KNEE IMPAIRMENT OF

KRISTY L. ZADORA · 2026 · Case ID: 26004546

MIXED

Summary

The veteran, who served from April 1977 to April 1979 and December 1979 to February 1987, appeals the denial of increased disability ratings for left and right knee conditions. The veteran sought higher ratings for traumatic arthritis in both knees, including specific periods and functional limitations. The Board reviewed the evidence, including multiple VA examinations and the veteran's statements. For the left knee, the Board found the criteria for a rating higher than 10% for traumatic arthritis with limitation of extension prior to September 5, 2019, were not met. Similarly, the criteria for higher ratings for residuals of total left knee replacement during specific periods were not met. For the right knee, the Board denied entitlement to a rating higher than 10% for traumatic arthritis with limitation of extension. However, the Board granted a 10% rating for right knee traumatic arthritis with instability beginning March 17, 2022, finding the criteria for this specific rating were met. The Board's decision was based on its interpretation of the medical evidence and the criteria outlined in the VA Schedule for Rating Disabilities, particularly concerning the veteran's reported functional limitations and the specific diagnostic codes applicable to knee conditions.

Rationale

Criteria for rating in excess of 10% not met; Left knee traumatic arthritis with limitation of extension; Prior to September 5, 2019

Special Benefit

NO SPECIAL BENEFIT

Docket No.

16-54 591

Full Decision Text

Citation Nr: 26004546
Decision Date: 04/15/26 Archive Date: 04/15/26

DOCKET NO. 16-54 591
DATE: April 15, 2026

ORDER

Entitlement to a rating in excess of 10 percent for left knee traumatic arthritis with limitation of extension prior to September 5, 2019 is denied.

Entitlement to a rating in excess of 30 percent from September 5, 2019 to May 18, 2020; and from July 1, 2021 to March 17, 2022; and in excess of 60 percent thereafter for residuals of total left knee replacement is denied.

Entitlement to a rating in excess of 10 percent for right knee traumatic arthritis with limitation of extension is denied.

Entitlement to a compensable rating for right knee traumatic arthritis with limitation of flexion is denied.

Entitlement to a rating of 10 percent, but no higher, for right knee traumatic arthritis with instability beginning on March 17, 2022 is granted.

FINDINGS OF FACT

1. For the period on appeal prior to September 5, 2019, the Veteran's left knee traumatic arthritis has been manifested by flexion limited to 60 degrees and extension limited to 5 degrees at worst and with pain, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination; or as a result of repetitive motion and/or flare-ups without recurrent subluxation, ankylosis, the functional equivalent of ankylosis or genu recurvatum

2. For the appeal period from September 5, 2019 to May 18, 2020; and from July 1, 2021 to March 17, 2022, the Veteran's residuals of total left knee replacement manifested as intermediate degrees of residual weakness, pain, or limitation of motion.

3. For the appeal period from March 17, 2022, the Veteran's residuals of total left knee replacement manifested with severe pain without amputation.

4. Throughout the period on appeal, the Veteran's right knee traumatic arthritis manifested in limitation of extension to 4 degrees and limitation of flexion to 55 degrees, both at worst, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, incoordination, or as a result of repetitive motion and/or flare-ups without ankylosis, functional impairments equivalent of ankylosis, malunion or nonunion of the tibia and fibula or genu recurvatum.

5. For the appeal period beginning on March 17, 2022 the right knee traumatic arthritis with instability is shown to involve recurrent instability without history of surgical repair and does not require a prescription from a medical provider for assistive device.

CONCLUSIONS OF LAW

1. The criteria for a rating in excess of 10 percent for left knee traumatic arthritis with limitation of extension prior to September 5, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.27, 4.40, 4.59, 4.71a, Diagnostic Codes 5010, 5261.

