Citation Nr: 22018363 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 18-55 349 DATE: March 29, 2022 ORDER A rating in excess of 10 percent for degenerative joint disease (DJD) of the right knee is denied. A rating in excess of 10 percent for DJD of the left knee is denied. A separate 10 percent rating under Diagnostic Code 5257 for slight right knee lateral instability since September 25, 2017 is granted. A separate 10 percent rating under Diagnostic Code 5257 for slight left knee lateral instability since September 25, 2017 is granted. A 20 percent rating under Diagnostic Code 5257 for moderate left knee lateral instability is granted beginning November 30, 2021. REMANDED Entitlement to service connection for right shoulder disorder is remanded. Entitlement to service connection for left shoulder disorder is remanded. FINDINGS OF FACT 1. For the rating period, the Veteran's DJD of the right and left knees has not been manifested by at least the absence of limitation of motion with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations, limitation of flexion to 30 degrees or less, or limitation of extension to 15 degrees or more. 2. During the appeal period since September 25, 2017, the Veteran's service-connected DJD of the right knee has been manifested by slight lateral instability. 3. During the appeal period since September 25, 2017 to November 29, 2021, the Veteran's service-connected DJD of the left knee has been manifested by slight lateral instability. 4. Since November 30, 2021, the Veteran's service-connected DJD of the left knee has been manifested by moderate lateral instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for DJD of the right knee have not been met. 38 U.S.C. §§ 1155, 5103, 5103A; 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.327, 4.1, 4.2, 4.3, 4.7, 4.21, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260. 2. The criteria for entitlement to a rating in excess of 10 percent for DJD of the left knee have not been met. 38 U.S.C. §§ 1155, 5103, 5103A; 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.327, 4.1, 4.2, 4.3, 4.7, 4.21, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5010-5260. 3. The criteria for entitlement to a separate 10 percent rating for lateral instability of the right knee since September 25, 2017 have been satisfied. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). 4. The criteria for entitlement to a separate 10 percent rating for lateral instability of the left knee since September 25, 2017 have been satisfied. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). 5. Since November 30, 2021, the criteria for a 20 percent rating for lateral instability of the left knee have been satisfied. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1996 to August 2004. In October 2021, the Board denied the issue of service connection for an acquired psychiatric disability, determined that new and material evidence was received to reopen the issues of service connection for right and left shoulder disorders, and remanded the remaining issues on appeal. The case has been returned to the Board for appellate review. There was substantial compliance with the October 2021 remand directives for the issues of entitlement to a rating in excess of 10 percent for DJD of the right knee and of the left knee discussed below on the merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the Veteran was provided a VA examination for knee and lower leg in December 2021. These issues were also readjudicated in a December 2021 supplemental statement of the case (SSOC). Additionally, with regards to the issues of entitlement to a rating in excess of 10 percent for DJD of the right knee and of the left knee, the requirements of 38 U.S.C. §§ 5103 and 5103A have been met. VA's duty to notify was satisfied by the December 2016 VA rating decision, October 2018 statement of the case (SOC), and December 2021 SSOC. 38U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate these claims to include where warranted by law, and affording the claimant VA examinations, VA medical opinions, and a hearing before the Board. 38 U.S.C. §§ 5103, 5103A. There is no evidence that additional records have yet to be requested relevant to the service-connected DJD of the right and left knees. The VA examination reports of record, collectively, are adequate because they were based upon consideration of the Veteran's pertinent medical history and current complaints, described his disability in detail sufficient to allow the Board to make a fully informed determination, and complied with the holding in Correia v. McDonald, 28 Vet. App. 158 (2016). See Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). There is no objective or subjective evidence indicating that there has been a material change in the severity of the Veteran's DJD of the right and left knees on appeal since he was last examined in December 2021. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95; 60 Fed. Reg. 43186 (1995). In sum, there is no evidence of any VA error in notifying or assisting him that reasonably affects the fairness of this adjudication on the merits. 