Citation Nr: 22013784 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 16-30 473 DATE: March 10, 2022 ORDER Entitlement to a disability rating higher than 20 percent for the service-connected cervical spine (neck) disability is denied. Entitlement to a disability rating higher than 20 percent for the service-connected thoracolumbar spine (low back) disability is denied. Entitlement to a disability rating higher than 10 percent for limitation of flexion associated with the service-connected right knee disability is denied. Entitlement to a separate disability rating of 10 percent, but not higher, for limited extension associated with the service-connected right knee disability is granted. Entitlement to a separate disability rating of 10 percent, but not higher, for right knee instability associated with the service-connected right knee disability is granted. Entitlement to a disability rating higher than 10 percent for limitation of flexion associated with the service-connected left knee disability is denied. Entitlement to a separate disability rating of 10 percent, but not higher, for limited extension associated with the service-connected left knee disability is granted. Entitlement to a disability rating higher than 10 percent for left knee instability associated with the service-connected left knee disability is denied. Entitlement to a disability rating of 20 percent, but not higher for the service-connected right ankle disability is granted. Entitlement to a disability rating higher than 10 percent for service-connected radiculopathy of the left lower extremity is denied. FINDINGS OF FACT 1. The service-connected neck disability is manifested by painful motion with forward flexion that exceeds 15 degrees. 2. The service-connected low back disability is manifested by painful motion with forward flexion that exceeds 30 degrees. 3. The service-connected right knee disability is manifested by painful motion with flexion of 45 degrees and with extension limited to 10 degrees. 4. The service-connected right knee disability is manifested by a strain 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. 5. The service-connected left knee disability is manifested by painful motion with flexion of 45 degrees and with extension limited to 10 degrees. 6. The service-connected left knee disability is manifested by 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. 7. The service-connected right ankle disability is manifested by painful motion with plantar flexion of 5 degrees, but with no ankylosis. 8. The service-connected radiculopathy of the left lower extremity is manifested by incomplete paralysis that is not worse than mild. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 20 percent for the service-connected neck disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 2. The criteria for a disability rating higher than 20 percent for the service-connected low back disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243. 3. The criteria for a disability rating higher than 10 percent for limitation of flexion associated with the service-connected right knee disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 4. The criteria for a disability rating of 10 percent for limitation of extension associated with the service-connected right knee disability are met; the criteria for any rating higher than 10 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 5. The criteria for a separate disability rating of 10 percent for right knee instability associated with the service-connected right knee disability are met; the criteria for any rating higher than 10 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 6. The criteria for a disability rating higher than 10 percent for limitation of flexion associated with the service-connected left knee disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 7. The criteria for a disability rating of 10 percent for limitation of extension associated with the service-connected left knee disability are met; the criteria for any rating higher than 10 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5261. 8. The criteria for a disability rating higher than 10 percent for left knee instability associated with the service-connected left knee disability are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 9. The criteria for a disability rating of 20 percent for the service-connected right ankle disability are met; the criteria for any rating higher than 20 percent are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5270, 5271. 10. The criteria for a disability rating higher than 10 percent for the service-connected radiculopathy of the left lower extremity are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.123, 4.124, 4.124a, Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a veteran (the Veteran) who had active duty service from June 1973 to November 1975, October 1982 to January 1995, and January 2003 to April 2008. This appeal comes before the Board of Veterans' Appeals (Board) from a January 2021 Order of the United States Court of Appeals for Veterans' Claims (Veterans Court). The appeal originated from a July 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran presented testimony at a Board hearing in Washington, DC, chaired by the undersigned Veterans Law Judge. At the Board hearing, the Veteran was informed of the basis for the RO's denial of his claims, and he was informed of the information and evidence necessary to substantiate each claim. 38 C.F.R. § 3.103. A transcript of the hearing is associated with the claims file. In a May 2020 decision, the Board granted an increased rating of 20 percent for the service-connected neck disability and denied the remaining claims. The Veteran appealed that decision to the Veterans Court. In a January 2021 Order, pursuant to a Joint Motion for Remand, the Veterans Court vacated the Board's decision in part, and remanded these issues to the Board for additional development consistent with the Joint Motion. In July 2021, the Board remanded these issues for additional evidentiary development in compliance with the Joint Motion. The appeal has since been returned to the Board. In a February 23, 2022, letter, the Veteran's attorney withdrew the pending privacy act request. The Board has considered whether the rating claims on appeal include the issue of TDIU entitlement in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). Because the increased ratings granted here result in a combined rating of 100 percent for the entire appeal period, the issue of TDIU entitlement becomes moot. While this is not always true, the only reason for adjudicating the issue would be to determine entitlement to Special Monthly Compensation (SMC) on the statutory housebound basis. In other words, if a single rating could satisfy entitlement to TDIU, the requirement of a total rating would be met, with sufficient addition disability to equal 60 percent or more. In this case, the highest rated single disability is 40 percent for diabetes. The evidence does not substantiate that the Veteran's diabetes alone, without consideration of other disabilities, renders him unable to secure or follow a substantially gainful occupation. Indeed, the medical evidence supporting the increase to 40 percent does not mention the need for regulation of activities. It mentions only the need for insulin. Accordingly, a single disability cannot support TDIU, and the issue of TDIU entitlement becomes moot. Increased Ratings-Law and Regulations Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). The rating must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. Staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during symptom flares or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca, supra; see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). During the course of this appeal, the musculoskeletal ratings were amended effective February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board must consider the application of prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. See nerve involved for diagnostic code number and rating. