Citation Nr: 25002011 Decision Date: 02/11/25 Archive Date: 02/11/25 DOCKET NO. 00-09 408 DATE: February 11, 2025 ORDER Entitlement to a rating in excess of 10 percent for right knee post-traumatic arthritis is denied. FINDING OF FACT 1. During the appeal period, the Veteran's right knee arthritis disability manifested with, at worst, flexion limited to 55 degrees and extension limited to an endpoint of 5 degrees, and not with ankylosis of the functional equivalent of ankylosis, genu recurvatum, malunion or non-union of tibia and fibula, shin splints, or incapacitating exacerbations. CONCLUSION OF LAW 1. The criteria for a rating in excess of 10 percent for a right knee arthritis disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1983 to December 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 1999 rating decision issued by a Regional Office of the Department of Veterans Affairs (VA), which is the Agency of Original Jurisdiction (AOJ). In April 2006, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript has been associated with the claims file. The October 1999 rating decision on appeal established service connection for a right knee instability disability rated 10 percent disabling. A March 2002 Board decision granted a separate 10 percent rating for arthritis with limitation of motion and denied an increased rating for instability. The Veteran appealed the March 2002 Board decision to the United States Court of Appeals for Veterans Claims. In March 2003, the Court granted a Joint Motion for Remand vacating the March 2002 Board decision denying entitlement to increased ratings for a right knee disability and remanding the matter for further proceedings consistent with that motion. In October 2003, and June 2005, the Board remanded the matter for additional development by the AOJ. In June 2006, the Board issued a decision denying increased right knee disability ratings. The Veteran appealed the June 2006 Board decision to the United States Court of Appeals for Veterans Claims. In April 2007, the Court granted a Joint Motion for Remand vacating the June 2006 Board decision denying entitlement to increased ratings for a right knee disability and remanding the matter for further proceedings consistent with that motion. In August 2007 and January 2009, the Board remanded the matter for additional development by the AOJ. In June 2010, the Board granted an increased 20 percent rating, but not higher, for right knee instability and denied a rating in excess of 10 percent for a separate right knee arthritis disability rating. The Veteran appealed the June 2010 Board decision to the United States Court of Appeals for Veterans Claims. In February 2011, the Court granted a Joint Motion for Remand vacating the June 2010 Board decision only with respect to the denial of an increased rating for a right knee arthritis disability and remanding the matter for further proceedings consistent with that motion. The parties agreed that the Veteran was abandoning pursuit of an increased right knee instability rating, and consequently the issue of an increased rating under Diagnostic Code 5257 on the basis of instability is not now before the Board. In July 2011, October 2012, October 2013, and May 2015, the Board remanded the claim for an increased rating for a right knee arthritis disability. In August 2017 the Board again remanded that issue and the issue of entitlement to a total disability rating based on individual unemployability. In May 2018, the Board denied a rating higher than 10 percent for right knee arthritis but granted a separate rating for meniscectomy residuals under Diagnostic Code 5259 effective August 9, 1999. The Veteran appealed the May 2018 Board decision to the United States Court of Appeals for Veterans Claims. In April 2019, the Court granted a Joint Motion for Partial Remand vacating the May 2018 Board decision only to the extent that it denied an initial rating in excess of 10 percent for a right knee disability characterized as osteoarthritis and remanding the matter for further proceedings consisting with that motion. As a result, the issue of a rating for that meniscectomy residuals disability under Diagnostic Code 5259 is not now before the Board. In October 2019, December 2020, May 2023, and May 2024 the Board remanded the matter for further development by the AOJ. Most recently, in May 2024, the Board remanded the matter to obtain a retrospective medical opinion regarding the severity of the Veteran's right knee disability. In November and December 2024, the requested retrospective VA medical opinion was obtained. Therefore, the Board finds that there has been substantial compliance with the May 2024 remand requests. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to a rating in excess of 10 percent for right knee post-traumatic arthritis As a preliminary matter, the Board notes that the only issue now before the Board is whether the Veteran is entitled to a rating higher than 10 percent for a right knee arthritis disability. In a February 2011 Joint Motion, the parties agreed that the Veteran was abandoning pursuit of a higher separate rating for right knee instability. Additionally, a May 2018 Board decision established a separate rating for a meniscectomy under Diagnostic Code 5259 effective August 9, 1999, and also denied an initial rating in excess of 10 percent for a right knee disability characterized as osteoarthritis. In April 2019, a Joint Motion for Partial Remand vacated the May 2018 Board decision only to the extent that it denied an initial rating in excess of 10 percent for a right knee disability characterized as osteoarthritis. The Veteran's right knee degenerative joint disease has been rated as 10 percent disabling under Diagnostic Code 5010 for posttraumatic arthritis. The issues of increased ratings for right knee instability under Diagnostic Code 5257 and meniscectomy residuals under Diagnostic Code 5258 are not now before the Board. However, the Board does not foreclose the possibility of any other separate disability ratings for symptomatology not captured or contemplated by those separate ratings for instability or meniscectomy residuals, or the arthritis disability rating now before the Board. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of the disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period for which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). If two ratings are potentially applicable, the higher rating 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. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. When the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Fenderson v. West, 12 Vet. App. 199 (1999). The Board has thoroughly reviewed all evidence in the claims file. Consistent with the law, the analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim, and the Board's reasons for rejecting evidence favorable to the appellant. Timberlake v. Gober, 14 Vet. App. 122 (2000). The appellant should not assume the Board has overlooked evidence not explicitly discussed. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a weight of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Rating a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, the regulations state that the functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the Veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. When rating the joints, inquiry will be directed as to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The rating of the same disability under different Diagnostic Codes, known as pyramiding, must be avoided. However, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259 (1994). During the pendency of the appeal, the rating criteria for rating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). Those amendments revised select diagnostic codes to ensure that the portion of the rating schedule used current medical terminology and provided detailed and updated criteria for the rating of musculoskeletal disabilities. 85 Fed. Reg. 230 (Nov. 30, 2020). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and the old and new rating criteria as of February 7, 2021. The criteria that are more favorable to the Veteran will be applied as of February 7, 2021. Diagnostic Code 5010, revised as of February 7, 2021, for post-traumatic arthritis, provides that post-traumatic arthritis should be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are two or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a. Before February 7, 2021, Diagnostic Code 5010 provides that arthritis, due to trauma, substantiated by X-ray imaging should be rated as degenerative arthritis using Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2020). Diagnostic Code 5003, used for rating arthritis other than post-traumatic, was revised as of February 7, 2021. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. Notes indicate that ratings under Diagnostic Code 5003 will not be combined with limitation of motion ratings and ratings conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Prior to February 7, 2021, Diagnostic Code 5003 is labelled as arthritis, degenerative (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020). Under Diagnostic Code 5055, knee replacement (prosthesis), a 30 percent is the minimum available rating after prosthetic replacement of the knee joint. A 60 percent rating is warranted for chronic residuals consisting of severe painful motion or weakness in the affected extremity, and intermediate degrees of residual weakness, pain or limitation of motion rate by analogy to diagnostic codes 5256 (ankylosis of knee), 5261, or 5262. A 100 percent rating is assigned for four months following implantation of prosthesis or resurfacing. A note indicates that there is no minimum evaluation for knee resurfacing. Prior to February 7, 2021, the 100 percent rating was assigned for 12 months. 38 C.F.R. § 4.71a. Diagnostic Code 5256, used for rating ankylosis of the knee, provides for a 30 percent rating where a knee is ankylosed in favorable angle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent rating is warranted for a knee ankylosed in flexion between 10 and 20 degrees, and a 50 percent rating for ankylosis in flexion between 20 and 45 degrees. A 60 percent rating is warranted for extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more. 38 C.F.R. § 4.71a. Diagnostic Code 5257, used for rating other impairment of the knee, provides for recurrent subluxation or instability and patellar instability. A separate rating for right knee instability under Diagnostic Code 5257 has been established and is not now before the Board, so the rating criteria have been omitted. 