Citation Nr: 25004809 Decision Date: 04/09/25 Archive Date: 04/09/25 DOCKET NO. 16-10 072 DATE: April 9, 2025 ORDER Entitlement to an initial rating in excess of 10 percent for service-connected chondromalacia of the right knee ("right knee disability") is denied. Entitlement to an initial rating in excess of 10 percent for service-connected chondromalacia of the left knee ("left knee disability") is denied. Prior to September 28, 2018, entitlement to an initial rating of 10 percent for service-connected right knee disability based on instability is granted. From September 28, 2018, entitlement to an initial rating of 20 percent for service-connected right knee disability based on instability is granted. Entitlement to an initial rating of 10 percent for service-connected left knee disability based on instability is granted. FINDINGS OF FACT 1. The service-connected right knee disability is manifested by, at worst, flexion limited to 45 degrees and extension to 0 degrees. 2. The service-connected left knee disability is manifested by, at worst, flexion limited to 65 degrees and extension to 0 degrees. 3. Prior to September 28, 2018, the record evidence shows that the Veteran has experienced, at worst, slight lateral instability in the right knee. 4. From September 28, 2018, the record evidence shows that a medical provider prescribed a brace for his right knee disability due to instability. 5. For the entire appeal period, the record evidence shows that the Veteran has experienced, at worst, slight lateral instability in the left knee and that there is no prescription from a medical provider for an assistive device or bracing for ambulation of the left knee. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 10 percent rating for a right knee disability have not been met. 38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes?5260, 5261. 2. The criteria for an initial rating greater than 10 percent rating for a left knee disability have not been met. 38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes?5260, 5261. 3. Prior to September 28, 2018, criteria for an initial rating of 10 percent for a right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 4. From September 28, 2018, the criteria for an initial rating of 20 percent for a right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 5. For the entire appeal period, the criteria for an initial rating of 10 percent for a left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from June 1996 to August 1996, from August 2004 to December 2008, from February 2009 to December 2012, from July 2019 to September 2019, from December 2020 to August 2021 and from April 2023 to September 2023. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2022, the Veteran and his spouse testified at a videoconference hearing. The transcript of the hearing is of record. By way of background, in August 2022 and February 2023, the Board remanded the issues on appeal for further evidentiary development and adjudication. In May 2023, the Board denied the issues on appeal. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In August 2024, the court issued a memorandum decision in which it remanded the issues on appeal. The matter has returned to the Board for appellate consideration. The Board observes that additional VA treatment records were received following the last adjudication by the RO in the March 2023 supplemental statement of the case. The Board has reviewed these records and observes that they are duplicative, cumulative, and/or not pertinent to the issues on appeal addressed in the decision below. The Board also observes that additional private treatment records were received following the last adjudication by the RO in the March 2023 supplemental statement of the case. However, as the Veteran's substantive appeal was received after February 2, 2013, an automatic waiver of evidence submitted by the claimant or his representative is presumed. Because the Veteran submitted these records, a waiver of RO consideration is presumed. Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Hart v. Nicholson, 21 Vet. App. 505, 509 (2007); see also Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. When evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability, and incoordination. 38 C.F.R. § 4.45. The evaluation of the same disability under several 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, 262 (1994). Separate ratings under Diagnostic Code 5260, for limitation of flexion of the knee, and Diagnostic Code 5261, for limitation of extension of the knee, may be assigned for disability of the same joint, but only where the criteria for a compensable rating are met under each diagnostic code. VAOGCPREC 9-2004 (2004). Pursuant to Diagnostic Code 5260, a 10 percent rating is warranted for knee flexion limited to 45 degrees. A 20 percent rating is warranted for knee flexion limited to 30 degrees. A maximum 30 percent rating is warranted for knee flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. As for extension, pursuant to Diagnostic Code 5261, a 10 percent rating is warranted for knee extension limited to 10 degrees. A 20 percent rating is warranted for knee extension limited to 15 degrees. A 30 percent rating is warranted for knee extension limited to 20 degrees. A 40 percent rating is warranted for knee extension limited to 30 degrees. A maximum 50 percent rating is warranted for knee extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal knee range of motion is to 140 degrees of flexion and 0 degrees of extension. 38 C.F.R. § 4.71a, Plate II. Diagnostic Code 5256 pertains to ankylosis. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Here, the records do not show that the Veteran has ankylosis at any point in the appeal period and as such Diagnostic Code 5256 is not applicable in this case. Under Diagnostic Code 5258, a 20 percent rating is available for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of semilunar cartilage, symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Here, the records do not show that the Veteran has removal of semilunar cartilage and as such Diagnostic Code 5259 is not applicable in this case. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities (including patellofemoral pain syndrome and knee instability) under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See 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. The Board will consider the 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. Prior to the regulatory change, Diagnostic Code 5257 states a 10 percent rating is warranted for slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (effective prior to February 7, 2021). The Board notes that under the old criteria, the terms "slight," "moderate," and "severe" are not defined. 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. As the terms are not defined in the regulations, the Board finds that slight recurrent subluxation is demonstrated by reports from the Veteran that he had knee instability, with limited objective evidence. Moderate instability is defined as more than slight, less than severe, and demonstrated by reports of instability as well as objective evidence of instability on examinations. Severe instability is more than both slight and moderate, is persistent and debilitating, is demonstrated by objective evidence on examination, and is documented by use of assistive devices for walking, prescribed by a medical provider, including a cane and brace, or a walker, or a wheelchair. After the regulatory change, Diagnostic Code 5257 states a 10 percent rating is warranted 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., canes, crutches, walker) or bracing for ambulation. A 20 percent rating is warranted for (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, crutches, walker) for ambulation; (b) unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes either an assistive device (e.g., canes, crutches, walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or fail repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., canes, crutches, walker) and bracing for ambulation. See 38 C.F.R. § 4.71a, Diagnostic Code 5257 (effective February 7, 2021). The revised Diagnostic Code 5257 also addresses patellar instability. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is warranted 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. 1. Entitlement to an initial rating in excess of 10 percent for service-connected right knee disability is denied. 2. Entitlement to an initial rating in excess of 10 percent for service-connected left knee disability is denied. 3. Prior to September 28, 2018, entitlement to an initial rating of 10 percent for service-connected right knee disability based on instability is granted. 4. From September 28, 2018, entitlement to an initial rating of 20 percent for service-connected right knee disability based on instability is granted. 5. Entitlement to an initial rating of 10 percent for service-connected left knee disability based on instability is granted. At the outset, the Veteran filed a service connection claim for his bilateral knee disability in October 2013. In a June 2014 rating decision, the RO granted service connection and assigned a noncompensable rating. During the appeal process, in an October 2022 rating decision, the RO granted a 10 percent rating for his bilateral knee disability, effective October 1, 2013. A review of the records shows that the Veteran was afforded VA examinations in April 2013, May 2014, March 2017, March 2022, August 2022, and November 2022. In the April 2013 VA examination, the Veteran stated that when there is a change in the weather his knees would hurt, and he would have to take Tylenol. On examination of the right knee, the Veteran was able to flex to 130 degrees and extend to 0 degree with no objective evidence of painful motion. On examination of the left knee, he was able to flex to 130 degrees with objective evidence of painful motion at 130 degrees and extend to 0 degree with no objective evidence of painful motion. He was able to perform repetitive-use testing with three repetitions and he was able to flex to 130 degrees and extend to 0 degree of the bilateral knee. He did not have additional limitation in range of motion of the knee following repetitive-use testing. There was no functional loss and/or functional impairment of the knee. He exhibited normal muscle strength and stability. There was no evidence or history of recurrent patellar subluxation or dislocation. An x-ray scan of bilateral knees showed no evidence of patellar subluxation. He had normal findings on anterior instability, posterior instability, and medial-lateral instability testing. He did not have any meniscal condition or surgical procedures for a meniscal condition. He denied using any assistive devices as a normal mode of locomotion. The examiner also noted that his bilateral knee disability had no impact on his ability to work. In a May 2014 VA examination, the Veteran stated that his knees feel stiff first thing in the morning, and that both seem to pop and give way at times. He denied having knee