2. The criteria for a rating in excess of 30 percent from September 5, 2019 to May 18, 2020; and from July 1, 2021 to March 17, 2022; and in excess of 60 percent thereafter for residuals of total knee replacement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.59, 4.68, 4.71a, Diagnostic Code 5055.

3. The criteria for a rating in excess of 10 percent for right knee traumatic arthritis with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.27, 4.40, 4.59, 4.71a, Diagnostic Codes 5010-5261.

4. The criteria for a compensable rating for right knee traumatic arthritis with limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.27, 4.40, 4.
traumatic arthritis with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.27, 4.40, 4.59, 4.71a, Diagnostic Codes 5010-5261.

5. The criteria for a rating of 10 percent, but no higher, for the right knee traumatic arthritis with instability for the appeal period beginning on March 17, 2022, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40, 4.59, 4.71a, Diagnostic Codes 5010, 5257.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from April 1977 to April 1979 and from December 1979 to February 1987.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a

November 2015 rating decision issued by a Department of Veterans Affairs (VA)

Agency of Original Jurisdiction (AOJ) continuing the 10 percent ratings for the

Veteran's left and right knee disabilities. Although the Veteran did not appeal that

decision, new and material evidence, in the form of the July 2016 VA examination report and the November 2015 and June 2016 statements of the Veteran, were

received within one year of the issuance of that decision. In response to this new

evidence, the AOJ issued the July 2016 rating decision which, in pertinent part,

granted the Veteran a non-compensable rating for traumatic arthritis, left knee,

limitation of flexion from November 30, 2015, continued the Veteran's right knee

traumatic arthritis with chondromalacia patella and sprain/strain at 10 percent, and

continued the Veteran's traumatic arthritis, left knee at 10 percent. This decision

was appealed in the July 2016 Notice of Disagreement (NOD) which led to the

appeal currently before the Board.

In November 2018, August 2021, June 2022, March 2023, and July 2024 the Board

remanded the appeal for further development. In these remand directives, the

Board directed the Agency of Original Jurisdiction (AOJ) to obtain updated VA treatment records, updated private treatment records, and adequate VA examinations and addendum opinions. Updated VA treatment records were obtained in August 2019, July 2020, and March 2022. Moreover, following the March 2023 Board remand, the AOJ completed a search for any outstanding VA treatment records and determined that no such additional records existed. See October 2023 Supplemental Statement of the Case. In addition, all private treatment records identified by the Veteran have been obtained. See September 2021 Private Treatment Records; May 2023 Private Treatment Records.

Following the November 2018, August 2021, and June 2022 Board remands, the

Board requested additional VA examinations and opinions. VA examinations and

addendum opinions where obtained in September 2019, February 2022,

March 2022, December 2022, January 2023. Unfortunately, the January 2023

addendum opinion does not comply with prior remand directives. Specifically, in

June 2022, the Board requested retrospective estimates of the Veteran's bilateral

knee functional impairment on repetitive use and during flare-ups. In the remand

directives, the Board noted that if the examiner could not provide this estimate

without speculation, he or she should indicate the reason why (e.g. deficiency in

the record, deficiency in state of general medical knowledge, deficiency in

personal training or experience). The Board then specifically stated "[t]he examiner may not rely solely upon his or her inability to personally observe the Veteran during a period of flare-up or following repeated use over time."

directives, the Board noted that if the examiner could not provide this estimate

without speculation, he or she should indicate the reason why (e.g. deficiency in

the record, deficiency in state of general medical knowledge, deficiency in

In the July 2024 remand, the Board noted that in a January 2023 addendum opinion, a VA examiner offered repetitive use and flare estimates for the September 2019, March 2022 and October 2022 VA examination reports as requested. Regarding the July 2016 VA examination report, the examiner offered a repetitive use over time estimate for the knees but did not estimate loss of motion during a flare-up, noting "I cannot opine since I was not there to examine the Veteran in 2016 and would have no idea what his R[ange]O[f]M[otion] with flares would have been." The Board indicated that this statement is in direct conflict with its remand instructions, requiring another remand.