38 C.F.R. § 4.71a. Diagnostic Code 5258, used for rating dislocated semilunar cartilage, provide a 20 percent rating with frequent episodes of locking, pain, and effusion into the joint. A separate rating under Diagnostic Code 5258 for right knee meniscectomy residuals has been established and is not now before the Board. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a. Diagnostic Code 5260, used for rating limitation of flexion of the leg, provides a 0 percent rating for flexion of the leg limited to 60 degrees or greater. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees or less. 38 C.F.R. § 4.71a. Diagnostic Code 5261, used for rating limitation of extension of the leg, provides a 0 percent rating for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5262 is used for rating impairment of tibia and fibula. Under the Version revised effective February 7, 2021, for medical tibial stress syndrome (MTSS), or shin splints, a 0 percent rating is warranted for treatment for less than 12 consecutive months for one or both lower extremities. A 10 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities. A 20 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity. A 30 percent rating is warranted for shin splints requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. Diagnostic Code also provides for a 40 percent rating for nonunion of tibia and fibula, with lose motion, requiring brace. The rating criteria indicate that malunion of the tibia and fibula should be rated under Diagnostic Codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest rating. 38 C.F.R. § 4.71a. Using the criteria in effect prior to February 7, 2021, Diagnostic Code 5262 was for impairment of fibula and tibia, malunion of tibia and fibula with slight knee or ankle disability warrants a 10 percent disability rating, malunion of tibia and fibula with moderate knee or ankle disability warrants a 20 percent rating, and malunion of the tibia and fibula with marked knee or ankle disability warrants a 30 percent rating. Nonunion of the tibia and fibula with loose motion requiring a brace warrants a 40 percent rating. 38 C.F.R. § 4.71a (2020). Diagnostic Code 5263, used for rating genu recurvatum, provides for a 10 percent rating in acquired traumatic genu recurvatum with weakness and insecurity in weight-bearing objectively demonstrated. 38 C.F.R. § 4.71a. September 1999 VA Medical Center records note that the Veteran's right knee had a range of motion from +5 to 140 degrees without effusion. The Veteran reported pain 10/10 and the examiner found VMO atrophy. The Veteran reported intermittent swelling with no catching, locking, or giving. The examiner's impression was pain at the right knee, probably secondary to VMO atrophy. At an August 2004 VA examination, the examiner noted that the Veteran's right knee X-ray was normal, and a right knee MRI showed an osteochondral defect of the medial femoral condyle. The examiner noted right knee had normal range of motion 0 to 140 degrees, active, passive, repetitive, and against resistance, and found that the weight of motion was not limited by pain, fatigue, weakness, or lack of endurance on repetition. At a January 2008 VA examination, the Veteran's right knee range of motion was found to be 0 to 140 degrees against gravity, and the examiner noted that pain began at 140 degrees and ended at 140 degrees. There was no inflammatory arthritis and no joint ankylosis. The examiner found crepitation, but found no mass behind knee, no bumps consistent with Osgood-Schlatter's disease, no clicks or snaps, no grinding, no instability, no patellar abnormality, no meniscus abnormality, and no other knee abnormality. There was no additional loss of motion on repetitive use. X-ray imaging showed mild degenerative changes. The examiner opined that the right knee disability in conjunction with left knee and back disabilities limited chores, shopping, and exercise, and prevented sports participation, but that there was no limitation in recreation, traveling, feeding, bathing, dressing, toileting, or grooming. At an April 2009 VA examination, the Veteran reported flare-ups of moderate severity with a "constant" frequency and a duration of hours precipitated by activity. The Veteran reported being able to stand for 15 to 30 minutes and being unable to walk more than a few yards, and using a brace constantly and a cane 90 percent of the time. The examiner found that the Veteran's right knee had 0 to 130 degrees range of motion with normal extension. The examiner found there were no additional limitations after three repetitions and no objective evidence of pain following repetitive motion. The X-ray imaging confirmed degenerative suprapatellar soft tissue calcification with a primary diagnosis of "minor abnormality." The examiner found severe limitations in chores, shopping, and exercise and that sports were completely prevented, but no limitation in recreation, traveling, feeding, bathing, dressing, toileting, or grooming. A January 2013 VA examination diagnosed right knee osteoarthritis with patellofemoral pain syndrome status-post right ACL reconstruction. The Veteran denied experiencing flare-ups of the right knee. The examiner found the Veteran's right knee had 115 degrees of initial flexion with objective evidence