swelling, redness, clicking, locking, fracture, subluxation, dislocation, limitation in range of motion, surgery, or other complaints. He reported that during flare ups he has intermittent duration of pain of the bilateral knees. However, he was very vague about the severity and did not respond to several questions. On examination of the bilateral knee, he was able to flex to 135 degrees and extend to 0 degree with no objective evidence of painful motion of the bilateral knee. He was able to perform repetitive-use testing with three repetitions with no additional limitation in the range of motion of the bilateral knee. There was no functional loss and/or functional impairment of the bilateral knee. There was tenderness or pain to palpation for joint line or soft tissues of the bilateral knee. He exhibited normal muscle strength. He denied having evidence or history of recurrent patellar, subluxation, or dislocation. On joint stability tests he had normal results. Specifically, he had no positive findings on anterior instability, posterior instability, and medial-lateral instability tests. He did not have any meniscal conditions or surgical procedures for a meniscal condition. The examiner noted that his left knee would pop repeatedly when flexing at 40 degrees. However, there was no ligament instability, and he had normal gait. He did not endorse using any assistive devices as a normal mode of locomotion. He also denied using any assistive devices for his condition. An April 2014 x-ray scan of the bilateral knee revealed no recent fracture or dislocation of the bilateral knees. The bilateral patellofemoral relationships appeared intact. His bilateral knees were within normal limits. The examiner determined that his bilateral knee disability would have no impact on his ability to work. The examiner stated that DeLuca provisions and Mitchell provisions cannot be clearly delineated. During a flare up, an individual could have limitations in range of motion, endurance, joint function, and amount of pain in functional capacity, but the examiner is unable to provide an estimate without resorting to mere speculation. There was no objective evidence of fatigue, weakness, lack of endurance, or lack of coordination. In a March 2017 VA examination, the Veteran stated that he has burning sensation, cracking, and popping of the knees. He endorsed having flare-ups of the knee. He reported that he had a flare up the previous night that lasted for couple of hours. He did not report having any functional loss or functional impairment of the joint or extremity including but not limited to repeated use over time. On examination of the bilateral knee, he exhibited full range of motion of the bilateral knees. Specifically, he was able to flex to 140 degrees and extend to 0 degree with no pain noted on examination. There was no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus. He was able to perform repetitive-use testing with three repetitions with no additional limitation in the range of motion of the bilateral knee. He was examined immediately after repetitive use over time. Pain, weakness, fatigability, or incoordination would not significantly limit functional ability with repeated use over a period of time for the bilateral knees. The examination was not conducted during a flare up of either knee. The examiner determined that the examination is neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during flare ups of the bilateral knee. The examiner determined that pain, weakness, fatigability, or incoordination would not significantly limit his functional ability with flare ups. He exhibited normal muscle strength with no evidence of muscle atrophy. There was no ankylosis of the bilateral knee. On joint stability tests he had normal results for the bilateral knee. He has never had a meniscus (semilunar cartilage) condition. The examiner determined that his bilateral knee disability has no impact on his ability to perform any type of occupational task. He denied using any assistive devices as a normal mode of locomotion. There were no objective findings of pain with non-weight bearing and weight bearing of the bilateral knee. There were no objective findings of pain with passive or active range of motion of the bilateral knee. His bilateral knee disability would not impact his ability to perform any type of occupational task. The treatment records also show that in March 2017 he had full range of motion of all extremities and in September 2017 he had good range of motion of all joints. See July 2022 CAPRI. In an August 2017 VA treatment record, he had normal range of motion of the right knee. See February 2023 CAPRI. In a June 2018 VA treatment record, he was able to flex to 120 degrees and extend to 0 degree of the bilateral knee. See July 2022 CAPRI. In a September 2018 VA treatment record, he was prescribed a custom right knee brace for pain, weakness, and instability. See December 2023 CAPRI. A May 2019 magnetic resonance imaging (MRI) scan of the left knee revealed normal findings; and small joint effusion and baker cyst of the right knee. See December 2023 CAPRI. In a November 2020 private treatment record, he was able to flex to 95 degrees and extend to 0 degree of the right knee. As for his left knee, he was able to flex to 135 degrees and extend to 0 degree. There was significant tenderness and pain on the inside of the right knee, and he was positive for McMurray sign. His left knee had patellofemoral crepitation and minimal effusion. In a February 2021 private treatment record, he had good range of motion despite having tenderness and pain. See March 2022 Medical