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. See nerve involved for diagnostic code number and rating. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. Generally, lay evidence is competent with regard to identification of a disease with unique and readily identifiable features which are capable of lay observation. A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir 2007). Lay persons may also provide competent evidence regarding a contemporaneous medical diagnosis or a description of symptoms in service which supports a later diagnosis by a medical professional. However, a lay person is not competent to provide evidence as to more complex medical questions, i.e., those which are not capable of lay observation. Lay statements are not competent evidence regarding diagnosis or etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau, at 1377, n. 4 ('sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer'); 38 C.F.R. § 3.159(a)(2). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A VA claimant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must weigh against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), Gilbert at 54. Entitlement to a disability rating higher than 20 percent for the service-connected neck disability. Entitlement to a disability rating higher than 20 percent for the service-connected low back disability. In a March 1996 rating decision, VA granted service connection for a cervical spine disability and assigned an initial disability rating of 0 percent under Diagnostic Code 5010, effective January 28, 1995. In an April 1998 rating decision, the disability rating was increased to 10 percent, effective January 28, 1995. The Veteran was called to active duty in 2003. A 10 percent rating was assigned upon his return, effective May 1, 2008. The current appeal arises from an increased rating claim received at VA on September 11, 2013. In a May 2020 decision, the agency of original jurisdiction implemented the Board's May 2020 grant of an increased 20 percent rating for the neck disability. The effective date assigned by the agency of original jurisdiction was September 11, 2013, the date of claim. In a March 1996 rating decision, VA granted service connection for a low back disability and assigned an initial disability rating of 20 percent under Diagnostic Code 5293, effective January 28, 1995. The Veteran was called to active duty in 2003. A 10 percent rating was assigned upon his return, effective May 1, 2008. The current appeal arises from an increased rating claim received at VA on September 11, 2013. In a July 2014 decision, the rating for the low back was increased to 20 percent under Diagnostic Code 5243, effective September 11, 2013, the date of claim. Effective February 7, 2021, degenerative arthritis, and degenerative disc disease other than intervertebral disc syndrome are to be rated under Diagnostic Code 5242. A rating under Diagnostic Code 5243 for intervertebral disc syndrome is only to be assigned when there is disc herniation with compression of the adjacent nerve root. See 85 Fed. Reg. 76464 (Nov. 30, 2020). These changes do not affect the ratings assigned, but simply affect the diagnostic code to be assigned. All disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. A rating of 100 percent requires unfavorable ankylosis of the entire spine. A rating of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine. A rating of 40 percent requires unfavorable ankylosis of the entire cervical spine; or forward flexion of the thoracolumbar spine limited to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A rating of 30 percent requires forward flexion of the cervical spine limited to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A rating of 20 percent requires forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Formula, note (2) (See also Plate V). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, General Formula, Note (5). During an appointment with his VA treating physician in May 2013, range of motion in the Veteran's neck was measured at 10 degrees flexion and 26 degrees extension. He was also noted to experience "occasional radicular symptoms" despite his sensation being generally intact. A VA neck examination report from November 2013 reveals prior diagnosis of degenerative disc disease of the cervical spine; he reported flares of this condition, which resulted in pain, trouble turning his neck, numbness in his fingers, and a burning sensation in his shoulders. On examination, flexion and extension were both measured to 35 degrees. Though abnormal range of motion was found to contribute to functional loss, the Veteran was able to complete repetitive use testing without additional loss of range of motion. Despite this, pain on use and pain on weightbearing were both noted to result in additional functional loss and limited range of motion. There was no evidence of pain on palpation or localized tenderness, though guarding and muscle spasms were documented. However, these were not severe enough to result in abnormal gait or spinal contour. The examiner also determined that the Veteran's neck disability resulted in pain on movement but no other symptoms. Nonetheless, pain, weakness, fatiguability, and incoordination were not found to significantly limit functional ability during flares or with repeated use over time. There were no indications of diminished muscle strength, muscle atrophy, ankylosis, or IVDS. The sensory and reflex examinations were likewise normal, with no evidence of radicular pain or other neurological abnormalities. Lastly, though the Veteran was noted to use a cane occasionally, this was due to his left knee impairment rather than his neck condition. Based on these findings, the examiner opined that the Veteran's service-connected neck disability would affect his ability to perform occupational tasks by limiting his mobility and overall functioning. A VA low back examination report from November 2013 reveals prior diagnoses of degenerative disc disease, IVDS, and a herniated nucleus pulposus of the thoracolumbar spine; he claimed that this condition resulted in flares, characterized by pain and spasms. On examination, flexion was measured to 60 degrees and extension to 15 degrees. Although abnormal range of motion was found to contribute to functional loss, the Veteran was able to complete repetitive use testing without additional loss of range of motion. Pain was noted during range of motion as well on weightbearing; however, no additional measurements were taken. There was no localized tenderness or pain on palpation. Gait and spinal curvature were normal, and there were no indications of guarding or muscle spasm. The Veteran's low back disability was found to result in pain on movement. Nonetheless, there was no evidence of diminished muscle strength, muscle atrophy, or ankylosis. While there was documented evidence of IVDS of the thoracolumbar spine, the