was unable to fully extend the knee for several hours, with pain primarily in the medial compartment. He walked with a limp using a cane, there was a very slight effusion, and puffiness and some tenderness over the patellar tendon. The provider noted the results of the prior x-rays and MRIs and agreed with those findings. The provider gave impressions of recent locking of the left knee, history of calcium pyrophosphate deposition disease, suspect medial torn meniscus, fusion pain in the left knee clinically probably has some patellar tendinitis, and an MRI was ordered. A February 14, 2019, MRI of the left knee included findings of mixed grade 2 and grade 3 patellofemoral chondromalacia, chondrocalcinosis with a small joint effusion and mild synovitis, and the medial and lateral menisci were intact. A February 25, 2019, VA orthopedic surgery clinic record noted a history of pseudogout and prior arthroscopies on the right knee, and that the left knee had effusions and locked a couple of times a month, with pain in the lateral compartment with locking. He walked with a limp using a cane, and there were no left knee effusions on examination. The provider noted the MRI findings and gave an impression of the left knee of chondrosis, stating that the Veteran described mechanical locking in the lateral compartment but there were no meniscal tears. A March 2019 VA treatment record noted that the Veteran's left knee was locking at times, he had a slight limp, and there was mild effusion and medial and lateral joint line tenderness. He appeared to have "true mechanical locking," not just crepitance. The provider noted that an anterior fat pad was probably causing the locking, as the February 2019 did not indicate any anatomic cause but the Veteran gave a very reliable accounting of his locking phenomena. During the May 2019 Board hearing, the Veteran testified that he had sought emergency treatment for the left knee twice in the last three months, when it was swollen and he was told he had pseudogout. This is consistent with his records. A September 2019 VA orthopedic record noted that the Veteran's left knee still hurt a fair amount, swelled, and locked. The provider noted that the Veteran described "true locking," not crepitance or mechanical symptoms, and the locking was painful when it occurred. Examination of the left knee showed a slight effusion and lateral and medial joint line tenderness. The provider stated that the February 2019 MRI of the left knee did not show any findings that contribute to locking, but basically just patellofemoral chondromalacia and chondrocalcinosis with a small joint effusion and mild synovitis. The provider's impressions for the left knee were a history of locking and effusions, hypophosphatasia and Ehlers Danlos, and continued locking with a recommendation of a repeat MRI and probably an arthroscopy after the MRI based on the Veteran's locking phenomena. The provider stated that an arthroscopy should not be detrimental with his other conditions, but a total knee replacement may be detrimental due to the Veteran's connective tissue hyperelasticity due to his genetic hypophosphatasia and Ehlers Danlos syndrome. An October 16, 2019, MRI of the left knee, compared to a February 2019 MRI and November 208 x-ray of the left knee, included findings of multidirectional tearing involving the posterior horn of the medial meniscus, mild free edge tearing of the posterior horn of lateral meniscus, and a small to moderate-sized joint effusion. An October 23, 2019, VA treatment record then noted a torn meniscus and left knee pain. A November 2019 endocrinology record noted that the Veteran had recently had sudden left knee swelling and an MRI was ordered that found a meniscus tear. A November 2019 orthopedic follow up record noted a similar history as in September 2019, the results of the October 2019 MRI, and overall diagnosed a complex medial meniscal tear and recommended arthroscopic surgery with a partial medial meniscectomy, which was performed on December 12, 2019. Subsequent VA treatment records in December 2019, January 2020, and February 2020 noted that the Veteran's left knee pain had improved significantly and was doing well since the surgery. VA treatment records from May 2020 through October 2020 noted complaints of left knee pain and other symptoms and that he had "bad knees" in September 2020, but there was no notation of meniscal impairment and no report or findings of locking or effusions into the joint. An October 2020 VA examination noted current left knee symptoms including pain on the outside of the knee and under the kneecaps, as well as locking of the knee joints. The examiner noted a history of recurrent effusion, noting swelling in the right knee joint (but not the left knee). The examiner further stated the tears to the left knee medial and lateral menisci that were shown in a 2019 MRI were repaired by the arthroscopic surgery in 2019. The examiner noted frequent episodes of locking and joint pain, but this appears to refer to the Veteran's history, or post-surgical symptoms; as there was no