38 C.F.R. § 3.159(c). 1. Entitlement to a rating in excess of 10 percent for DJD of the right knee 2. Entitlement to a rating in excess of 10 percent for DJD of the left knee Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, such as for the service-connected DJD of the right and left knees in this case, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. 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. 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."). On September 8, 2016, the Veteran filed a VA Form 21-0966 (Intent to File a Claim for Compensation), and within one year, on September 26, 2016, he filed a VA Form 21-526EZ requesting higher ratings for the service-connected DJD of the right and left knees. The Board considers whether a rating in excess of 10 percent for DJD of the right and left knees is warranted at any time since or within one year prior to the date of claim on September 8, 2016. Diagnostic Criteria During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select Diagnostic Codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. Id. Review of the portion of the rating schedule that addresses the musculoskeletal system revised effective February 7, 2021 shows that Diagnostic Codes 5010, 5257, and 5262 were changed. See 38 C.F.R. § 4.71a. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Moreover, although the portion of the rating schedule that addresses the musculoskeletal system was revised effective February 7, 2021, Diagnostic Codes 5256, 5258, 5259, 5260, 5261, and 5253 were not changed. 38 C.F.R. § 4.71a. Prior to the regulatory change, Diagnostic Code 5010 provides that arthritis, due to trauma and substantiated by x-ray findings, is rated as degenerative arthritis. See 38 C.F.R. § 4.71a. Degenerative arthritis is rated under Diagnostic Code 5003, which provides that degenerative arthritis, established by x-ray findings, is rated according to limitation of motion for the joint or joints involved. Id. In the absence of compensable limitation of motion, the next-higher and maximum rating of 20 percent is assigned for x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. Id. As of February 7, 2021, under the amended criteria, Diagnostic Code 5010 provides that post-traumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under the affected joint. See 38 C.F.R. § 4.71a. Diagnostic Code 5260 (limitation of flexion of the leg) provides the next-higher 20 percent rating when flexion is limited to 30 degrees; and a 30 percent rating, the maximum available, when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. For VA compensation purposes, normal range of motion for the knee is flexion to 140 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5261 (limitation of extension of the leg) provides the next-higher 20 percent rating when extension is limited to 15 degrees; a 30 percent rating when extension is limited to 20 degrees; a 40 percent rating when extension is limited to 30 degrees; and a 50 percent rating, the maximum available, when extension is limited to 45 degrees. 38 C.F.R. § 4.71a. For VA compensation purposes, normal range of motion for the knee is extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Analysis Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. The Board considers whether a rating in excess of 10 percent for DJD of the right and left knees is warranted at any time since or within one year prior to the date of claim on September 8, 2016. The Veteran's DJD of the right and left knees are rated under Diagnostic Code 5010-5260 during the appeal period. First, the May 2017 VA examination report shows diagnostic imaging results revealed bilateral arthritis; however, the Veteran demonstrated active limited right knee flexion to 90 degrees and left knee flexion to 120 degrees. His extension was normal. He did not report experiencing flare-ups. The Veteran underwent a VA examination on December 14, 2021. His reported symptom was knee pain and he did not report functional loss. He stated that he had flare ups that occurred every day, and lasted for the entire day. He stated that they were "severe." They were caused by too much motion and alleviated by resting. At the examination, he demonstrated full active bilateral knee flexion and extension with no pain. Passive range of motion was tested, and the examiner specifically found that it was the same as his active range of motion. There was no pain during passive range of motion testing. There was no pain on weightbearing or non-weightbearing. There was no additional loss of motion after repeated use over time. The examiner found that although he was not examined after repeated use over time or during a flare up, his range of motion would not be further limited by pain, fatigability, weakness, lack of endurance, or incoordination during either. The VA examiner affirmed the Veteran's diagnosis of bilateral knee degenerative arthritis. To meet the next-higher and maximum rating of 20 percent under Diagnostic Code 5010 (prior to