Veteran had not experienced any incapacitating episodes in the previous 12 months. Lastly, though the Veteran was noted to use a cane occasionally, this was due to his left knee impairment and not because of his low back disability. Based on this evidence, the examiner opined that the Veteran's service-connected low back disability would affect his ability to engage in occupational tasks by resulting in pain and weakness. An MRI of the Veteran's cervical spine performed at a VA facility in July 2014 revealed advanced multilevel degenerative changes at the C3-C4 and C6-C7 levels. There was also flattening of the ventral cord at the C3-C4 and C6-C7 levels, along with moderate to severe canal stenosis at the C3-C4 level with mild to moderate canal stenosis throughout. Lastly, severe foraminal stenosis was documented at multiple levels. An MRI of the Veteran's thoracolumbar spine taken at a VA facility in July 2014 showed no cord compression. However, thoracic spondylosis with multilevel mild degenerative disc disease was present, along with mild central canal narrowing at the T2-T3, T3-T4, T5-T6, T6-T7, T7-T8, and T9-T10 levels. The study also found postsurgical changes of the lower lumbar spine with multilevel degenerative changes and grade 1 spondylolisthesis at the L5-S1 level. Lastly, there was disc desiccation throughout. Private chiropractic treatment records dating between 2016 and early 2018 contain three range of motion measurements related to the Veteran's cervical spine. In March 2016, his cervical range of motion was measured at 5 degrees flexion and 45 degrees extension (total range of motion 205 degrees). In February 2017, flexion was recorded as 15 degrees with extension to 35 degrees (total range of motion 180 degrees). In April 2018, cervical flexion was measured at 15 degrees and extension to 45 degrees (total range of motion 177 degrees). Though these records also reflect numerous complaints of neck pain, there were no indications of cervical radiculopathy. Private chiropractic treatment records dating between 2016 and early 2018 contain three range of motion measurements related to the Veteran's thoracolumbar spine. In March 2016, his lumbar range of motion was measured at 80 degrees flexion and 10 degrees extension. In February 2017, flexion was recorded as 90 degrees with extension to 15 degrees. In April 2018, lumbar flexion was measured at 90 degrees and extension to 29 degrees. A VA neck examination report from August 2018 reveals prior diagnosis of degenerative arthritis of the cervical spine. The Veteran denied experiencing flares but claimed that this condition resulted in pain and decreased mobility. On examination, forward flexion was measured from zero to 45 degrees, with extension from zero to 30 degrees. Range of motion was not found to contribute to functional loss, nor was there evidence of localized tenderness, pain on palpation, or pain on weightbearing. Indeed, no pain was noted during the examination. The Veteran was also able to complete repetitive use testing without additional functional loss. The examination was found to be neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with repeated use over time. Additionally, the examiner was unable to state without resorting to mere speculation whether pain, weakness, fatiguability, or incoordination would significantly limit functional ability with repeated use over time because there was no objective evidence upon which to base such a conclusion. There was no indication of guarding, muscle spasm, or muscle atrophy. Muscle strength, reflex, and sensory testing were normal, with no evidence of ankylosis, IVDS, radiculopathy, or other neurological abnormalities. However, the examiner noted the Veteran's diabetes, which was found to result in numbness in his hands and feet. While there was objective evidence of arthritis in the Veteran's cervical spine, none of the available imaging showed a vertebral fracture with loss of 50 percent or more of height. Based on this information, the examiner determined that the Veteran's service-connected neck disability would affect his ability to work by resulting in increased absenteeism and tardiness, having to be assigned different duties, pain, and impaired mobility. A VA low back examination report from August 2018 reveals prior diagnosis of degenerative arthritis of the thoracolumbar spine. Though the Veteran denied experiencing symptom flares of this condition, he asserted that it resulted in pain and limited mobility. On examination, forward flexion was measured from zero to 90 degrees, with extension from zero to 20 degrees. Range of motion was not found to contribute to functional loss. There was no evidence of pain on weightbearing, pain on palpation, or localized tenderness. Indeed, no pain was noted during the examination. The Veteran was also able to perform repetitive use testing without additional functional loss. While the Veteran was not examined after repeated use over time, the results of the evaluation were found to be neither medically consistent nor inconsistent with his statements. Moreover, the examiner could not opine whether pain, weakness, fatiguability, or incoordination significantly limited functional ability with repeated use over time without resorting to mere speculation because there was no objective evidence upon which to base such a conclusion. There was no evidence of guarding, muscle spasm, or muscle atrophy. There were no indications of ankylosis, IVDS, or other neurological abnormalities. The Veteran did not use any assistive devices. The examiner noted the presence of an 8-centimeter by 1-centimeter surgical scar on the Veteran's lower back. However, this was not found to be painful, unstable, or greater in total area than 39 square centimeters. Lastly, while objective evidence confirmed the existence of arthritis throughout the Veteran's thoracolumbar spine, there were no indications of a vertebral fracture with loss of 50 percent or more of height. Based on these findings, the examiner concluded that the Veteran's service-connected low back disability would affect his ability to perform occupational tasks, resulting in increased absenteeism, tardiness, having to be assigned different duties, pain, limited mobility, and difficulty lifting and carrying. Dr. D.A., a private chiropractor, wrote in March 2019 that the Veteran experienced advanced spinal degeneration. Specifically, she pointed out that he had spondylolisthesis at the L5 level and a laminectomy at the L3-L5 levels. Dr. D.A. went on to state that the Veteran's condition will continue to deteriorate as he ages. When he is able to receive chiropractic care, these therapies allow him to function and perform his activities of daily living with less pain and discomfort. However, when he cannot receive chiropractic care, he will often miss work due to pain. She therefore recommended that the Veteran have chiropractic therapy one to two times per week so he can be prevented from having to use pain medication. A February 2020 letter from Dr. D.A. contains a report of physical examination conducted of the Veteran in In January 2020. The evaluation reflected thoracolumbar range of motion of 55 degrees flexion with pain and 25 degrees extension without pain. Dr. D.A. also commented that the Veteran's condition had worsened over the last six months, with an MRI showing progressed degenerative changes. Lastly, the Veteran exhibited severe muscle spasms throughout his thoracolumbar paraspinal muscles, and examination confirmed the existence