evidence of another meniscus tear. This examiner further opined that the February 2019 MRI had no indication of a left knee medial or lateral meniscus injury, then the October 2019 MRI did show an injury to the medial and lateral menisci, as noted in the November 2019 orthopedic record. The examiner stated that the two MRIs were consistent with an acute injury to the medial and lateral menisci at some point between February 2019 and October 2019. The two MRI reports did not show evidence of chronic degenerative changes in the menisci, so the findings pointed more toward an acute injury such as during a fall or a slip, and the record showed him falling at times. VA treatment records in November 2020 and March 2021 found no knee effusions. Overall, the weight of the evidence reflects left knee medial and lateral meniscus tears and symptoms including frequent pain, locking, and effusions at times since 2019. These symptoms are not otherwise compensated by the assigned ratings for this period. Accordingly, the Veteran has sufficient non-overlapping right knee symptoms due to pre-surgical meniscal tears in 2019 to warrant a 20 percent rating under DC 5258 since 2019. Resolving reasonable doubt in the Veteran's favor and to avoid unnecessary confusion, the Board will apply this rating as of February 19, 2019, the current effective date for meniscal impairment as applied by the AOJ. In contrast to the right knee, there was no evidence of a left knee meniscus tear prior to 2019. As summarized above, although the Veteran has had pain and effusions at times in both knees since service, as noted in the September 2014 VA examiner's opinion and April 2017 rheumatologist's record, his effusions and occasional locking were attributed to arthritis or multiple other causes, not to a torn meniscus of the left knee, prior to December 2019. These medical opinions by multiple treating providers and examiners were based on consideration of all available evidence, including the Veteran's credible lay reports as to his symptoms and repeated testing to determine the underlying cause. Therefore, they are highly probative, and there is no contrary competent evidence. Although the Veteran is competent to describe his observable complaints, he is not competent to give a diagnoses or opinion as to the underlying etiology due to its complex nature. Accordingly, the Veteran's effusions, pain, and occasional locking prior to February 19, 2019, are contemplated by his other assigned ratings, and moreover, his symptoms do not rise to the level of frequent episodes for a meniscal rating. As there was no additional meniscus tear after the December 12, 2019, partial medial meniscectomy, the current 10 percent rating for a symptomatic left knee post-meniscectomy, including occasional locking, is appropriate since that date. Instability There is no current rating for recurrent subluxation or instability of the left knee under DC 5257. The Veteran has consistently denied a history of recurrent subluxation or dislocation, and there is also no medical evidence to suggest such impairment. There is a suggestion of left knee instability that the Veteran described as giving way, collapsing, buckling, or weakness. However, the evidence does not rise to the level of non-overlapping symptoms to warrant a separate rating. VA treatment records and examinations noted the Veteran's occasional subjective reports as to sensations relevant to instability. However, they consistently found objectively stable or intact ligaments (including in x-rays and MRIs), with the exception of MRIs in 2019, and normal or negative results for joint stability tests (including posterior and anterior drawer, Lachman's, varus and valgus stress). In a December 2009 correspondence for his claim, the Veteran described multiple right knee problems, including giving way, falling, and feeling unstable, and stated that his left knee was starting to have the same problems as his right knee. However, during the January 2010 VA examination, he reported right knee giving way, but he stated that his left knee did not give way. In an April 2010 VA orthopedic consult, the Veteran reported that his left knee sometimes gives out, but testing showed intact ligaments and muscle strength of 5 out of 5 on the left. An August 2010 VA physical therapy record for the right knee again measured left knee strength as 5 out of 5, and tests for instability were negative. A December 2010 SSA evaluation found no left knee laxity and normal strength testing. During the March 2012 VA examination, the Veteran reported bilateral pain and that his right knee buckled and was worse than the left knee, but "now the left knee is getting bad." Left knee muscle strength and stability tests were again normal. A June 8, 2012, VA physical therapy record noted left knee pan and intermittent giving way, and a brace was requested. A subsequent June 2012 record noted that a knee sleeve (soft brace) was issued for the left knee to prevent buckling and pain. The Veteran continued to wear a soft brace on the left knee after this time. A July 2013 VA treatment