In February 2025, a VA retrospective opinion that addresses estimated range of motion with flares for the July 2016 examination report was obtain. The Board therefore determines that there has been substantial compliance with its previous remand.

Increased Rating Criteria

Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3.

Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). VA's determination of the present level of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased-rating claim has been pending. Hart v. Nicholson, 21 Vet. App. 505, 509 (2007); Fenderson v. West, 12 Vet. App. 119 (1999).

The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016).

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4
.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[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 [or 4.73] criteria.").]

Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011).

The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after February 7, 2021. Claims pending prior to the effective date will be considered under both former and revised rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal.

VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the Veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change.

VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021, and both the former and revised rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied.

Finally, the Board has considered whether an inferred claim for a total disability based upon individual unemployability (TDIU) has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran reported that he was a retired high school teacher. The Veteran has not reported, and the record does not suggest, that his right knee disorder and/or left knee disorder prevented him from securing or following substantially gainful employment. As such, the Board finds that a claim for a TDIU is not raised in connection with the instant appeals. See Rice v. Shinseki, supra.

from February 7, 2021. The criteria that is more favorable to the Veteran will be applied.

The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

1. Entitlement to a rating in excess of 10 percent for left knee traumatic arthritis with limitation of extension prior to September 5, 2019 is denied.

2. Entitlement to a rating in excess of 30 percent from September 5, 2019 to May 18, 2020; and from July 1, 2021 to March 17, 2022; and in excess of 60 percent thereafter for residuals of total left knee replacement is denied.

3. Entitlement to a rating in excess of 10 percent for right knee traumatic arthritis with limitation of extension is denied.

4. Entitlement to a compensable rating for right knee traumatic arthritis with limitation of flexion is denied.

5. Entitlement to a rating of 10 percent, but no higher, for right knee traumatic arthritis with instability beginning on March 17, 2022 is granted.

The Veteran generally contends that his left knee and right knee disorders are worse than contemplated by the currently assigned ratings. See March 2022 statement in support of claim; October 2016 Form 9 and July 2016 notice of disagreement. He reports that he experiences marked swelling and pain post operative with painful scars and flareups, swelling and instability.

This appeal stems from a July 2015 claim for increase ratings for the service connected knee disabilities. The Veteran's left knee traumatic arthritis with limitation of extension has been rated as 10 percent disabling from 1998 to September 5, 2019 under Diagnostic Code 5010-5261; residuals of left total knee replacement as 30 percent disabling from September 5, 2019 to May 18, 2020 and from July 1, 2021 to March 17, 2022 under Diagnostic Code 5055 and 60 percent disabling since March 17, 2022 under Diagnostic Code 5055. The right knee traumatic arthritis with limitation of extension has been rated as 10 percent disabling from 1998 under Diagnostic Code 5010-5261, and non-compensable (zero) percent disabling for limitation of flexion from March 17, 2022 under Diagnostic Code 5010-5260.

Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The hyphenated diagnostic code in this case indicates that the service connected disability of degenerative arthritis (Diagnostic Code 5010) is rated based on analogy to limitation of flexion of the knee (Diagnostic Code 5260) as well as limitation of extension of the knee (Diagnostic Code 5261).

Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63, 603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56, 703 (1998); VA
as limitation of extension of the knee (Diagnostic Code 5261).

Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63, 603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56, 703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59, 988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017).

Under Diagnostic Code 5010, it is directed that the disability (arthritis due to trauma) be rated as degenerative arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010.

Under Diagnostic Code 5003, 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. 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 such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.

Under Diagnostic Code 5055, a 100 percent rating is warranted for the one year following implantation of the prosthesis; a 60 percent rating is warranted for a total knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity; and a 30 percent rating is the minimum possible rating assignable. Intermediate degrees of residual weakness, pain, or limitation of motion (i.e. a level of disability in between those contemplated by the 30 and 60 percent ratings) are to be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055.