of hypoesthesia at the L2-L5 levels. A February 2020 letter from Dr. D.A. contains a report of physical examination conducted of the Veteran in January 2020. The evaluation reflected cervical range of motion of 17 degrees flexion and 34 degrees extension, both with pain. Dr. D.A. also commented that the Veteran's condition had worsened over the last six months, with an MRI showing "mildly progressed" degenerative changes. Lastly, the Veteran complained of numbness and tingling in his hands; however, the examination only confirmed the existence of hypoesthesia at the C6-C7 level. A February 2020 letter from Dr. D.A. contains a report of physical examination conducted of the Veteran in In January 2020. He complained of constant, shooting pain in his left leg, which he rated as ranging between 5 and 9 out of 10. The Veteran also reported numbness and weakness throughout his lower left extremity, along with left calf atrophy. Although Dr. D.A. noted weakness of the left hip flexor and left extensor hallucis longus, the examination report does not establish muscle atrophy in the Veteran's left calf. A VA neck examination in August 2021 reveals the Veteran's complaint of current neck pain that is constant with burning down both arms, and with worsening symptoms on the left versus right. He reported no flares as he is in constant pain. He reports limitations with turning his head while driving and with sitting at the computer for extended periods of time. On examination, forward flexion was measured to 40 degrees. Extension was to 35 degrees; lateral flexion was to 20 degrees right, 15 degrees left; lateral rotation was to 60 degrees right, 25 degrees left. All motion was painful. Passive range of motion testing was contraindicated due to pain. The Veteran declined to perform repetitive use testing. The examiner estimated range of motion after repeated use over a period of time. Forward flexion was estimated to 30 degrees. Extension was to 25 degrees; lateral flexion was to 10 degrees right, 5 degrees left; lateral rotation was to 50 degrees right, 15 degrees left. The Veteran did not report flares. Tenderness and spasms did not result in abnormal gait or abnormal spinal contour. There was no guarding. Muscle strength in the upper extremities was full, with the exception of the fingers, which was reduced. Reflexes were normal. Sensory examination was normal with the exception of decreased sensation in the fingers. Constant pain and numbness were assessed as mild. Intermittent pain and paresthesias were assessed as moderate. There was no ankylosis or prescribed bedrest. The examiner diagnosed degenerative arthritis, intervertebral disc syndrome, spinal stenosis, and degenerative disc disease other than intervertebral disc syndrome. The examiner also diagnosed bilateral upper extremity radiculopathy. The Veteran's marked degenerative changes throughout his cervical spine led to issues with range of motion, pain and radiculopathy, which all impact his ability to perform occupational tasks such as overhead lifting/activities, driving to and from his place of employment, and being seated in front of a computer for prolonged periods of time. A VA low back examination in August 2021 reveals the Veteran's complaint of pain in the low back and lower extremities. The Veteran reports extreme difficulty with walking and standing for prolonged periods of time. His limitations in his back range of motion also make it difficult for the Veteran to bend forward to lift any items. Flares occur three times per year and last one hour. At these times, the Veteran is unable to move or ambulate. On testing of active range of motion, forward flexion was measured to 75 degrees. Extension was to 20 degrees; lateral flexion was to 20 degrees, bilaterally; lateral rotation was to 20 degrees right and 15 degrees left. All motion was painful. Testing of passive range of motion was considered medically contraindicated due to the risk of severe pain. There was pain with weight-bearing. The Veteran declined repetitive use testing. Estimates were made as to range of motion after repetitive use over a period of time. Forward flexion was to 75 degrees. Extension was to 15 degrees; lateral flexion was to 15 degrees, bilaterally; lateral rotation was to 15 degrees right and 10 degrees left. Estimates were also made as to range of motion with flares. Forward flexion was to 45 degrees. Extension was to 10 degrees; lateral flexion was to 10 degrees, bilaterally; lateral rotation was to 10 degrees right and 5 degrees left. Localized tenderness, guarding or muscle spasm of the thoracolumbar spine did not result in an abnormal gait or abnormal spinal contour. There was no guarding. The examiner diagnosed degenerative arthritis of the lumbar spine, intervertebral disc syndrome, degenerative disc disease other than intervertebral disc syndrome, spinal stenosis, and bilateral radiculopathy of the lower extremities. There was no prescription of bed rest with treatment by a physician for intervertebral disc syndrome. After a review of all of the evidence, the Board finds that the criteria for higher disability ratings are not met for either the neck or the low back. To summarize the legal requirements for higher ratings, the next higher rating for the neck requires that motion more nearly approximate limitation to 15 degrees of forward flexion than it does a higher degree, or that the entire cervical spine be fixed in place. While there are several measurements which show flexion at or less than 15 degrees, there are at least as many showing flexion to higher degrees, to include estimates during flares or with repeated use over a period of time. The August 2021 examination estimated forward flexion to 45 degrees during a flare. The Board notes that a May 2013 test showing flexion to 10 degrees was conducted prior to the current claim. Moreover, testing shortly after May 2013, in November 2013, showed forward flexion to 35 degrees. As explained in the Board's May 2020 decision, the lower results were used to balance against the results showing greater range of motion. On balance, this supported the increased rating of 20 percent granted by the Board in that decision. The Joint Motion did not contest the Board's reasoning on this determination. The Board finds that these results, interspersed among much better results, do not substantiate a sustained increase in disability that could support a higher or staged rating during any period. The next higher rating for the low back requires that motion of the thoracolumbar spine be limited to 30 degrees or less of forward flexion, or that that the entire thoracolumbar spine be fixed in place. This is neither shown nor approximated, to include estimates during flares or with repeated use over a period of time. The Veteran's report of experiencing pain with all motion is not itself probative of entitlement to a rating higher than 20 percent. While it is clear from the record that there is limited motion and painful motion, evaluations in excess of the minimum compensable rating must be based on demonstrated functional impairment. The issue is not whether pain limits flexion, but whether that additional limitation would decrease the flexion to less than 30 degrees for the low back or 15 degrees for the neck. Here, the clinical evidence and the Veteran's statements simply do not demonstrate or even suggest impairment to that level. As such, the Board concludes that a rating higher than 20 percent under the General Rating Formula is not warranted for either