record had a negative Lachman's test bilaterally. A March 2016 VA orthopedic record for complaints of bilateral knee pain and buckling noted that a left knee MRI showed some patellofemoral chondromalacia, and examination showed a stable knee and normal strength. A November 2016 VA orthopedic record noted continued bilateral knee pain in the patellar area, worse with stairs, and occasional buckling. Examination showed normal stability, and the impression was patellofemoral syndrome and chondromalacia. A January 2017 VA orthopedic record noted continued knee pain, primarily on the left at the medial aspect, and ligaments were intact on testing. A February 2017 MRI of the left knee showed intact ligaments, moderate effusion, chondromalacia, possible chondrocalcinosis, moderate tendinosis of the distal quadriceps tendon with no tear, mild patellar tendinosis, and a Baker's cyst. The October 2017 VA examination noted continued bilateral knee pain, stiffness, and a sensation of instability. Muscle strength was 5 out of 5, and stability tests were normal. The Veteran reported using braces and a cane for both knees. X-rays in November 2018 for left knee pain showed mild degenerative changes with chondrocalcinosis. A February 11, 2019, VA orthopedic record noted that the Veteran had bilateral knee pain and swelling, and prior x-rays and MRIs of the left knee did not show much mechanical findings. The prior week, his left knee had buckled under him and then locked. The impressions noted a suspected torn meniscus, and some probable patellar tendonitis for fusion pain in the left knee. Among other findings, a February 14, 2019, MRI showed a "slight wavy appearance" of the anterior cruciate ligament (ACL), but the majority of the ligament was intact and posterior cruciate ligament (PCL) and collateral ligaments were intact. A September 2019 orthopedic record noted left knee problems, but there was no ligament laxity on examination. Among other findings (including torn menisci as discussed above), an October 2019 MRI of the left knee showed slight laxity with mild attenuation of the proximal/mid fibers of the ACL, which was unchanged in appearance since the February 2019 MRI. This was noted to possibly reflect low-grade tearing with superimposed fibrosis, but correlation with an orthopedic examination was recommended. The ACL, PCL, medial and lateral supporting structures, and extensor mechanism were otherwise intact. A November 2019 orthopedic record noted that this MRI showed laxity in the ACL that was likely a sequela of chronic low-grade tearing with superimposed fibrosis, unchanged since the February 2019 MRI, and the ACL and PCL were grossly intact. The overall impression was a torn meniscus. Surgery was recommended and performed in December 2019, which included a partial meniscectomy and chondroplasty. A May 2020 VA treatment record noted the Veteran's report of bilateral knee hyperextension for many years, and he used knee braces and a cane for this. He was wearing a hard brace on his right knee and a soft brace on his left knee. During the October 2020 VA examination, the examiner noted a "hyperlax" patella bilaterally, and that the Veteran wore a sleeve (soft brace) on his left knee for support, but he reported that the left knee was not as unstable as his right knee. The examiner noted no history of lateral instability, and stability tests were normal. As noted above, the Veteran was first issued a soft brace for his left knee in June 2012, and he began using a cane in June 2017. As summarized above, medical records reflect that bilateral knee braces and a cane were used, at least in part, to prevent hyperextension, buckling, giving way, or instability of the left knee. Knee arthritis and nonservice-connected hypophosphatemia, low back problems, and lack of sensation of feet were noted a reasons for a brace or cane at times. As also noted above, the criteria under DC 5257 in effect prior to February 7, 2021, address recurrent lateral instability. They do not give specific definitions of mild, moderate, or severe conditions. Instead, the Board must make the determination based on consideration of all evidence. Medical evidence is not automatically more probative than lay evidence, but it may outweigh lay evidence. Overall, the weight of the evidence does not support a separate compensable rating on this basis. Specifically, the Veteran is competent to report his observable sensations, and his reports are credible because they are consistent throughout the appeal period. Nevertheless, he described only occasional or intermittent buckling, giving way, or instability of his left knee, stating that his right knee was worse, which is also consistent with the medical testing and observations as to both knees. The Veteran is not competent to identify the underlying basis for such sensations or whether they are due to lateral instability or another cause because the knee is very complex and requires medical expertise to interpret the evidence and tests. As summarized above, the medical evidence reflects that the Veteran's occasional sensations of