of pain at 80 degrees and full range of extension with no objective evidence of painful motion during extension. After repetitive use there was no additional loss in range of motion, and the examiner found that pain on movement was the only contributing factor contributing to functional impairment. There was right knee pain on palpation, and no evidence of patellar subluxation or dislocation, and the examiner found the Veteran had a right knee meniscal tear or residuals symptoms from a residual tear as well as frequent episodes of joint pain. The Veteran reported constant cane and brace use and the examiner noted that available imaging showed right knee degenerative or traumatic arthritis. The January 2013 VA examiner found that the Veteran did not have shin splints, stress fracture of the lower extremity, chronic exertional compartment syndrome, genu recurvatum, or leg length discrepancy, and opined that the Veteran's knee disabilities did not have any impact on the Veteran's ability to work. In a November 2013 medical opinion, a VA examiner was asked to reconcile the Veteran's conflicting reports of experiencing flare-ups and not experiencing flare-ups. The examiner opined that the Veteran had flare-ups with the knee giving out and pain worse with prolonged standing or walking, but did not provide rationale for that or discuss the previous conflicting reports or even indicate which knee, or whether both knees, were being discussed. In a January 2014 VA medical opinion, an examiner noted that the Veteran had joint instability but indicated that instability did not necessarily lead to a loss of range of motion and noted that based on records review the Veteran's knee range of motion was not significantly impaired. In April 2014, a VA examiner opined that flare-up range of motion estimates would be speculative and flare-up range of motion values could only be provided if examining the Veteran during a flare-up. At a November 2015 VA examination, the Veteran was diagnosed with right knee joint osteoarthritis with residuals of ACL repair surgery. The Veteran reported flare-ups with pain worsening in the right knee and functional loss of knee pain with limited range of motion. The Veteran's initial range of motion was from 0 to 130 degrees, and the examiner noted pain at extreme of motions on both flexion and extension, as well as pain on weight bearing, objective evidence of pain or localized tenderness on palpation, and objective crepitus. The examiner noted that there was no additional functional loss after three repetitions. The examiner found the examination consistent with the Veteran's reports of functional loss with repeated use over time, and estimated the Veteran's range of motion to be 0 to 130 degrees after repeated use over time. The examiner indicated that it was not possible to estimate flare-up range of motion without resorting to mere speculation because the Veteran was not examined during a flare-up. The examiner found the Veteran had a reduction in muscle strength, with 4/5 strength (active movement against some resistance) in both flexion and extension. The Veteran did not have ankylosis but did report regular use of a brace and cane. In an April 2016 medical opinion, the November 2015 VA examiner noted that there was nothing to reconcile about past examination flare-up notations because the Veteran reported flare-ups during some examinations and denied flare-ups during others. The examiner reiterated that it would be speculation to estimate the range of motion in degrees during flare-up conditions. August 2016 private medical records note that the Veteran reported having problems with the right knee and wearing a brace on the right knee. At an April 2017 VA examination, the Veteran reported experiencing flare-ups daily, with pain, limited range of motion, instability, and swelling after the day's activities. The Veteran's range of motion was, at worst, estimated to be during a flare-up or after repeated use over time 0 to 125 degrees. The examiner noted bilateral weakness and muscle atrophy, which one leg measuring 38 centimeters and one leg measuring 41 centimeters, but did not indicate which side was atrophied or where on the leg the measurements were taken. The Veteran did not have right knee ankylosis, recurrent subluxation, or lateral instability. The Veteran reported using a brace and walker constantly and a cane occasionally. The examiner opined that the Veteran's bilateral knee disabilities manifested with limited standing and walking. At a January 2019 VA examination, the Veteran's right knee range of motion was estimated to be, at worst, 0 degrees to 80 degrees flexion and 80 degrees to 0 degrees of extension during a flare-up or after repeated use over time. The examiner found that the Veteran's knee had normal strength, graded 5/5, for both flexion and extension and no ankylosis was present. The examiner reported constant use of a cane and regular use of a walker, and found that the Veteran did not have genu recurvatum. The examiner opined that the Veteran was unable to sit or walk for long periods, unable to lift heavy things, and unable to perform activities of daily living without pain and discomfort. The examiner opined that the Veteran was unable to walk for long periods of time due to severe right ankle pain, so it appears