The revised Diagnostic Code 5055 was amended to include resurfacing of the knee. Under the revised Diagnostic Code 5055, the time period for the assignment of the 100 percent rating following implantation of the prosthesis or resurfacing is limited to 4 months. The revised Diagnostic Code 5055 also specifies that the rating criteria for residuals only apply to prosthetic replacement of the knee joint, and that the minimum rating of 30 percent only applies to a total replacement, not resurfacing. Resurfacing is to be evaluated under diagnostic codes 5256 through 5262 at the conclusion of the 100 percent evaluation period. As the period on appeal is after February 7, 2021, such revisions are applicable.

Of note, a schedular rating greater than 60 percent is prohibited by the "amputation rule," found in 38 C.F.R. § 4.68, which prohibits the assignment of a combined rating for disabilities of an extremity higher than the rating for the amputation at the elective level, were amputation to be performed. Amputation at the elective level would be at thigh level, middle or lower thirds. Amputation at that level warrants only a 60 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5165. As such, the Veteran cannot receive a higher rating for his total left knee arthroplasty than for an amputated leg. Accordingly, a schedular rating in excess of 60 percent for the Veteran's service-connected total left knee arthroplasty is not warranted. The appropriate diagnostic codes for disabilities of the knee are rated under Diagnostic Codes 5256 to 5263. 38 C.F.R. § 4.71a.

Under Diagnostic Code 5257, recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257.

Under Diagnostic Code 5258, when the knee disability affects the meniscus, a 20 percent rating is warranted when there is dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint
throplasty is not warranted. The appropriate diagnostic codes for disabilities of the knee are rated under Diagnostic Codes 5256 to 5263. 38 C.F.R. § 4.71a.

Under Diagnostic Code 5259, a 10 percent rating is warranted when there has been removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Code 5259.

Under Diagnostic Code 5260, flexion of the knee limited to 15 degrees warrants a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a zero percent (noncompensable) rating. 38 C.F.R. § 4.71a, Diagnostic Code 5259.

Under Diagnostic Code 5261, extension of the knee limited to 45 degrees warrants a 50 percent rating; extension limited to 30 degrees warrants a 40 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to15 degrees warrants a 20 percent rating; extension limited to 10 degrees warrants a 10 percent rating; and extension limited to 5 degrees warrants a zero percent (noncompensable) rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261.

Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege, that he has tibia or fibula impairment, genu recurvatum, or ankylosis of either knee. As such, those diagnostic codes are not for application.

The normal range of motion of the knee is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II.

The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). In the present case, the Veteran's claim for increased ratings stem from a claim filed in July 2015 and there is relevant evidence related to the knee dated after February 7, 2021. Diagnostic Codes 5260 and 5261 are unchanged under the revised criteria. While Diagnostic Code 5257 for recurrent subluxation and lateral instability as well Diagnostic Code 5262 for impairment of the tibia and fibula were revised. Further, Diagnostic Code 5010 was amended to the disability (post-traumatic arthritis) be rated as limitation of motion, dislocation, or other specified instability under the affected joint. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2021). If there are 2 or more joints affected, each rating is to be combined in accordance with 38 C.F.R. § 4.25. As the February 2021 musculoskeletal criteria applies to aspects of the Veteran's claims on appeal the appropriate criteria are discussed below.

As of February 7, 2021, under the amended criteria, Diagnostic Code 5257 evaluates knee, other impairment of, which may be rated under separate criteria for recurrent subluxation or instability or, alternatively, patellar instability. Under the amended criteria for rating 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 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 warrants a 20 percent rating. A maximum 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.

Diagnostic Code 5257, Note (1), as amended, defines the patellofemoral complex as consisting of the quadriceps tendon, the patella, and the patellar tendon. Note (2) instructs that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration).