instability were due, in part, to hyperextension of the patella, pain, chondromalacia, and/or a torn meniscus. There were generally no objective findings of lateral or other instability on repeated testing, and no ligament tears. Although MRIs in 2019 noted a slight wavy appearance or slight laxity of the ACL, which may represent a low-grade tearing with superimposed fibrosis, this involved an anterior ligament, not a lateral ligament. Moreover, the overall findings after those MRIs were medial and lateral meniscal teras, which were surgically repaired. The Veteran's left knee brace was issued in part due to pain. In contrast to the right knee, the frequency, severity, and extent of the Veteran's buckling, giving way, or other sensations of instability are already compensated by his ratings based on limited extension (including due to pain) and meniscus tears. For the above reasons, assigning a separate rating under DC 5257 for these manifestations would be impermissible pyramiding. This is true under both the old and new versions of DC 5257. Moreover, even if a compensable rating were warranted under the criteria effective since February 7, 2021, the Veteran is already in receipt of the maximum allowable combined rating for his left knee, effective since September 22, 2020, without violating the amputation rule, as noted below. Other Rating Considerations Throughout the appeal period, there is no argument or indication of left knee ankylosis (DC 5256), tibia or fibula impairment (DC 5262), or genu recurvatum (DC 5263) to warrant a separate rating or discussion of those diagnostic codes. Finally, the Veteran's left knee surgical scars from a 2019 surgery are service-connected as noncompensable, effective February 19, 2019. Although the rating criteria for scars were amended effective August 13, 2018, during the course of this appeal, they are essentially the same as relevant to this Veteran's case, and neither version is more favorable. The evidence consistently shows that the left knee scars are not painful or unstable, there is no suggestion that they are "deep" scars or are associated with underlying soft tissue damage, and they do not measure at least 144 square inches (929 square cm). There is also no suggestion of disabling effects due to the scarring itself. Therefore, a separate compensable rating is not warranted on this basis. See 38 C.F.R. § 4.118, DCs 7801 to 7805 (2017 & 2020). In light of the Board's determinations of entitlement to increased ratings for the left knee, effective since September 22, 2020, the Veteran has ratings of 50 percent for limitation of extension under DC 5261, 10 percent for limited flexion under DC 5260, and 10 percent for meniscus under DC 5259. These ratings combine to 60 percent. 38 C.F.R. § 4.25. This is the maximum allowed for knee impairment under the amputation rule. See 38 C.F.R. §§ 4.68 (the combined rating for a disability shall not exceed the rating for amputation at the elective level of the extremity, were amputation to be performed) & 4.71a, DC 5164 (amputation of the lower extremity not improvable by prosthesis controlled by natural knee action will be rated 60 percent). Accordingly, the Veteran may not be paid more than 60 percent compensation for his left knee, effective since September 22, 2020, as this would violate the amputation rule. Id. However, as he is entitled to the indicated separate and increased ratings for portions of the appeal period prior to September 22, 2020, and the ratings do not combine to higher than 60 percent, they should remain in effect for compensation for those prior periods. Temporary Total Rating Although not specifically, argued, the record raises the possibility for a temporary total rating based on the Veteran's December 2019 left knee arthroscopic surgery under 38 C.F.R. § 4.30. However, the evidence does not reflect a level of convalescence or residuals after that surgery to warrant a temporary total rating. Shortly before the surgery, a November 1, 2019, VA orthopedic record noted that the Veteran had been seen earlier that year for left knee pain, his knee still hurt a fair amount, swelled, and locked, which was painful when it occurred. The provider noted the results of left knee MRIs in 2019 and x-rays in November 2018, and findings included laxity in the ACL, multidirectional tearing of the posterior horn of the medial meniscus, small-moderate joint effusion, synovitis. Overall, the provider noted a complex medial meniscal tear of the left knee and recommend an arthroscopy with partial medial meniscectomy. Another November 1, 2019, record noted that he was wearing bilateral knee braces and walking with a cane. A December 8, 2019, VA pre-procedure note summarized the Veteran's bilateral knee history of worsening pain over time, prior right knee surgeries, and the Veteran's report of being unable to work since 2017 due to his knees. He had pain with bilateral range of motion, wore braces for instability, and used a cane. A December 12, 2019, brief operative note for left knee pain identified the principal procedure as a left knee arthroscopy