the regulatory change), the absence of limitation of motion with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations would need to have been shown. See 38 C.F.R. § 4.71a, Diagnostic Code 5010, 5003. The evidence does not show incapacitating exacerbations. Even though the Veteran reported daily flare-ups and knee pain, he had normal and painless motion at his examination, and the examiner specifically found that even during a flare-up, his range of motion would not change due to factors such as pain. The record does not otherwise support a finding that the Veteran's DJD of either knee has resulted in incapacitation. "Incapacity" is defined as, "the quality or state of being incapable," and "lack of physical or intellectual power...." See Merriam-Webster's Collegiate Dictionary 628 (Eleventh Ed. 2012). "Incapable" is defined as, "lacking capacity, ability, or qualification for the purpose or end in view." Id. "Capacity" is "an individual's mental or physical ability." Id. at 182. The Board finds that incapacitation requires something more than pain and decreased function during flare-ups, it would preclude activity and perhaps even require medical assistance for relief. The evidence does not show that the Veteran's DJD results in this type of limitation. For these reasons, ratings in excess of 10 percent for DJD of the right and left knees based on arthritis is not warranted at any time during the appeal period. 38 C.F.R. §§ 4.3, 4.7. The medical evidence of record shows the Veteran demonstrated limited knee flexion, at worst, to 90 degrees on the right side and to 120 degrees on the left side at the May 2017 VA examination upon active motion testing. Review of VA treatment records shows the Veteran demonstrated flexion to 100 degrees in September 2017 and full range of motion of the right knee in October 2017. The Veteran also demonstrated full bilateral knee flexion at the December 2021 VA examination upon active and passive motion testing. To meet the 20 percent criteria, flexion limited to at least 30 degrees would need to have been shown. See 38 C.F.R. § 4.71a, Diagnostic Code 5260. For these reasons, ratings in excess of 10 percent for DJD of the right and left knees based on limitation of flexion are not warranted at any time during the appeal period. 38 C.F.R. §§ 4.3, 4.7. The medical evidence of record shows the Veteran demonstrated full bilateral knee extension to 0 degrees at the May 2017 VA examination and at VA treatment sessions in September 2017 and October 2017 for the right knee. He also demonstrated full bilateral knee extension to 0 degrees at the December 2021 VA examination. To meet the 20 percent criteria, extension limited to at least 15 degrees or more would need to have been shown. See 38 C.F.R. § 4.71a, Diagnostic Code 5261. A separate rating for DJD of the right and left knees based on limitation of extension is not warranted at any time during the appeal period. 38 C.F.R. §§ 4.3, 4.7. The Board emphasizes that the Veteran is already being compensated for painful motion of the right and left knee joints during the appeal period, as noted by the Agency of Original Jurisdiction (AOJ) in the November 2005 VA rating decision. 38 C.F.R. §§ 4.40, 4.45, 4.59. Next, the Board considers whether separate ratings are warranted in this case under additional rating criteria for the knee, specifically Diagnostic Code 5258 (dislocated semilunar cartilage). In the December 2018 VA Form 9, the Veteran reported that he cannot have his knees bent for an extended period of time or they will lock up or just hurt. He reported at the December 2020 Board hearing that he has severe left knee pain, sometimes it wants to "go out" and is very weak, he cannot stand on it for long periods of time, after being on it for a long period of time it goes numb, and it has buckled and tightened up and locked. He also reported the right knee does the same thing but not as often. Review of the May 2017 VA examination report shows the examiner marked "no" for any clinical findings of a meniscus (semilunar cartilage) condition and "no" for history of recurrent effusion. Review of VA treatment records shows June 2017 x-ray results of the right knee revealed joint effusion that was noted to be "resolving" later that month, July 2017 MRI results of right medial meniscal tear, right knee locking but clinical findings of "RLE: no effusion" in September 2017, and denial of right knee locking or giving out in October 2017. VA treatment records also shows left medial meniscus complex tears per report in chart in September 2017 and January 2019 x-ray results of the left knee revealed patellar enthesophytes and patellar osteophytes. The Veteran has had meniscus conditions during the appeal period. However, the meniscus conditions were noted sporadically, not frequently. They were noted in 2017 and 2019, and not at any other time. Further, he had one instance of an effusion in the right knee during the appeal period, which cannot be reasonably described as "frequent." There were no records of effusion in the left knee. Additionally, the