Citation Nr: 22016209 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 17-13 151 DATE: March 21, 2022 ORDER An initial evaluation of 20 percent, but no higher, under Diagnostic Code 5260 for the left knee disability, status post arthroscopic repair lateral meniscus tear, with excision of plica/synovectomy, is granted, effective from April 28, 2014 to December 15, 2020. A separate 20 percent evaluation, but no higher, under Diagnostic Code 5257 for moderate left knee instability, is granted, effective from April 28, 2014 to December 15, 2020. A separate 20 percent evaluation, but no higher, under Diagnostic Code 5258 for a disorder of the left knee meniscus is granted, effective from April 28, 2014 to December 15, 2020. From February 1, 2022, forward, a 60 percent evaluation, but no higher, under Diagnostic Code 5055 for the left knee disorder, status post total knee replacement, is granted. FINDINGS OF FACT 1. Prior to December 15, 2020, the Veteran's left knee disorder was manifested by moderate recurrent lateral instability; a disorder of the semilunar cartilage, with frequent symptoms of effusion/swelling; and degenerative joint disease with painful, limited motion and flare ups and functional limitations including chronic pain, limited and painful motion, crepitation, pain on weight bearing, disturbance of locomotion, interference with sitting and standing; there is no competent evidence of ankylosis, impairment of the tibia and fibula, or genu recurvatum. 2. Since February 1, 2022, the Veteran's left knee disorder, status post total knee replacement, most closely approximates chronic residuals consisting of severe painful motion or weakness. CONCLUSIONS OF LAW 1. For the entire appellate period prior to December 15, 2020, the criteria are met for an initial evaluation of 20 percent, but no higher, for the left knee degenerative joint disease based on limitation of flexion. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260 (2020). 2. For the entire appellate period prior to December 15, 2020, the criteria are met for a separate evaluation of 20 percent, but no higher, for disability of the left knee based on moderate recurrent lateral instability. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2020). 3. For the entire appellate period prior to December 15, 2020, the criteria are met for a separate evaluation of 20 percent for dislocated left knee semilunar cartilage. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.71a, Diagnostic Code 5258 (2020). 4. Since February 1, 2022, the criteria are met for an evaluation of 60 percent, but no higher, for the left knee disorder, status post total knee replacement. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.68, 4.71a, Diagnostic Code 5055 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the United States Army from January 1983 to April 1992. In October 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the claims file. The Board notes that the Veteran underwent a total knee replacement surgery for his service-connected left knee disability during the appeal. Accordingly, the Veteran's left knee is in receipt of a temporary 100 percent rating from December 15, 2020, through January 31, 2022. Thus, the period in which this disability was assigned a 100 percent rating is excluded from the appeal and will not be addressed. Increased Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14. However, the evaluation of the same disability or its manifestation under various diagnoses, which is known as pyramiding, is to be avoided. Id. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 126. In increased-rating claims, where a claimant seeks a higher evaluation for a previously service-connected disability, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In such claims, VA considers the level of disability for the period beginning one year prior to the claim for a higher rating. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); Hart, 21 Vet. App. at 509. 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 flare-ups 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 v. Brown, 8 Vet. App. 202 (1995); 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; 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) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Although the rating schedule for evaluating musculoskeletal disabilities was amended effective February 7, 2021, the relevant appellate period as concerning the Veteran's left knee degenerative joint disease involves consideration of the time period prior to the Veteran's total knee replacement, as noted above, so prior to December 15, 2020. As such, the amended regulations do not apply to the period prior to the Veteran's December 2020 left knee replacement. Additionally, regarding the evaluation of the left knee, status post total knee replacement, the Board notes that the only changes to the pertinent rating criteria following the February 7, 2021 amendments pertains to