Treatment Record - Non-Government Facility. His joints were stable. A May 2021 private treatment shows that he had a full range of motion of the bilateral knees with popping. See March 2022 Medical Treatment Record - Non-Government Facility. His joint was stable. However, an x-ray scan of the knees showed patella shifting laterally on the bilateral knees. The Veteran stated that he felt unstable at times. In an October 2021 VA treatment record, the Veteran complained of his knees popping lately. See July 2022 CAPRI. In a March 2022 VA examination, the Veteran stated that he has constant aching in his bilateral knees. He feels like there is grinding under his kneecaps. He reports burning and occasional popping of the bilateral knees. He claimed that cold and rainy weather increases his pain. Due to his bilateral knee disability, he argued that he is unable to stand or walk for long periods of time. However, he denied having flare ups of the bilateral knees. He also denied having a history of instability or recurrent subluxation of the knee. He also denied having a history of frequent effusion of the knee. On examination of the right knee, he was able to flex to 50 degrees with evidence of pain on active and passive range of motion. On examination of the left knee, he was able to flex to 80 degrees with evidence of pain on active and passive range of motion. There was no objective evidence of crepitus of the bilateral knee. There was objective evidence of mild localized tenderness on palpation and hypermobility of the patella of the bilateral knee. He was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions of the bilateral knee. The Veteran was not examined immediately after repeated use over time. The examiner noted that pain would significantly limit his functional ability with repeated use over time of the bilateral knee. The examiner opined that during repeated use over time he can flex to 45 degrees and extend to 0 degree of the right knee. The examiner opined that during repeated use over time he can flex to 75 degrees and extend to 0 degree of the left knee. He endorsed having increased pain with prolonged standing and walking. There was no evidence of muscle atrophy of the bilateral knee. There was no ankylosis of the bilateral knee. There was no recurrent subluxation, persistent instability, ligament tear, recurrent patellar instability of the bilateral knee. He had normal findings on anterior instability, posterior instability, medial instability, and lateral instability test for the bilateral knee. He did not claim that he requires a prescription for a cane, walker, crutches, or braces for his bilateral knee disability. However, he stated that he uses a brace on a regular basis for patellar stabilization of his right knee. He did not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to his bilateral knee disability. He has never been diagnosed with meniscus (semilunar cartilage) condition. He has never had chronic exertional compartment syndrome of the bilateral lower extremities. The examiner noted that the Veteran claimed that he is unable to stand or walk for prolong period of time and is unable to climb, squat, or crawl repeatedly due to his bilateral knee disability. In a February 2021 private treatment record, a physician noted that a recent MRI scan showed chondromalacia around the patella but that all the major ligament structures and meniscus were intact with no tears. See March 2022 Medical Treatment Record - Non-Government Facility. In the March 2022 hearing, the Veteran stated that his condition is worse than as indicated in the March 2022 VA examination. He reported that he fell several times and that his knees would pop, and he would fall. In an April 2022 VA treatment record, he endorsed having a history of falls in the past three months. See July 2022 CAPRI. In an August 2022 VA examination, the Veteran stated that he has constant throbbing and aching in both knees. He claimed that he has popping in both knees. He stated that he has increased pain with increased physical activity, at the end of a day, and when the weather changes. He reported that he is unable to sit, stand, or walk for prolonged periods of time; squat or crawl for any amount of time; climb repeatedly; or run or perform high impact activities. He denied having a history of instability or recurrent subluxation of the knee, or frequent effusion of the knee. He denied having flare ups of the bilateral knees. On examination of the bilateral knee, he was able to flex to 70 degrees and extend to 0 degree with evidence of pain. There was no change on passive range of motion. There was evidence of pain on active motion and passive motion that could cause functional loss and decreased range of motion. There was objective evidence of crepitus of the bilateral knee. There was objective evidence of mild localized tenderness on palpation of the medial and lateral joint lines. He was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions of the bilateral knee. He was not examined immediately after repeated use over time. Pain would significantly limit his functional ability with repeated use over time. The examiner estimated that he would be able to flex to 65 degrees and extend to 0 degree after repeated use over time for the bilateral knees. He was not examined during a flare up. Pain, fatigability, weakness, lack of endurance, or incoordination would not significantly limit his functional ability with flare ups as the Veteran denied having flare ups. The examiner defined flare ups as intermittent and significant worsening requiring