At the outset, a January 2023 rating decision granted service connection for painful residual surgical scars of bilateral knees is with a rating of 30 percent effective October 27, 2022. The Veteran has not appealed the rating. As such, these issues will not be further addressed in the decision below.

Turning to the evidence of record, in an October 2015 VA examination the Veteran complained of worsening bilateral knee pain with popping while walking. No treatment other than pain medications. He reports he works as a full time science teacher requiring prolonged standing and lot of walking. He says he is on his feet almost six to eight hours, however he continues working. The Veteran denies flare-ups. Range of motion reveals right knee flexion to 100 degrees and extension was 0 degrees. The left knee was not tested as the Veteran complained of excruciating pain on slightest touch to the knee and on attempt to flex knee passively. The examiner noted that the Veteran could perform repetitive use testing with at least three repetitions with no additional functional loss for the right knee. The left knee was not tested. Muscle strength reveals 5/5 bilaterally. No reduction in muscle strength, no muscle atrophy, or no ankylosis in either knee. Moderate left knee instability was noted; however, unable to test due to pain. No tibia or fibula condition or meniscus condition.

During July 2016 VA examination, the Veteran reports his knees are getting worse, the left worse than the right. They hurt when he stands or sits for prolonged periods of time, the left knee catches sometimes, flare-ups when walking every day which last an hour or more. He reports functional impairment in that he is limited for bending, stooping, lifting, distance walking. Range of motion reveals right knee flexion was 100 degrees and extension is 0 degrees without pain on weight bearing. Left knee range of motion reveals flexion to 80 degrees and extension is 0 degrees with pain on weight bearing. The examiner noted that the Veteran could perform repetitive use testing with at least three repetitions with no additional functional loss for the right knee. The left knee revealed 60 degrees of flexion and 0 degrees of extension after three repetitions. No ankylosis, recurrent subluxation, or lateral instability of either knee on examination. The examiner noted a history of recurrent effusion. More specifically, the examiner indicated that the left knee swells after an hour of nonstop standing or walking. The knee disorders impacts the Veteran's ability to work in that he is limited for bending and stooping and lifting with the knees. He is limited for distance walking; he walks his dog about a quarter mile and then goes back in due to knee pain. He experiences pain after several minutes of sitting and stands on the right knee. The Veteran is estimated to be mildly impaired for seated sedentary work and moderately to severely impaired for prolonged standing and severely impaired for other physical work.

During September 2019 VA examination, the Veteran reports
ation, or lateral instability of either knee on examination. The examiner noted a history of recurrent effusion. More specifically, the examiner indicated that the left knee swells after an hour of nonstop standing or walking. The knee disorders impacts the Veteran's ability to work in that he is limited for bending and stooping and lifting with the knees. He is limited for distance walking; he walks his dog about a quarter mile and then goes back in due to knee pain. He experiences pain after several minutes of sitting and stands on the right knee. The Veteran is estimated to be mildly impaired for seated sedentary work and moderately to severely impaired for prolonged standing and severely impaired for other physical work.

During September 2019 VA examination, the Veteran reports daily pain, stiffness, and swelling in left knee, limited walking, standing, kneeling, and squatting. Range of motion reveals right knee flexion was 90 degrees and extension is 0 degrees with pain with weight bearing. Left knee range of motion reveals flexion to 80 degrees and extension is 20 degrees with pain on weight bearing. The examiner noted that the Veteran could perform repetitive use testing with at least three repetitions with no additional functional loss for either knee. Relevant to flare-ups there was no loss in the right knee; the left knee reveals pain loss with flare-up but no range of motion was provided. Muscle strength reveals 5/5 right knee and 4/5 in the left knee. No reduction in muscle strength in the right knee; however, decreased reduction noted in the left knee. No muscle atrophy noted in the right knee; however, atrophy noted in the left knee. No ankylosis in either knee. In regards to meniscal conditions, there is no symptomatology in the right knee; however, the left knee reveals frequent episodes of locking, pain, and effusion.