the period for which a temporary 100 percent rating is warranted under Diagnostic Code 5055. Specifically, under the old (pre-February 2021) criteria, a 100 percent rating was assigned for one year following implantation of a prosthesis. Under the new (post-February 2021) criteria, this temporary 100 percent rating is available for four months following such implantation. The pertinent criteria for evaluating the knee upon expiration of the total rating remained the same, with the exception of resurfacing the knee. See 38 C.F.R. § 4.71a, Diagnostic Code 5271 (2021). Because there is no evidence or assertion reflecting that the Veteran has undergone resurfacing of the knee, the regulation changes, effective February 7, 2021, do not affect the Board's analysis. As pertinent to the present appeal, diagnostic Codes (DCs) relevant to knee disabilities include 5003, 5010, 5055, and 5256 through 5263. Under Diagnostic Codes 5003 and 5010, arthritis established by x-ray findings is rated on the basis of limitation of motion of the affected joints. When however, the limited motion of the specific joint or joints involved would be noncompensable under the appropriate diagnostic codes, a 10 percent rating is assigned for each involved major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. 38 C.F.R. § 4.71a (2020). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under Diagnostic Code 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. (The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30). Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, DC 5055 (2020). Diagnostic Code 5256, which evaluates ankylosis of the knee, assigns a 30 percent rating for favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is assigned when there is ankylosis of the knee in flexion between 10 and 20 degrees. 38 C.F.R. § 4.71a, DC 5256. Under Diagnostic Code 5257, other knee impairment is evaluated based upon recurrent subluxation and/or lateral instability. This Diagnostic Code provides that a 10 percent disability rating is warranted for slight disability, a 20 percent rating is warranted for moderate disability, and a maximum 30 percent evaluation is warranted for severe disability. 38 C.F.R. § 4.71a (2020). See also Johnson v. Brown, 9 Vet. App. 7, 11 (1996) (holding that DC 5257 is not predicated on loss of range of motion). Objective evidence of instability is not necessarily required to satisfy the criteria for a rating under DC 5257. English v. Wilkie, 30 Vet. App. 347 (2018) The words "slight," "moderate" and "severe" as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Diagnostic Code 5258 provides for assignment of a 20 percent rating for dislocation of the semilunar cartilage, with frequent episodes of "locking," pain and effusion into the joint. 38 C.F.R. § 4.71a (2020). Diagnostic Code 5259 provides for the assignment of a single 10 percent rating for removal of the semilunar cartilage, symptomatic. Id. Diagnostic Code 5260 pertains to limitation of leg flexion, and provides for a noncompensable rating when flexion is limited to 60 degrees. A 10 percent rating requires flexion limited to 45 degrees; a 20 percent rating requires flexion limited to 30 degrees; and the highest available 30 percent rating requires flexion limited to 15 degrees. Id. Also, Diagnostic Code 5261 provides that limitation of motion of the knee will be assigned a noncompensable rating when extension is limited to 5 degrees. A 10 percent evaluation requires extension limited to 10 degrees; a 20 percent rating requires extension limited to 15 degrees; a 30 percent rating requires extension limited to 20 degrees; a 40 percent rating requires extension limited to 30 degrees; and a maximum 50 percent rating is assigned when extension is limited to 45 degrees. Id. Normal range of motion for the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. VA's Office of General Counsel determined that separate disability ratings may be assigned for limitation of knee flexion and of knee extension without violation of the rule against pyramiding (at 38 C.F.R. § 4.14), regardless of whether the limited motions are from the same or different causes. VAOPGCPREC 9-04 (September 17, 2004), 69 Fed. Reg. 59,990 (2004). Moreover, VAOPGCPREC 23-97 held that a claimant may receive separate disability ratings for arthritis and instability of the knee, under Diagnostic Codes 5003 and 5257, respectively. See VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63,604 (1997). In order for a knee disability rated under Diagnostic Code 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 does not have to be compensable, but must meet the criteria for a zero-percent rating. VAOPGCPREC 9-98 (August 14, 1998), 63 Fed. Reg. 56,704 (1998). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Entitlement to a rating in excess of 10 percent prior to December 15, 2020, for left knee degenerative joint disease. The Veteran asserts entitlement to a higher rating for his service-connected left knee degenerative joint disease during the appellate period prior to his total knee replacement. The Veteran's left knee degenerative joint disease is in receipt of a 10 percent evaluation prior to December 15, 2020 under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260 (2020), pertaining to degenerative arthritis and rated on the provisions regarding limitation of flexion of the knee. See 38 C.F.R. § 4.27 (reflecting that hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen). Based on the evidence of record, the Board finds that the Veteran's left knee limitation of motion and additional symptomatology and functional limitations most closely approximate the criteria for a 20 percent initial rating, but no higher, for limitation of flexion under Diagnostic Code 5260 for the entire appellate period, so prior to December 15, 2020. In this regard, the Veteran's medical records, including his private treatment records and the August 2015 VA examination report, document the presence of left knee degenerative joint disease (arthritis) during the relevant appellate period. See, e.g., August 2015 VA Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ); April 2014 Orthopedic Evaluation from P.K.D., M.D. (reflecting that X-rays of the left knee revealed "complete obliteration of the medial joint space with patella-femoral degenerative changes"). Moreover, VA medical evaluation of the Veteran found chronic painful, limited motion of the left knee. See id. (noting that the Veteran experienced limited flexion of the left knee that was further limited by pain on range of motion testing). Furthermore, the Veteran has consistently maintained, and the VA examination report confirms, that his left knee disability is productive of additional symptomatology and functional limitations including chronic pain, crepitation, pain on weight bearing, disturbance of locomotion, and interference with sitting and standing. See id. (reflecting that the Veteran experienced constant left knee pain, pain on weight bearing, impaired locomotion and ambulation, and difficulty sitting, with flare ups of increased symptoms that render him "unable to stand or walk for any extended period"). These additional symptoms and functional limitations have also required intra-articular injections to temporarily alleviate his left knee symptoms and aid in ambulating. See, e.g., November 2020 Progress Note from P.K.D., M.D. (noting that the Veteran has a history of corticosteroid injections in the left knee). The Board thus finds that the Veteran's competent statements and testimony concerning the functional effects of his left knee disability are credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (holding that a Veteran is competent to report observable symptomatology); see, too, Baldwin v. West, 13 Vet. App. 1 (1999) (the Board must analyze the credibility of the evidence). Based on the evidence of record and resolving all doubt in favor of the Veteran, the Board finds that, when considering the noted flare-ups and functional limitations, the chronic pain, limited and painful motion, crepitation, pain on weight bearing, disturbance of locomotion, interference with sitting and standing, and the intra-articular injections required, for the period prior to December 15, 2020, the Veteran's left knee condition more closely approximates the criteria for a 20 percent rating under DC 5010-5260, but no higher. See 38 C.F.R. § 4.71a (2020). See also Mitchell, 25 Vet. App. at 43; DeLuca, 8 Vet. App. at 206 -07; 38 C.F.R. §§ 4.40, 4.45. In this regard, the Board notes that none of the available range of motion measurements meets the criteria for this higher 20 percent rating. See 38 C.F.R. § 4.71a, DCs 5260, 5261 (2020). The Veteran's knee disability is, however, productive of additional functional limitation beyond what is reflected in his range of motion measurements, as discussed. Accordingly, given the Veteran's overall disability picture, and taking into account his functional limitations, including during flare-ups, the Board concludes that an increased initial 20 percent rating, but no higher, is warranted for the Veteran's left knee condition under DC 5260 for the entire appellate period, so from April 28, 2014 to December 14, 2020. See 38 C.F.R. § 4.71a (2020); Mitchell, 25 Vet. App. at 43; DeLuca, 8 Vet. App. at 206-07; 38 C.F.R. §§ 4.40, 4.45. See also Fenderson, 12 Vet. App. at 126. A higher 30 percent rating under DC 5260 is, however, unwarranted because, as noted, the Veteran has not demonstrated left knee flexion limited to 15 degrees or less. See 38 C.F.R. § 4.71a, DC 5260 (2020). Additionally, a separate rating based on left knee limitation of extension under Diagnostic Code 5261 is unwarranted because at no point during the appellate period has the Veteran's left knee disability been manifested by extension limited to 10 degrees or more. See 38 C.F.R. § 4.71a, DC 5260; VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004) (requiring that, in order to establish entitlement to separate ratings for limitation of extension and flexion, the limitation must be compensable in both planes). Furthermore, there is no evidence suggesting that the Veteran has had ankylosis of the knee, nonunion or malunion of the tibia or fibula, or genu recurvatum at any point during the pendency of this claim. Thus, DC's 5256, 5262, and 5263, which pertain to these conditions, respectively, do not apply. See 38 C.F.R. § 4.71a (2020). 