treatment or intervention such as narcotics, physical therapy, hospitalization, or physician prescribed bed rest. Although he reported that he has increase pain in his bilateral knees about twice a week, he did not seek medical attention. As such, this does not constitute as a flare up. There was no evidence of muscle atrophy of the bilateral knee. There was no ankylosis of the bilateral knee. He denied having recurrent subluxation, persistent instability, ligament tear, and/or recurrent patellar instability of the bilateral knee. He did not require a prescription of a cane, walker, crutches, or braces. However, he uses a brace on a regular basis on his right knee. He has never been diagnosed with meniscus (semilunar cartilage) condition. He had normal findings on anterior instability, posterior instability, medial instability, and lateral instability test for the bilateral knee. He has never had chronic exertional compartment syndrome of the bilateral lower extremities. In the November 2022 VA examination, the Veteran stated that he has daily aches and stiffness of his bilateral knees. He also claimed that he has flare ups on a weekly basis for one to two days. He would have throbbing pain and increased stiffness of his knees with flare ups. He denied having a history of instability or recurrent subluxation of the knee. On examination of the bilateral knee, on active range of motion, he was able to flex to 90 degrees and extend to 0 degree with evidence of pain. On passive range of motion, he was able to flex to 110 degrees and extend to 0 degree with evidence of pain. There was evidence of pain on weight bearing, active motion, and passive motion that causes functional loss. There was objective evidence of crepitus. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. He was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions of the bilateral knee. He was not examined immediately after repeated use over time. Pain, fatigability, and lack of endurance would significantly limit his functional ability with repeated use over time of the bilateral knee. The examiner estimated that he would be able to flex to 80 degrees and extend to 0 degree after repeated use over time of the bilateral knee. He was not examined during a flare up. Pain, fatigability, and lack of endurance would significantly limit his functional ability during flare ups of the bilateral knee. The examiner estimated that he would be able to flex to 80 degrees and extend to 0 degree during flare ups of the bilateral knee. There was no evidence of muscle atrophy of the bilateral knee. There was no ankylosis of the bilateral knee. He denied having recurrent subluxation, persistent instability, ligament tear, or recurrent patellar instability of the bilateral knee. He has never been diagnosed with meniscus (semilunar cartilage) condition. He was not prescribed a cane, walker, crutches, or braces for ambulation. However, he uses a brace for his bilateral knees. There was no other pertinent physical findings, complications, conditions, signs, or symptoms related to his bilateral knee disability. The examiner noted that his bilateral knee disability impacts his ability to work as he would have difficulty with prolonged walking or standing, difficulty walking on uneven surfaces, and difficulty with going up or down stairs. A June 2024 x-ray scan of the bilateral knees revealed normal findings, and no acute bony process was noted. See June 2024 CAPRI. Having reviewed the record evidence, the Board finds that the criteria for an initial rating greater than 10 percent for bilateral knee disability under the limitation of motion codes have not been met. On physical examination of the right knee, he was able to flex, at worst, 45 degrees and extend, at worst, to 0 degree. As for his left knee, he was able to flex, at worst, 65 degrees and extend, at worst, to 0 degree. These findings are consistent with no more than a 10 percent rating under Diagnostic Code 5260 and a noncompensable rating under Diagnostic Code 5261. They do not support assigning an initial rating greater than 10 percent under Diagnostic Code?5260 as a 20 percent rating requires limited flexion to 30 degrees. Under Diagnostic Code?5261, a compensable rating of 10 percent requires extension to 10 degrees. Because the Veteran was able to flex to 45 degrees of the right knee and 65 degrees of the left knee, the Board finds that the current 10 percent rating for bilateral knee disability adequately compensates him for the level of disability which he experiences. As for his claimed instability of the right knee, the Board finds the Veteran's instability of the right knee is consistent with a 10 percent rating prior to September 28, 2018 and 20 percent rating thereafter. The Board acknowledges that the Veteran had normal findings on joint stability testing (i.e., anterior instability, posterior instability, and medial-lateral instability testing) in the April 2013, May 2014, March 2017, March 2022, August 2022, and November 2022 VA examinations. Moreover, he denied having a history of recurrent patellar, or/and instability in the April 2013, May 2014, March 2022, August 2022, and November 2022 VA examinations. However, in the May 2014 VA examination, the Veteran stated that his knees would pop and give way at times. The Board has carefully considered the Veteran's reports about instability. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Under Diagnostic Code 5257 prior to the regulatory change, the Board finds that the Veteran's complaint of instability is consistent with slight recurrent lateral instability. Further, under Diagnostic Code 5257 after the regulatory change, his claimed instability of the right knee is consistent with a 10 percent rating as he did not have a prescribed assistive device or bracing for ambulation. He is not entitled to a higher rating of 20 percent as he did not have a prescribed assistive device or bracing for ambulation. From September 28, 2018, the Board finds that under Diagnostic Code 5257 after the regulatory change, his claimed instability of the right knee is consistent with a 20 percent rating as he received a custom right knee brace for pain, weakness, and instability. See December 2023 CAPRI. He is not entitled to a higher rating of 30 percent as he has no ligament tear, and he did not undergo a surgical repair. In fact, a 2021 MRI scan showed that all the major ligament structures and meniscus were intact with no tears. See March 2022 Medical Treatment Record - Non-Government Facility. The Board further finds that he is not entitled to a 30 percent rating based on previous Diagnostic Code 5257, as a finding of severe instability requires persistent and debilitating instability that is demonstrated by objective evidence on examination, which is not supported in the medical records as stated above. As for his claimed instability of the left knee, in the light most favorable to the Veteran, the Board finds that his instability of the left knee is consistent with no more than a 10 percent rating for the entire appeal period. The Board finds that he is not entitled to the next higher rating of 20 percent as the records do not indicate that he was prescribed a brace and/or assistive device. In fact, he did not use a knee brace for his left knee until November 2022. The Board further finds that a 20 percent rating for his claimed instability of the left knee is not warranted under the previous Diagnostic Code 5257 as the Veteran did not address the frequency, duration, or severity of his instability. Instead, the records show that he affirmatively denied having a history of recurrent patellar, or/and instability in the April 2013, May 2014, March 2022, August 2022, and November 2022 VA examinations. Moreover, there is no objective evidence of instability on examinations. Accordingly, the Board finds that his claimed instability of the left knee is consistent with no higher than a 10 percent rating for the entire appeal period. Regarding his claim of popping, the Board has considered whether the Veteran is entitled to a 20 percent rating under Diagnostic Code 5258. However, the records show that he is not diagnosed with semilunar cartilage and that he denied having a history of dislocation, swelling, and frequent effusion in the April 2013, May 2014, March 2022, August 2022, and November 2022 VA examination. Additionally, a 2021 MRI scan showed chondromalacia around the patella but that all the major ligament structures and meniscus were intact with no tears. See March 2022 Medical Treatment Record - Non-Government Facility. As the records do not support a finding of frequent episodes of effusion in the joints and as the Veteran affirmatively denied having these symptoms, the Board is unable to award the Veteran a 20 percent rating under Diagnostic Code 5258. The Board acknowledges the Veteran's argument that his bilateral knee disability should be considered for extraschedular rating. An extraschedular disability rating is warranted if the case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321 (b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms," which include marked interference with employment or frequent periods of hospitalization. Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). The Board concludes that the evidence in the Veteran's case does not present such an exceptional disability picture that the available schedular ratings for his service-connected bilateral knee disability are inadequate. In fact, the Veteran did not specifically claim how his bilateral knee disability presents an exceptional or unusual disability picture. Instead, he requested the maximum benefit allowed by law and regulation to include extraschedular rating. See April 2023 Appellate Brief. Based on the records, the Board finds that his bilateral knee disability does not present an exceptional and/or unusual symptoms and severity of his bilateral knee disability. The rating criteria contemplates loss of motion and instability of the knees. See 38 C.F.R. § 4.71a Diagnostic Codes 5256 to 5262. Thus, the first Thun criteria is not met. Moreover, the Veteran's bilateral knee disability does not present an exceptional disability picture with related factors such as marked interference with employment or frequent hospitalization. 38 C.F.R. § 3.321 (b)(1). Indeed, the Veteran consistently stated that he has not been hospitalized for this condition. Moreover, the records show that the Veteran is employed and works with Youth Challenge. See April 2023 CAPRI. In an October 2020 VA treatment record, he stated that he enjoys walking and working with young people. He also enjoys coaching youth football, and he tries to stay active in the day. Further, none of the VA examiners found that the Veteran's bilateral knee disability would prevent the Veteran from working. As the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321 (b)(1) is not met, referral of the claim for extra-schedular consideration is not required. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Christopher Seppanen Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, 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.