the examiner considered all or at least more than one of the Veteran's service-connected disabilities in providing that opinion. The examiner also opined that it was at least as likely as not that the Veteran was unable to secure or follow substantially gainful occupation due to the service-connected disabilities. At an October 2023 VA examination, the Veteran's right knee range of motion was estimated to be, at worst, 50 degrees of flexion and 0 degrees of extension during a flare-up or after repeated use over time. The examiner noted pain on weight-bearing, active motion, and passive motion, and found that the Veteran did not have ankylosis, muscle atrophy, patellar instability, recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment including genu recurvatum or shin splints, and noted regular use of a brace, a cane, and a walker. In November 2024 and December 2024, a retrospective VA medical opinion was obtained considering the severity of the Veteran's right knee disability during the appeal period. Based on a review of available evidence, the examiner opined that the Veteran's pain and instability had remained relatively consistent since the initial 1999 injury, with evidence of only mild fluctuation. The examiner noted there was no evidence of a significant decrease in range of motion during flare-up or due to repetitive motion prior to the January 2019 VA examination. The examiner noted that the Veteran had retained normal extension throughout the appeal period, even considering the effects of flare-up or repeated use over time. The Veteran's right knee arthritis disability has been rated 10 percent under Diagnostic Code 5010 since August 19, 1999. The pre-February 2021 Diagnostic Code 5010 directs the adjudicator to rate under Diagnostic Code 5003. Diagnostic Code 5003 provides for a 10 percent rating with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. The right knee is a single major joint, therefore a 10 or 20 percent rating is not warranted based solely on that joint. The Board notes that separate disability ratings under 5010 for other joints were present during the appeal period, with a right ankle disability rated as 10 percent disabling under Diagnostic Code 5010 since July 6, 1998, and a left knee arthritis disability rated as 10 percent disabling from January 1, 1994, to January 19, 2017. Diagnostic Code 5003 (and pre-February 2021 Diagnostic Code 5010, by extension) expressly contemplates assigning ratings for multiple major joints or multiple groups of minor joints, with involvement of at least two major joints or two minor joint groups required for a 10 percent rating. A knee is expressly defined as a major joint. 38 C.F.R. §§ 4.45, 4.71a. However, the right knee arthritis at the time was assigned the minimum compensable rating. That would be appropriate under the more current interpretation of 38 C.F.R. § 4.59, although later ratings for right knee disability were added. The Board finds that the weight of the evidence does not show that the Veteran's right knee arthritis manifests with occasional incapacitating exacerbations. While the weight of the evidence shows that the Veteran experiences flare-ups of increased pain, especially with use such as walking or standing for extended periods of time, it has not been shown that the Veteran is incapacitated during those flare-ups and therefore an increased 20 percent rating under pre-February 7, 2021, Diagnostic Code 5010 (applying Diagnostic Code 5003 rating criteria) is not warranted. The revised version of Diagnostic Code 5010, effective February 7, 2021, requires that posttraumatic arthritis be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are two or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. The Board finds that an increased rating on the basis of range of motion restrictions is not warranted. The Board has considered whether an increased or separate rating is warranted under limitation Diagnostic Codes 5260 and 5261 for limitation of flexion and extension, respectively. The Board notes that pre-February 2021 Diagnostic Code 5010 requires assignment of a rating under Diagnostic Code 5003. Diagnostic Code 5003 indicates that a rating under that code is only appropriate where a rating higher than 0 percent based on limitation of motion is not warranted. Therefore, an increased rating under limitation of motion would require the criteria for a 20 percent rating (or higher) to be met, as any 10 percent rating under limitation of motion would replace the 10 percent rating under Diagnostic Code 5010 and therefore would not result in an increased rating. The revised version of Diagnostic Code 5010 expressly requires rating under limitation of motion, dislocation, or other specified instability. Regarding Diagnostic Code 5261, the Board finds that the weight of the evidence is against a finding that the Veteran's right knee disability manifests with extension limited to 15 degrees or less. The Veteran's right knee extension was, at worst, measured to be limited to 5 degrees in a September 1999 VA examination. At many other examinations, the Veteran was measured to have full range of motion of extension, or to 0 degrees. In November 2015, April 2017, January 2019, and October 2023, VA examiners estimated the Veteran to retain full extension range of motion, to 0 