Veteran's reports of locking are not frequent, and the record does not show that he has pain that is due specifically due to his meniscus as opposed to being from his joint. As a result, separate ratings of 20 percent for dislocated semilunar cartilage with frequent episodes of "locking" pain and effusion are not warranted under Diagnostic Code 5258 at any time during the appeal period. Instability under Diagnostic Code 5257 The Board considers whether a separate compensable rating is warranted in this case under Diagnostic Code 5257 (instability). See 38 C.F.R. § 4.71a; VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63,604 (1997). Again, review of the portion of the rating schedule that addresses the musculoskeletal system revised effective February 7, 2021 shows that Diagnostic Code 5257 was changed. Id. Prior to the regulatory change, Diagnostic Code 5257 (recurrent subluxation or lateral instability) provided a 10 percent rating when slight, 20 percent rating when moderate, and 30 percent, the maximum available, when severe. 38 C.F.R. § 4.71a. The rating schedule does not define the terms "slight," "moderate," and "severe," as used in Diagnostic Code 5257 to describe the degree of instability of the knee. Instead, adjudicators must evaluate all of the evidence and render a decision that is "equitable and just." 38 C.F.R. § 4.6. As of February 7, 2021, under the amended criteria, Diagnostic Code 5257 (other impairment of knee) provides for the following: Recurrent subluxation or instability at 10 percent for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; 20 percent for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or (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; and 30 percent, the maximum available, for 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; and Patellar instability at 10 percent for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker; 20 percent for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker; and 30 percent, the maximum available, for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. 38 C.F.R. § 4.71a. The Veteran reported in the December 2018 VA Form 9 that he cannot have his knees bent for an extended period of time or they will lock up or just hurt, and that he wore a brace. The Veteran also reported at the December 2020 Board hearing left knee symptomatology, including severe left knee pain, goes out, weakness, and unable to stand on it for long periods of time, as well as that the right knee does the same thing but not as often. Nevertheless, the May 2017 VA examiner marked "none" for any history of bilateral recurrent subluxation and bilateral lateral instability and "normal" for clinical findings of bilateral joint stability testing results. The December 2021 VA examiner marked "no" for any report or history of instability or recurrent subluxation of the knee, "no" for any clinical findings of recurrent subluxation or persistent instability of the right and left knees, and "no" for any clinical findings of recurrent patellar instability of the right and left knees. Additionally, review of VA treatment records during the appeal period is silent for any clinical findings of instability of the right or left knee. Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, his bilateral knee lateral instability warrants a separate 10 percent rating for each knee under the old Diagnostic Code 5257. The award is effective September 25, 2017, which is when the record first shows that he used a knee brace on his right knee. The Veteran has competently and credibly reported bilateral knee lateral instability which causes functional impairment but is undetectable on all forms of examination. The older version of Diagnostic Code 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. See English v. Wilkie, 30 Vet. App. 347 (2018). His instability is best categorized as slight. In addition to the clinical testing showing that the joints are stable, the December 2021 VA examiner found that there was no history of instability of the knee. Further, in a September 2017 VA treatment record, he reported wearing his right knee brace "about once a month." He did not wear a brace on his left knee. To be more accurately described as moderate, it is reasonable to conclude that an assistive device would be used more often than once a month on the right knee. His left knee instability is less severe than the right, as he did not use a brace for it at all. A 20 percent rating for the right knee is denied for the entire appeal period, and a 20 percent rating for the left knee is denied prior to November 30, 2021. On December 7, 2021, the Veteran reported to his VA health care provider that he had to use a cane "now," because his left knee gives out on him and he has "almost fallen" a few times. The addition of an assistive device combined with an assertion of almost falling makes his left knee instability more accurately described as "moderate" under the older criteria. A 20 percent rating is assigned for his left knee instability. The award is effective