and partial medial meniscectomy. He was advised to do weightbearing activities as tolerated, use crutches as needed, and follow up in 10 to 14 days. A December 26, 2019, VA orthopedic record noted that the Veteran reported that his left knee pain had improved since prior to the surgery, he had mild swelling, was ambulating with a cane, and range of motion was from 0 to 115 degrees. Sutures were removed, and there were no signs of infection. The Veteran was that it was okay for him to use a stationary bike and walk, but he should avoid high-impact activities, and he should followup in four weeks to re-check the left knee. More than one month after surgery, a January 22, 2020, VA orthopedic record noted that the Veteran's left knee continued to improve since his surgery, although he continued to have right knee pain, and he was ambulating with a cane. There was no effusion, minimal swelling, and range of motion from 0 to 130 degrees for the left knee. A February 12, 2020, orthopedic record by another provider noted that the left knee was doing well and the incision was healed. There was full range of motion and no joint line pain. The Veteran again had right knee complaints. He was advised to use ice and medications as in the past (NSAIDs and diclofenac cream) as needed. Several months later, a May 2020 VA treatment record noted pain in both knees rated as 5 to 7 out of 10 that interrupted some activities, and the Veteran used a cane or crutches and worse braces on both knees. He reported having bilateral knee hyperextension for many years and that he used knee brace and a cane for this. In summary, the Veteran's left knee pain improved immediately after the surgery, his incision was healed with no signs of infection, and other findings showed mild swelling or limitation of motion. Although he continued to use a cane or braces at times, he also complained of right knee problems. There is no indication that any continuing left knee symptoms, to include as noted in May 2020 or subsequently, were related to this surgery, as opposed to longstanding complaints or his diagnosed hypophosphatemia as noted in May 2020 or Ehlers-Danlos syndrome. He did not require convalescence for one month or more or have severe residuals. Accordingly, a temporary total rating under 38 C.F.R. § 4.30 is not warranted. Conclusion In summary, the Veteran's left knee disability warrants staged ratings, with separate or increased ratings as discussed above, which are partial grants of the appeal. Otherwise, the Veteran's left knee manifestations were relatively stable during the staged periods on appeal, and any increases in severity were not sufficient to meet the criteria for a higher or separate rating. The preponderance of the evidence is against a higher or separate rating under any reasonably raised theory, and there is no reasonable doubt to be resolved in his favor. The appeal is otherwise denied. REASONS FOR REMAND 13. Entitlement to a TDIU is remanded. As noted above, the Veteran's claim for a TDIU is inferred as part and parcel of the underlying appeal from the ratings assigned for his bilateral knee disabilities. VA should request the Veteran to complete a formal TDIU application (VA Form 21-8940) with his prior employment and educational history and other relevant information, and complete any other indicated development for this inferred claim. VA previously obtained records from the Social Security Administration (SSA) pertaining to the Veteran's August 2010 SSA claim for disability benefits, which was claimed as based on his knees and other disabilities, several of which are now service-connected. That prior claim was denied in January 2011. However, the Veteran's bilateral knee disabilities have increased in severity over time, and it is unclear if he filed a subsequent SSA claim around 2017. Therefore, any additional relevant SSA records since the prior determination in 2011 should be requested. In general, the Veteran's treatment and SSA records reflect that he worked in the construction or finish carpentry business since approximately 1985. He identified different dates for when he stopped working, ranging from 2010 to 2013, and different dates for when he felt he was disabled of 2009 or 2017. He reported that he stopped working due to his knees, but he also identified impacts from other disabilities. Therefore, more information is needed to decide the TDIU matter. This matter is REMANDED for the following action: 1. Request to the Veteran to complete a VA Form 21-8940 for his inferred TDIU claim. 2. Request copies of medical records and disability determinations from the Social Security Administration for any disability claims by the Veteran since 2011. (It is noted that the current SSA records in the claim file include the Veteran's employment and educational history to that date.) 3. After completing any other indicated development, adjudicate the inferred TDIU claim with consideration of all service-connected disabilities. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wheatley 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.