the neck disability or the low back disability. As the Veteran has no prescribed bedrest by a physician, with treatment from a physician, a rating in accordance with the schedule for rating intervertebral disc syndrome is not warranted. The Veteran is already assigned a rating for neurological abnormalities of the right lower extremity. The left lower extremity is part of the current appeal and is addressed below. There are no other associated neurological abnormalities. In light these findings of fact, the Board concludes that no higher or separate ratings are warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence weighs against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to a disability rating higher than 10 percent for limitation of motion (flexion/extension) associated with the service-connected right knee disability. Entitlement to a disability rating higher than 10 percent for limitation of motion (flexion/extension) associated with the service-connected left knee disability. Entitlement to a separate disability rating for right knee instability associated with the service-connected right knee disability. Entitlement to a disability rating higher than 10 percent for left knee instability associated with the service-connected left knee disability. In a June 1979 rating decision, VA granted service connection for a left knee meniscal disability and assigned an initial disability rating of 0 percent under Diagnostic Code 5259, effective February 26, 1979. In a March 1996 rating decision, the disability rating was increased to 10 percent under Diagnostic Code 5010, effective January 28, 1995. In a January 2001 decision, VA assigned a separate rating of 10 percent for left knee instability under Diagnostic Code 5257, effective January 28, 1995. The Veteran was called to active duty in 2003. A 10 percent rating was assigned upon his return, effective May 1, 2008. In a November 2008 decision, service connection was granted for a right knee disability. A rating of 0 percent was assigned under Diagnostic Code 5024, effective May 1, 2008. The current appeal arises from an increased rating claim received at VA on September 11, 2013. The rating for the right knee was increased to 10 percent in July 2014 under Diagnostic Code 5260, effective September 11, 2013. Under Diagnostic Code 5256 ankylosis is rated 60 percent where it is extremely unfavorable, in flexion at an angle of 45 degrees or more; a rating of 50 percent where in flexion between 20 degrees and 45 degrees; a rating of 40 percent where in flexion between 10 degrees and 20 degrees; and a rating of 30 percent where at a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Since February 7, 2021, under Diagnostic Code 5257, other impairment of the knee can be rated on the basis of either recurrent subluxation or lateral instability, or on the basis of patellar instability. Where a rating is assigned on the basis of recurrent subluxation or lateral instability, a rating of 30 percent is assigned if there is an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A rating of 20 percent is assigned with one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A rating of 10 percent is assigned for a sprain, incomplete ligament tear, or complete ligament tear repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Where a rating is assigned on the basis of patellar instability, a rating of 30 percent is assigned where there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A rating of 20 percent is assigned with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker . A rating of 10 percent is assigned with a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Prior to February 7, 2021, under Diagnostic Code 5257, recurrent subluxation or lateral instability is assigned a rating of 30 percent if severe, a rating of 20 percent if moderate, or a rating of 10 percent if slight. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). Under Diagnostic Code 5258, a rating of 20 percent is assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, symptomatic removal of the semilunar cartilage is assigned a rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, limitation of flexion of the knee is assigned a rating of 30 percent where flexion is limited to 15 degrees; a rating of 20 percent where flexion is limited to 30 degrees; a rating of 10 percent where flexion is limited to 45 degrees; or a rating of 0 percent where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, limitation of extension of the knee is assigned a rating of 50 percent where extension is limited to 45 degrees; a rating of 40 percent where extension is limited to 30 degrees; a rating of 30 percent where extension is limited to 20 degrees; a rating of 20 percent where extension is limited to 15 degrees; a rating of 10 percent where extension is limited to 10 degrees; or a rating of 0 percent where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5262, impairment of the tibia and fibula is assigned a rating of 40 percent with nonunion, with loose motion, requiring brace. With malunion of tibia and fibula, Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, are to be applied, whichever results in the highest evaluation. For medial tibial stress syndrome (MTSS), or shin splints, a rating of 30 percent requires treatment for no less than 12 consecutive months, and unresponsiveness to surgery and either shoe orthotics or other conservative treatment, both lower extremities; a rating of 20 percent requires treatment for no less than 12 consecutive months, and unresponsiveness to surgery and either shoe orthotics or other conservative treatment, one lower extremity; a rating of 10 percent requires treatment for no less than 12 consecutive months, and unresponsiveness to either shoe orthotics or other conservative treatment, one or both lower extremities; a rating of 0 percent is appropriate with treatment less than 12 consecutive months, one or both lower extremities. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5263, genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) is assigned a rating of 10 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5263. A VA knee examination report from November 2013 reveals prior diagnoses of left knee meniscectomy and bilateral knee arthritis. The Veteran reported flares of his knee condition, which resulted in severe pain and constant throbbing. During these episodes, he had difficulty going up and down stairs, felt unstable, and limped. On examination, flexion in the right knee was measured to 140 degrees and extension to zero degrees. Flexion in the left knee was measured to 90 degrees and extension to zero degrees. Abnormal range of motion in both knees was found to contribute to functional loss. The Veteran was able to complete repetitive use testing with his right knee without additional functional loss. Although the examiner indicated that he experienced additional functional loss in his left knee after repetitive use testing, flexion was still measured to 90 degrees and extension to zero degrees. Pain during range of motion and weightbearing was found to contribute to additional functional loss in both knees, though no additional measurements were taken. There was also no evidence of localized tenderness or pain on palpation in either knee. The examiner determined that the Veteran's left knee impairment resulted in excess fatiguability, pain on movement, swelling, and instability of station. Pain, weakness, fatiguability, and incoordination were not found to