2. Entitlement to a separate rating from April 28, 2014 to December 14, 2020 for left knee instability. Next, the Board finds that the Veteran is entitled to a separate, 20 percent rating for moderate recurrent lateral instability of the left knee under 38 C.F.R. § 4.71a, DC 5257, for the entire appellate period, so from April 28, 2014 to December 14, 2020. In this regard, the Board notes that the only VA examination of the left knee during the relevant period is the August 2015 VA knee examination performed for the purposes of determining entitlement to service connection, and it did not include knee joint stability testing as part of the Veteran's evaluation. See August 2015 VA Knee and Lower Leg Conditions DBQ (reflecting that knee joint stability testing was not performed). However, the Veteran is competent to report observable left knee symptomatology of persistent lateral instability, including buckling and giving way, which caused multiple falls and resulted in a number of injuries, and which required the use of a knee brace and a cane to assist in ambulation and to provide stability. See, e.g., November 2015 Notice of Disagreement (NOD) (VA Form 21-0958) (reporting that his left knee is "giving out and causing [him] to fall"); October 2021 Board Hearing Transcript (testifying that his left knee would "give out" approximately once a week and that, prior to his total left knee replacement, the manifestations of his left knee pathology required that he wear a brace and use a cane to keep himself steady during ambulation); August 2015 VA Knee and Lower Leg Conditions DBQ (noting that the Veteran uses assistive devices, including a left knee brace, to assist in locomotion). See also Layno, 6 Vet. App. at 470 (A Veteran is competent to report observable symptomatology.). And the Board finds his competent statements in this regard to be credible. See Caluza, 7 Vet. App. at 506. See also English, 30 Vet. App. 347 (finding that objective medical evidence of knee instability is not required and noting that objective medical evidence is not categorically more probative than lay evidence). Accordingly, in light of the Veteran's competent and credible assertions of experiencing intermittent episodes of left knee instability resulting in repeated falls and requiring the use of assistive devices including a knee brace and a cane, and resolving all doubt in the Veteran's favor, the Board finds that a separate 20 percent rating for moderate instability of the left knee is warranted under DC 5257 for the entire appellate period, so from April 28, 2014 to December 14, 2020. See 38 C.F.R. § 4.71a, DC 5257 (2020) (providing for a 20 percent rating for "moderate" recurrent subluxation or lateral instability); see also Fenderson, 12 Vet. App. at 126. See, too, VAOPGCPREC 23-97 (July 1, 1997) (reflecting that separate disability ratings may be assigned for arthritis and instability of the knee, under Diagnostic Codes 5003 and 5257, respectively). Given the Veteran's report of intermittent episodes of left knee instability, and considering that the VA and private medical records do not document positive objective joint stability testing, the Board cannot conclude the Veteran's left knee disability has resulted in severe instability. See, e.g., November 2020 Progress Note from P.K.D., M.D. (reflecting that X-ray results demonstrate "bone on bone" degenerative joint disease but finding no instability on objective testing). See also 38 C.F.R. § 4.71a, DC 5257 (2020) (providing for a 30 percent rating for "severe" recurrent subluxation or lateral instability). Accordingly, a rating in excess of 20 percent for the Veteran's left knee instability is not warranted at any point during the appeal period. 3. Entitlement to a separate rating from April 28, 2014 to December 14, 2020 for a pathology related to the left knee semilunar cartilage. Additionally, based on the record, the Board finds that the Veteran is entitled to a separate, 20 percent rating for a disorder of the semilunar cartilage of the left knee under 38 C.F.R. § 4.71a, DC 5258, for the entire appellate period, so from April 28, 2014 to December 14, 2020. In this regard, the Board notes that the August 2015 VA examiner checked the box indicating that the Veteran did not currently have, nor had he ever had, a meniscal condition. See August 2015 VA Knee and Lower Leg Conditions DBQ. However, the VA examiner noted in a subsequent section of the report that the Veteran experienced "[r]esidual signs or symptoms due to [a] meniscectomy," including pain and "almost constant[]" left knee swelling. See id. Notably, the Veteran underwent multiple procedures on the left knee prior to his total knee replacement, including specifically a partial meniscectomy in January 1991, during his active service. See, e.g., January 1991 Medical Record Report (reflecting that the Veteran underwent left knee arthroscopic surgery during which "an old anterior horn tear of the medial meniscus... was excised"); September 1992 Inpatient Treatment Record Cover Sheet (reflecting a history of left knee meniscal tear and noting in-service surgical procedures including a partial medial meniscectomy of the left knee); August 2016 VA Physician Note (documenting the Veteran's left knee surgical history, including both "arthroscopy, and open knee" surgeries"). However, the Board finds insufficient medical evidence to support a finding that the Veteran has undergone complete removal of the left knee meniscus, so as to warrant the assignment of a separate rating under DC 5259 for "symptomatic" removal of the semilunar cartilage (meniscus). See 38 C.F.R. § 4.71a. Nevertheless, the Veteran's VA records confirm that he experiences persistent left knee swelling and his private medical records document left knee effusion. See, e.g., August 2016 VA Physician Note (reflecting that the Veteran's left knee swells); April 2014 Orthopedic Evaluation from P.K.D., M.D. (document the presence of left knee effusion). As such, because the medical evidence of record tends to indicate that the Veteran suffered from a meniscal pathology of the left knee prior to and during the appellate period, and considering the persistent swelling and documented effusion, the Board finds that, for the period from April 28, 2014 to December 14, 2020, a separate 20 percent rating under DC 5258 for dislocation of the semilunar cartilage (meniscus) is most closely approximated. See Fenderson, 12 Vet. App. at 126. This is the maximum schedular rating under this diagnostic code. See 38 C.F.R. § 4.71a, DC 5258 (2020). The Board recognizes that a separate rating has been assigned for left knee instability under Diagnostic Code 5257, as discussed above. See VAOPGCPREC 23-97 (July 1997) and VAOPGCPREC 9- 98, (August 1998) (holding that separate ratings may be assigned for arthritis of the knee with limited motion and instability of the knee and/or cartilage impairment with associated locking and effusion); Esteban v. Brown, 6 Vet. App. 259, 262 (holding that separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition). However, the symptomatology associated with the Veteran's meniscal pathology (i.e., effusions and persistent left knee swelling) does not necessarily overlap with instability of the knee under DC 5257. The Board additionally notes that the Veteran's chronic pain is not accounted for in the rating under DC 5258, which, as detailed above, is assigned due to his additional symptomatology of effusion/swelling. Accordingly, a separate rating under DC 5258 does not violate the rule against pyramiding. See 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 262. Additionally, the assignment of a separate 20 percent rating for the left knee under DC 5257 for dislocation of the semilunar cartilage is more favorable to the Veteran than granting a separate 10 percent disability rating under DC 5259 (the maximum possible rating for symptomatic removal of the semilunar cartilage). See 38 C.F.R. § 4.71. Moreover, the Board cannot grant separate evaluations for the same knee joint under DCs 5258 and 5259, as doing so would constitute impermissible pyramiding because both DC 5259 and DC 5258 compensate for the symptoms associated with meniscal dysfunction. See id. See also 38 C.F.R. § 4.14. In sum, the evidence shows that, for the entirety of the appellate period prior to December 15, 2020, the Veteran's left knee disability warrants an increased initial rating of 20 percent, but no higher, under DC 5260 on the basis of limitation of flexion and functional loss due to chronic pain, painful motion, crepitation, pain on weight bearing, disturbance of locomotion, and interference with sitting and standing. See 38 C.F.R. § 4.71a. Additionally, a separate 20 percent rating is warranted for the entire appellate period for moderate lateral instability of the left knee under DC 5257. See id. Finally, a separate rating of 20 percent is warranted under DC 5258, based on dislocation of the semilunar cartilage resulting in frequent episodes of effusion/swelling for the entire appellate period from April 28, 2014 to December 14, 2020. See id. However, as the evidence persuasively favors against the assignment of higher or separate ratings at any point during the relevant appellate period, other than those granted in this decision, the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Moreover, staged ratings are not appropriate for the time frame on appeal. See Fenderson, 12 Vet. App. at 126. 