November 30, 2021, because this earlier VA treatment record noted that he had a cane with him at an appointment. Prior to that date, no cane is noted in his records. His instability in his left knee is not more accurately described as "severe." As noted above, his knee is consistently normal on testing. In addition, the medical and lay evidence does not show that he has fallen because of his left knee instability. He did not report falling or stumbling due to instability at his December 2021 examination. It is reasonable to conclude that to be "severe," there would be evidence of falling, stumbling, balance difficulty, or altered gait due to instability of the knee. Considering the new criteria, the criteria for a 20 percent rating are not met for either knee during the appeal period because the record does not show that an assistive device was actually prescribed by a medical provider. Beginning November 30, 2021, the record does not show that the Veteran had an unrepaired or failed repair of a complete ligament tear. Additionally, the record does not show that the Veteran has been prescribed an assistive device or bracing for ambulation by a medical provider. Additional Considerations The Board considers whether higher ratings are warranted in this case under additional rating criteria for the knee: Diagnostic Code 5256 (ankylosis) and Diagnostic Code 5262 (impairment of tibia and fibula). 38 C.F.R. § 4.71a. Again, review of the portion of the rating schedule that addresses the musculoskeletal system revised effective February 7, 2021 shows that Diagnostic Code 5262 was changed. Id. The Veteran demonstrated active range of motion of the right and left knees at VA examinations and VA treatment sessions during the appeal. The May 2017 and December 2021 VA examiners marked "no" for any clinical findings of ankylosis of the Veteran's right and left knees. Additionally, review of VA treatment records during the appeal period is silent for any clinical findings of ankylosis of the right or left knee, nor has the Veteran asserted the presence of such symptomology pertinent to the knees. As a result, separate ratings in excess of 10 or 20 percent for ankylosis is not warranted under Diagnostic Code 5256 at any time during the appeal. The May 2017 and December 2021 VA examiners marked "no" for any clinical findings of recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment of the Veteran's right or left knee. Additionally, review of VA treatment records during the appeal period is silent for any clinical findings of tibial and/or fibular impairment of the right or left knee, nor has the Veteran asserted the presence of such symptomology pertinent to the knees. As a result, regardless of the regulatory changes effective February 7, 2021, separate ratings in excess of 10 or 20 percent for impairment of the right and left tibia and fibula is not warranted under Diagnostic Code 5262 at any time during the appeal. Furthermore, the Veteran's reported symptomatology did not, when viewed in conjunction with the medical evidence, tend to establish additional limitations of motion to the degree that would warrant higher ratings under 38 C.F.R. §§ 4.40, 4.45, 4.59 and the holdings in DeLuca and Mitchell. As previously noted, the 10 percent disability ratings prior to December 14, 2021 were assigned for painful motion of the right and left knees effective from the date following separation from active service by the AOJ in the November 2005 VA rating decision. See 38 C.F.R. §§ 4.6, 4.71a, Diagnostic Code 5010-5260. The Board considers other potentially applicable Diagnostic Codes to warrant higher ratings for the service-connected DJD of the right and left knees, as discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In this case, the evidence does not reflect that there are any other musculoskeletal disorders or muscle injuries of the knees that the Veteran's right and left knee disabilities are more properly rated under another Diagnostic Code. Accordingly, higher ratings under alternate Diagnostic Codes are not warranted. The Board also considers the Veteran's reported history of symptomatology related to the service-connected DJD of the right and left knees, including pain, flare-ups, limited range of motion, difficulty bending, weakness, buckling, numbness, locking, tightening up, and use of pain medication, braces, and cane. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for ratings higher than the currently assigned ratings have been met at any time during the appeal periods. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, competent evidence concerning the nature and extent of the Veteran's DJD of the right and left knees has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective reported worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Lastly, the Board considers the possibility of additional staged ratings and finds that the proper ratings for the DJD of right and left knees have been in effect for the appropriate periods on appeal prior to December 14, 2021 and thereafter. Accordingly, further staged ratings are inapplicable. See Hart v. Mansfield, 21 Vet. App. 505 (2007). REASONS FOR REMAND 1. Entitlement to service connection for right shoulder disorder 2. Entitlement to service connection for left shoulder disorder On September 8, 2016, the Veteran filed a VA Form 21-0966 (Intent to File a Claim for Compensation), and within one year, on September 26, 2016, he filed a VA Form 21-526EZ requesting to reopen his claim for right and left shoulder disorders. As noted in the October 2021 Board decision, treatment records, the Veteran reported at the December 2020 Board hearing that his right and left shoulder disorders are related to his in-service job duties as a boatswain mate which entailed a lot of carrying, lifting, and pulling on lines and chain joists. Pursuant to the October 2021 Board remand directives, the AOJ was instructed to schedule the Veteran for an examination and to obtain medical opinions regarding a direct nexus between the Veteran's right and left shoulder disorders and any incident of service. The Veteran was provided a VA examination for shoulder and arm conditions in December 2021 by Dr. B. S. which reflects a current diagnosis of bilateral shoulder pain, unspecified etiology, and that diagnostic testing was not performed. VA medical opinions by Dr. B. S. were also provided which explained why the claimed right and left shoulder disorders were not incurred in or caused by an in-service injury, event, or illness; however, the rationale provided relied on the lack of recent imagining of the shoulders for the last two years. The Board finds that the VA examiner did not take into consideration the Veteran's reported in-service job duties as well as documented complaints and treatment for the shoulders in service treatment records. Additionally, review of VA treatment records associated with the claims file in December 2021 shows that an x-ray for the right shoulder was ordered in April 2020; however, as of this date, there is no indication that the AOJ has attempted to obtain outstanding VA treatment records dated from February 2019 to September 2020, to include x-ray results of the right shoulder. The most recent treatment record in the claims file is a December 2021 VA treatment record. As a result, the Board finds that additional development is needed to properly adjudicate the appeal, specifically to include an addendum VA medical opinion and outstanding VA treatment records dated from February 2019 to September 2020 and since December 2021. See 38 U.S.C. § 5103A(a); 38 C.F.R. §§ 3.159, 3.303; Barr v. Nicholson, 21 Vet. App. at 312. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file all outstanding VA treatment records dated from February 2019 to September 2020 and since December 2021, to include any relevant x-ray results (as ordered for the right shoulder in April 2020). If these records cannot be located, it must specifically document the attempts that were made to locate them and the Veteran must be notified. 2. Then, return the Veteran's claims file to the examiner (Dr. B. S.) who conducted December 2021 VA examination for shoulder and arm conditions and provided the December 2021 VA medical opinions for right and left shoulder disorders so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran's claims file to a similarly qualified clinician. A new examination is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner's attention to the following: Service treatment records show treatment for the left shoulder in January1999 and for mild left shoulder or scapular muscle strain in October 2001 Service treatment records show May 2004 right shoulder MRI findings of suspicious for superior posterior labrum tear and suspicious for Hill-Sachs deformity and dislocated right shoulder noted on the May 2004 Report of Medical Assessment June 2011 VA treatment record shows an assessment of right shoulder pain most likely due to muscle strain At the December 2020 Board hearing the Veteran reported that his right and left shoulder disorders are related to his in-service job duties as a boatswain mate which entailed a lot of carrying, lifting, and pulling on lines and chain joists The examiner must opine as to the following: (a.) Whether the Veteran's right shoulder disorder began during active service, is related to an incident of service, or if any findings of arthritis began within one year after discharge from active service. (b.) Whether the Veteran's left shoulder disorder began during active service, is related to an incident of service, or if any findings of arthritis began within one year after discharge from active service. Note The examiner is advised that pain plus functional impairment is considered a disability for VA purposes, even if no diagnosable condition is present. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Then, review all examination reports and medical opinions provided to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 4. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Carter, 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.