significantly limit functional ability in the Veteran's right knee during a flare or with repeated use over time. Nonetheless, the examiner found that these factors would limit his left knee flexion to 90 degrees and his left knee extension to zero degrees. Specifically, the examiner noted instability with left knee extension and pain with left knee flexion. There was no evidence of reduction in muscle strength, muscle atrophy, or ankylosis in either knee. Though no joint instability was found in the Veteran's right knee, multiple tests revealed variances of zero to 5 millimeters in his left knee. The examiner also noted the Veteran's left knee meniscectomy, but the examination report contains no indication of residual symptoms. Lastly, the examiner determined that the Veteran used a cane occasionally due to his left knee impairments. Based on these findings, the examiner concluded that the Veteran's service-connected bilateral knee impairments would not affect his ability to perform any type of occupational tasks. A VA treatment record from April 2016 states that the Veteran was still walking on his left knee despite an anterior cruciate ligament tear. A VA medical note from August 2016 indicates that the Veteran still experienced knee pain but had generally good results with medication. The attending physician wrote that he walked with an antalgic gait. Another record from three months later shows that the Veteran was then receiving injections in his knees. A VA examination report from August 2018 reveals prior diagnoses of a left knee meniscal tear, as well as a bilateral osteoarthritis. The Veteran denied flares but complained of pain, stiffness, and impaired mobility. On examination, right knee flexion was measured from zero to 130 degrees, with extension from 130 to zero degrees. Left knee flexion was measured from zero to 110 degrees, with extension from 110 to zero degrees. There was no evidence of pain on weightbearing, localized tenderness, pain on palpation, or crepitus in either knee. Indeed, no pain was noted during the evaluation. The Veteran was also able to complete repetitive use testing in both knees without additional functional loss. Though the Veteran was not tested after repetitive use over time, the results of the evaluation were found to be neither medically consistent nor inconsistent with the Veteran's statements. The examiner also could not determine whether pain, weakness, fatiguability, or incoordination would significantly limit functioning of the Veteran's knees with repeated use over time without resorting to mere speculation because no objective evidence existed upon which to render such a conclusion. Muscle strength testing was normal, with no indications of muscle atrophy, ankylosis, or joint instability. A meniscal condition was noted in the Veteran's left knee but found to be asymptomatic. There was also a surgical scar on the Veteran's left knee, measuring 9 centimeters by 1 centimeter. However, the examiner concluded that it was not painful, unstable, or greater in total area than 39 square centimeters. The Veteran did not use any assistive devices. Based on these findings, the examiner opined that the Veteran's service-connected bilateral knee impairments would affect his ability to work by resulting in increased absenteeism and tardiness, having to be assigned different duties, impaired mobility, and pain. An August 2018 VA knee examination reveals prior diagnoses of a left knee meniscal tear, as well as bilateral osteoarthritis. The Veteran denied flares but complained of pain, stiffness, and impaired mobility. On examination, right knee flexion was measured from zero to 130 degrees, with extension from 130 to zero degrees. Left knee flexion was measured from zero to 110 degrees, with extension from 110 to zero degrees. There was no evidence of pain on weightbearing, localized tenderness, pain on palpation, or crepitus in either knee. Indeed, no pain was noted during the evaluation. The Veteran was also able to complete repetitive use testing in both knees without additional functional loss. Though the Veteran was not tested after repetitive use over time, the results of the evaluation were found to be neither medically consistent nor inconsistent with the Veteran's statements. The examiner also could not determine whether pain, weakness, fatiguability, or incoordination would significantly limit functional ability in the Veteran's knees with repeated use over time without resorting to mere speculation because no objective evidence existed upon which to render such a conclusion. Muscle strength testing was normal, with no indications of muscle atrophy, ankylosis, or joint instability. A meniscal condition was noted in the Veteran's left knee, but it was found to be asymptomatic. There was also a surgical scar on the Veteran's left knee, measuring 9 centimeters by 1 centimeter. However, the examiner concluded that it was not painful, unstable, or greater in total area than 39 square centimeters. The Veteran did not use any assistive devices. Based on these findings, the examiner opined that the Veteran's service-connected bilateral knee impairments would affect his ability to work by resulting in increased absenteeism and tardiness, having to be assigned different duties, impaired mobility, and pain. A VA knee examination in August 2021 reveals the Veteran's complaint of right knee instability. He will experience increases in pain that are severe enough that he has to use a cane to ambulate. This occurs occasionally. The Veteran reports his most recent fall being 2 weeks ago. He denies any history of surgeries or invasive treatments. He describes his symptoms as painful popping and grinding. His right knee pain causes him to "shuffle up and down the stairs and change my gait." His imaging studies for the right knee demonstrate degenerative joint disease. The Veteran reports multiple instances of the right knee giving out and leading to falls. The Veteran reported sharp, deep pain of the left knee that is constant but will occasionally increase in intensity with activity. He reported painful popping and grinding of the right knee with report of buckling/giving out leading to falls, also with constant pain that occasionally increases with intensity when the Veteran performs more physical activities. He had undergone surgery on the left knee in 1974. The Veteran reported no flares. The Veteran reported instability of the right knee, but no effusion of either knee. On examination, range of motion of the right knee was from 10 degrees extension to 75 degrees flexion. Passive and active range of motion were the same. There was pain on weight-bearing. The severity of the right knee pain was moderate. Range of motion of the left knee was from 10 degrees extension to 80 degrees flexion. Passive and active range of motion were the same. There was pain on weight-bearing and motion. The severity of the left knee pain was moderate. Repetitive use testing was not conducted due to pain. With repetitive use over a period of time in both knees, range of motion was estimated to be from 10 degrees extension to 45 degrees flexion. There was no muscle atrophy or ankylosis. There was instability in the left knee. The Veteran did not require a prescription of a cane, walker, crutches, or braces. The examiner diagnosed right knee strain and instability, bilateral arthritis, and left knee meniscal tear and anterior cruciate ligament tear. The Veteran is limited in his ability to perform occupational tasks due to bilateral knee pain. His