4. Entitlement to a rating in excess of 30 percent from February 1, 2022 for status post left knee total replacement. As concerning the Veteran's left total knee replacements, the Board notes that the Veteran is currently in receipt of a 30 percent evaluation, effective from February 1, 2022, forward, under 38 C.F.R. § 4.71a, Diagnostic Code 5055. See May 2021 Rating Decision Codesheet. On VA examination in May 2021, the VA examiner noted that the Veteran experienced left knee pain with flare ups of increased left knee pain several times per week lasting as long as 6 hours. See May 2021 Knee and Lower Leg Conditions DBQ. Clinical evaluation revealed left knee flexion limited to 110 degrees and extension limited to 15 degrees, with pain on active and passive flexion, resulting in functional limitations including interference with sitting and standing for any extended period of time. See id. (reflecting that the Veteran "cannot stand [for] more that 2-3 minutes in one place without increase[d] pain). Additionally, the examining VA clinician noted that the Veteran's left total knee replacement required "constant" use of cane to assist in locomotion. See id. VA and private medical treatment records reflect that the Veteran reported experiencing "chronic" left knee pain and further note that, three weeks after his left knee replacement, the Veteran "twisted his [left] leg wrong" and sustained a hairline fracture of his left femur. See January 2021 VA Community Based Outpatient Clinic (CBOC) Note; January 2020 Progress Note from P.K.D., M.D. (reflecting the Veteran's report that he "felt a pop and had a sharp pain in his [left] thigh" after rising from a seated position and reporting X-ray evidence of a "hairline fracture of distal third of the [left] femur"). Additionally, the records reflect that the Veteran has been prescribed the use of a left knee brace by his private orthopedist. See January 2021 Progress Note from P.K.D., M.D. Additionally, at the October 2021 Board hearing, the Veteran testified that, since his left total knee replacement, he has experienced significant pain, decreased left knee flexion and extension, an inability to stand for more than two to three minutes, inability to walk more than 75 to 100 yards, disturbance of locomotion, soreness, difficulty climbing stairs, left knee weakness, difficulty ambulating on uneven surfaces, left knee instability, interference with sitting for prolonged periods, and flare ups of increased left knee symptoms precipitated by activity. See October 2021 Board Hearing Transcript (additionally stating that he minimized the severity of his left knee pain at the May 2021 VA examination because he had experienced more severe pain in the past, but reporting that he currently experiences significant, chronic left knee pain). The Board finds the Veteran to be credible in his report of his post-left-knee-replacement symptoms. See Layno, 6 Vet. App. at 470; Caluza, 7 Vet. App. at 506. Accordingly, in light of the foregoing, given the Veteran's chronic left replacement residuals including significant pain; painful, limited flexion and extension on both active and passive motion; soreness; disturbance of locomotion; interference with sitting and standing for any extended period of time; instability; weakness; and flare-ups of increased pain and additional functional limitations, considering that the Veteran's left knee replacement manifestations have required the use of a knee brace and the "constant" use of a cane to assist in ambulation, and viewing the evidence in the light most favorable to the Veteran, the Board finds that the Veteran's total left knee replacement residuals most closely approximate chronic residuals consisting of severe painful motion or weakness. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that a 60 percent rating, but no higher, is warranted under DC 5055 for the entirety of the relevant appellate period, so from February 1, 2022, forward. See 38 C.F.R. § 4.71a, DC 5055. A 60 percent rating under DC 5055 is the maximum schedular rating available. A higher rating of 100 percent is only warranted for the 1-year period following the implantation of the prosthesis. 38 C.F.R. § 4.71a, DC 5055 (2021). Finally, the Board has considered whether an inferred claim of entitlement to a total disability rating based on individual unemployability (TDIU) has been raised by the record in conjunction with the increased rating claims adjudicated in this decision. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the evidence demonstrates that the Veteran has been employed on a full-time basis during the period under consideration, and there is no indication that this employment was marginal in nature or performed in a protected work environment. Accordingly, the Board declines to raise an inferred claim of entitlement to a TDIU. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. McCabe, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.