degrees, at worst and during a flare-up. Accordingly, the Board concludes that the weight of the evidence is against a finding that the Veteran had a limitation of extension range of motion to an endpoint of 10 degrees as required by 10 percent rating criteria or to 15 degrees (or more) as required by 20 percent rating criteria under Diagnostic Code 5261. Therefore, a higher or separate rating is not warranted under Diagnostic Code 5261. Regarding Diagnostic Code 5260, the Board finds that the weight of the evidence is against a finding that the Veteran's right knee disability manifested with a limitation of flexion to 45 degrees, as required by 10 percent rating criteria, or 30 degrees, as required by 20 percent rating criteria, or less. At worst during the appeal period, the Veteran's right knee flexion range of motion was estimated to be limited to 50 degrees during a flare-up by the October 2023 VA examiner. Accordingly, a 10 percent or 20 percent rating, or any separate rating, under Diagnostic Code 5260 for limitation of right knee flexion is not warranted. The Board has also considered whether a separate rating under another Diagnostic Code is warranted. No VA examiner found that the Veteran had ankylosis during the appeal period and some made express findings that there was no ankylosis. The Veteran does not claim, and the weight of the evidence does not show, that the Veteran has had at any time, actual ankylosis or the functional equivalent of ankylosis as a significant range of motion is present at all times. Therefore, a separate rating under Diagnostic Code 5256 for ankylosis is not warranted. Considering both limitation of flexion and limitation of extension, the Board finds a rating in excess of 10 percent already in place under Diagnostic Code 5010 for a right knee arthritis disability is not warranted. VA examiners prior to January 2013 did not make a finding that the Veteran had genu recurvatum, and January 2013, January 2019, and October 2023 VA examiners expressly found that the Veteran did not have genu recurvatum. Accordingly, the Board finds that a separate disability rating for genu recurvatum under Diagnostic Code 5263 is not warranted. Similarly, VA examiners either did not find that the Veteran had shin splints or malunion or nonunion of the tibia and fibula or expressly found that the Veteran did not have those disabilities, and therefore a separate rating under Diagnostic Code 5262 for a right knee disability is not warranted. As discussed above, separate ratings have already been established for instability and meniscal surgery residuals under Diagnostic Codes 5257 and 5258, respectively, and the issue of those separate ratings is not now before the Board. Diagnostic code 5259 covers essentially the same disability as 5258. The Board acknowledges some examinations during the appeal period may be incomplete because, for example, the examiner did not provide an estimate of flare-up range of motion. However, the Board finds that the examinations are complete when taken in aggregate, and the Board used only the worst range of motion estimates in the examinations in the interest of resolving reasonable doubt or any ambiguity in favor of the Veteran. The Board notes that this matter has been remanded several times previously and some of the examinations of record were conducted pursuant to remand instructions. The Board has considered the lengthy history of this case as evidence that additional remands might not yield additional useful evidence, and has instead applied more recent and more favorable right knee examination results retrospectively in the interest of resolving any reasonable doubt in favor of the Veteran. The Board has also considered the retrospective opinion. The Board notes that the Veteran has been awarded TDIU for the entire appeal period and has considered whether TDIU on the basis of a single disability is warranted. The Board finds that the weight of the evidence shows that the Veteran's right knee disability alone does not make the Veteran unable to secure or maintain even sedentary employment. Although the right knee disability causes substantial physical limitations, the Board finds that, with appropriate accommodations, the right knee disability alone, without consideration of any other disability, does not prevent the Veteran from working in an office or performing other sedentary work. The Board defines sedentary work as that is not physically demanding or requiring physical labor, long periods of walking, standing, or sitting without the possibility of any break, bending, crawling, etc. Most types of office work, clerical work, or administrative work would be considered sedentary. The weight of the evidence shows that multiple disabilities together are responsible for the Veteran's unemployability. Accordingly, the Board finds that the weight of the evidence is against the assignment of a rating higher than 10 percent for a right knee arthritis disability. The Board finds that the evidence is not in approximate balance, the criteria for a higher rating are not met or more nearly approximated, and there is no reasonable doubt to resolve in favor of the Veteran. Therefore, the claim for increase is denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Hood, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.