right knee instability and left knee meniscectomy/partial anterior cruciate ligament tear residuals lead to difficulty with walking, going up and down stairs, bending at the knee or kneeling. He will occasionally use a cane in order to prevent falls from right knee instability. After a review of all of the evidence, the Board finds that the criteria for higher ratings on the basis of limitation of flexion are not met for either knee. The requirement for the next higher rating is flexion limited to 30 degrees. The measurements have always exceeded this. The Board finds that separate ratings for limitation of extension are warranted for each knee. The August 2021 examination confirms that extension is limited to 10 degrees. This warrants a rating of 10 percent. As the examinations prior to August 2021 were found to be inadequate by the parties to the Joint Motion as not compliant with the holding in Sharp v. Shulkin, 29 Vet. App. 26 (2017), based on findings reported for range of motion, the Board applies the August 2021 findings to the entire period on appeal. The Board reiterates that the measured range of motion does not support any higher rating than 10 percent at any time. The Board finds that, under the current rating criteria, a rating of 10 percent is warranted for right knee instability. The August 2021 VA examiner noted instability of both knees. A 10 percent rating is already in effect for left knee instability (Diagnostic Code 5257). With respect to both knees, the Board finds that the condition most closely approximates a strain 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. These are the criteria for a rating of 10 percent. However, as that report finds no basis for prescription of a brace, and/or assistive devices, the criteria for a rating higher than 10 percent are not warranted. The Board finds that, with respect to the right knee, an effective date of August 12, 2021, is appropriate. All prior examinations showed negative findings for instability. Neither the examiner nor the Veteran commented as to when the right knee instability started. The August 2021 examination is the first time it became factually ascertainable that an increase in the disability had occurred. Regarding the diagnostic codes for meniscal conditions, as the left knee meniscal tear is post-operative, the highest rating available would be 10 percent (maximum rating) under Diagnostic Code 5259. A separate rating would not be warranted under that code, as the code uses the term "symptomatic removal." This general term would apply to any symptom. The symptoms attributable to the left knee are pain, stiffness, and instability. Thus, a separate rating under Diagnostic Code 5259 would constitute pyramiding in this case. In light of the above findings of fact, the Board concludes that higher ratings are not warranted on the basis of limitation of flexion; separate ratings of 10 percent, but not higher, are warranted for limitation of extension; a separate rating of 10 percent, but not higher, is warranted for right knee instability; and that a rating higher than 10 percent is not warranted for left knee instability. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, to the extent of denial of higher ratings the evidence weighs against the claims. Therefore, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. Entitlement to a disability rating higher than 10 percent for the service-connected right ankle disability. In a March 1996 rating decision, VA granted service connection for a right ankle disability and assigned an initial disability rating of 10 percent under Diagnostic Code 5010, effective January 28, 1995. The Veteran was called to active duty in 2003. A 10 percent rating was assigned upon his return, effective May 1, 2008. The current appeal arises from an increased rating claim received at VA on September 11, 2013. Under Diagnostic Code 5270 ankylosis is assigned a rating of 40 percent, if in in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity; a rating of 30 percent is assigned if in plantar flexion, between 30 degrees and 40 degrees, or in dorsiflexion, between 0 and 10 degrees; a rating of 20 percent requires ankylosis in in plantar flexion, less than 30 degrees. Limitation of motion of the ankle is assigned a rating of 20 percent if marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion); a rating of 10 percent is assigned if moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion). 38 C.F.R. § 4.71a, Diagnostic Codes 5270, 5271. A VA ankle examination report from November 2013 reveals prior diagnosis of post-operative right ankle arthritis; he reported flares of this condition, which resulted in pain and limping. On examination, plantar flexion was measured to 35 degrees and dorsiflexion to 10 degrees. Abnormal range of motion was not found to contribute to functional loss. While the Veteran was able to complete repetitive use testing, the examiner noted that repetitive use resulted in additional functional loss; plantar flexion was measured to 35 degrees and dorsiflexion to 10 degrees. Pain on motion and pain on weightbearing were found to contribute to additional functional loss, though no measurements were taken. The examination report also reflects localized tenderness and pain on palpation in the Veteran's lateral right ankle. Indeed, his right ankle condition was found to result in pain on movement and instability of station. Though pain, weakness, fatiguability, and incoordination were determined to significantly limit functional ability during flares and with repeated use over time, the examiner concluded that these factors would only restrict plantar flexion to 35 degrees and dorsiflexion to 10 degrees. There was no evidence of diminished muscle strength, muscle atrophy, or ankylosis. Testing revealed right ankle instability, which was lax compared to the opposite side. Lastly, though the Veteran was noted to use a cane occasionally, this was due to his left knee impairment rather than his right ankle disability. Based on these findings, the examiner concluded that the Veteran's service-connected right ankle condition would not affect his ability to perform occupational tasks. A VA ankle examination report from August 2018 reveals prior diagnosis of a lateral collateral ligament sprain in his right ankle. Though the Veteran denied experiencing flares of this condition, he complained that it resulted in pain, decreased mobility, increased absenteeism and tardiness, and having to be assigned different duties at work. On examination, dorsiflexion was measured from zero to 10 degrees, with plantar flexion from zero to 45 degrees. Range of motion was not found to contribute to functional loss. There was no evidence of pain on weightbearing, pain on palpation, or localized tenderness. Indeed, no pain or crepitus was noted during the examination. The Veteran was also able to perform repetitive use testing without additional functional loss. Though he was not examined immediately after repetitive use over time, the evaluation was found to be neither medically consistent nor inconsistent with the Veteran's statements. The examiner also could not opine whether pain, weakness, fatiguability, or incoordination would significantly limit functional ability with repeated use over time without resorting to mere speculation because there was no objective evidence upon which to base such a conclusion. However, the Veteran's service-connected right ankle condition was found to result in mild swelling. Muscle strength testing was normal, with no indications of muscle atrophy, ankylosis, or shin splints. Although joint instability or dislocation was suspected, all tests were negative. The examiner noted the presence of a surgical scar on the Veteran's right ankle, measuring 19 centimeters by 1 centimeter. Nonetheless, this was not found to be painful, unstable, or greater in total area than 39 square centimeters. Lastly, the Veteran did not use any assistive devices, and there was no evidence of traumatic or degenerative arthritis. Based on this evidence, the examiner determined that the Veteran's service-connected right ankle condition would affect his ability to work. Despite this, no additional details were provided. A VA ankle examination in September 2021 reveals the Veteran's complaint that he continues to have chronic pain at the right ankle, although his instability has improved. At the present time he also reports very limited range of motion of the ankle due to pain as well as some swelling on the lateral aspect. Of note, the Veteran has a history of diabetes mellitus (uncontrolled in the past) as well as lumbar radiculopathy which contribute to pain/paresthesia/numbness/dysesthesia that the Veteran also experiences in the right foot and ankle. The Veteran reported no flares. The Veteran reported pain and stiffness, leading to issues with gait and concern about falling. On examination, dorsiflexion was to 15 degrees and plantar flexion was to 5 degrees. All motion was painful. There was pain with active and passive range of motion, and with weight-bearing. Testing of the nonservice-connected left ankle could not be performed due to pain. Repetitive testing of the service-connected right ankle could not be conducted due to pain. With repetitive use over a period of time, dorsiflexion would be reduced to 10 degrees and plantar flexion was unchanged. There were no flares. Additional factors included interference with standing, swelling, disturbance of locomotion, less movement than normal, and weakness; however, there was no muscle atrophy or ankylosis. The Veteran deferred testing for instability. The examiner diagnosed right lateral collateral ligament sprain, right tendonitis, right degenerative arthritis, right tendinopathy, and tenosynovitis. The Veteran's right ankle condition impacts his ability to perform various occupational tasks such as standing for prolonged periods of time, walking for short distances and with going up and down stairs. After a review of all of the evidence, the Board finds that the criteria for an increased rating of 20 percent are met for the right ankle. The September 2021 VA examination demonstrates that plantar flexion of the right ankle was less than 10 degrees. This meets the requirements as marked limitation of motion. However, there is no manifestation of ankylosis (complete bony fixation of the joint) at any time during the period on appeal. Accordingly, application of Diagnostic Code 5270 is not appropriate. Although, prior to the September 2021 examination report, there is no showing of entitlement to a 20 percent rating on the basis of either dorsiflexion or plantar flexion, the prior examinations were found by the parties to the Joint Motion to be inadequate as non-complaint with the holding in Sharp, 29 Vet. App. 26. Accordingly, the Board will apply the more favorable finding in September 2021 to the entire appeal period. The Board has considered the application of Diagnostic Code 5262, impairment of the tibia and fibula; however, that code requires nonunion of these bones for the maximum rating of 40 percent. There is no finding of nonunion in this case. With malunion, the rating is to be made under Diagnostic Codes 5270 or 5271, which the Board has applied. Based on the above findings, the Board concludes that a rating of 20 percent is warranted, however no higher rating is warranted. In reaching the conclusion that a rating higher than 20 percent is not warranted, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence weighs against the claim to that extent, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. Entitlement to a disability rating higher than 10 percent for service-connected radiculopathy of the lower left extremity. In a November 2008 rating decision, a separate disability rating of 10 percent was assigned for radiculopathy of the left lower extremity associated with the service-connected low back disability, effective May 1, 2008. The current appeal arises from an increased rating claim received at VA on September 11, 2013. Under Diagnostic Code 8520 paralysis, neuritis, or neuralgia of the sciatic nerve is assigned a rating of 80 percent if it is complete; the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. For incomplete paralysis, a rating of 60 percent requires a severe condition, with marked muscular atrophy; rating of 40 percent requires a moderately severe condition; a rating of 20 percent requires a moderate condition; a rating of 10 percent is appropriate for a mild condition. 38 C.F.R. § 4.124a, Diagnostic Codes 8520, 8620, 8720. A VA neurological examination report from November 2013 reveals negative straight leg raising tests, bilaterally, with no evidence of pain in either of the Veteran's lower extremities. Reflex testing was likewise normal, but reduced sensation to light touch was noted in his left leg. There was also mild paresthesias and mild numbness in this extremity. Based on these findings, the examiner determined that the Veteran experienced radiculopathy, characterized by involvement of the sciatic nerve on the left side. The overall severity of this condition was found to be mild. A VA neurological examination conducted as part of the August 2018 back examination reveals that, although the Veteran's reflexes were found to be hypoactive in both knees, straight leg raising tests were negative bilaterally. There were no indications of radiculopathy. Muscle strength and sensory examinations of the lower extremities were normal. The numbness he experienced in his hands and feet was attributed to his diabetes. A VA neurological examination conducted as part of the August 2021 low back examination reveals that lower extremity muscle strength was full, with the exception of left hip flexion, which was reduced. There was left mid-calf atrophy, with 41.5 centimeters on the right, and 38 centimeters on the left. Reflexes were normal. There was decreased sensation on the left. The examiner assessed mild radiculopathy overall, bilaterally, with mild paresthesias, bilaterally, and mild numbness, bilaterally. Pain was considered moderate, bilaterally. After a review of all of the evidence, the Board finds that the criteria for a rating higher than 10 percent are not met. The most recent findings show moderate pain, but an overall finding of mild radiculopathy. This is consistent with the finding in November 2013. Indeed, the August 2018 examiner found no evidence of lower extremity radiculopathy, and the August 2018 examiner attributed the Veteran's symptoms to diabetes mellitus. The Board finds that, on balance, the evidence does not substantiate more than mild symptomatology. In light of these findings of fact, the Board concludes that a rating higher than 10 percent for left lower extremity radiculopathy is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence weighs against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. 366, 371. [SIGNATURE ON NEXT PAGE] JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Cramp The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.