In a February 2022 clarification opinion for the right knee, as pursuant to the August 2021 Board remand, the examiner indicated that since the September 2019 VA examination, the Veteran has undergone a left total knee replacement which would lessen the stresses on his right knee. The examiner indicates that Dr. S. saw the Veteran several times before and several times after surgery. There was no right knee edema, no warmth, and no tenderness. As per the most recent November 2020 examination by Dr. S., notes the Veteran had no limitation of range of motion and denied pain. He walked with a normal gait. There was no mention of any flare-ups or limitations in his activity. Examination of the right knee in May 2020 revealed range of motion 0 to 135, no evidence of effusion, normal strength, no evidence of instability, and no limp. X-rays of the right knee have revealed no evidence of effusion, and mild to moderate osteoarthritis. The examiner noted that the September 2019 VA examination reveals the range of motion was noted to be 0 to 90. In the July 2016 VA examination, the range of motion was noted to be 0 to 110. In the October 2015 VA examination, the range of motion was noted to be 0 to 100. The examiner opines, there are no longer any functional impairments of the Veteran's right knee disabilities due to flare-ups, or accounting for pain, and in fact, the disabilities which were present before the knee replacement appear to be no longer present as earlier his right knee range of motion was measured at no better than 0 to 110 whereas now it is 0 to 135, normal values.

During March 2022 VA examination, diagnoses include bilateral knee instability. Other documented diagnoses include right knee traumatic arthritis with chondromalacia patella and sprain/strain; also left knee meniscal tear and anterior cruciate ligament tear and traumatic arthritis. The Veteran reports current symptoms of pain, constant ache, instability in both knees. Right knee sharp pain and difficulty bending the joint, sitting and walking for long periods of time. He experiences bilateral knee flare-up sharp pain and difficulty bending, occurs twice a week lasting up to two hours resulting in sharp pain and difficulty bending. Range of motion reveals right knee flexion was 60 degrees and extension is zero degrees. Left knee range of motion reveals flexion to 90 degrees and extension is 0 degrees. Passive range of motion was the same as active range of motion in both knees. Pain noted on active, passive, weight, non-weight resulting in decreased range of motion in both knees. The examiner noted that the Veteran could perform repetitive use testing with at least three repetitions. Range of motion studies revealed right knee flexion was 55 degrees of flexion and 0 degrees of extension; and left knee flexion was 85 degrees and extension 0 degrees. No change in estimated range of motion studies for both repeated use over time and flare-ups. In
bending. Range of motion reveals right knee flexion was 60 degrees and extension is zero degrees. Left knee range of motion reveals flexion to 90 degrees and extension is 0 degrees. Passive range of motion was the same as active range of motion in both knees. Pain noted on active, passive, weight, non-weight resulting in decreased range of motion in both knees. The examiner noted that the Veteran could perform repetitive use testing with at least three repetitions. Range of motion studies revealed right knee flexion was 55 degrees of flexion and 0 degrees of extension; and left knee flexion was 85 degrees and extension 0 degrees. No change in estimated range of motion studies for both repeated use over time and flare-ups. In regards to joint stability, right knee reveals recurrent sublux or instability; ligament tear repair failed; left knee reveals ligament tear incomplete also notes cane use for left knee. Symptoms of meniscus reveals meniscal tear with frequent episodes of joint locking, pain, and effusion in the left knee and meniscal tear with frequent episodes of joint locking, and pain in the right knee. Left knee is status post total knee joint replacement with chronic residuals consisting of severe painful motion or weakness.

During December 2022 VA examination, the Veteran reports right knee pain is located inside patella, pain is constant, aching, pain is 4-8/10. Pain is worse with kneeling/squatting and walking for long periods for long periods. Lessened with rest and Ibuprofen. Left knee pain is located in posterior knee, pain is constant, aching, pain is 5-10/10. Pain is worse with kneeling/squatting and walking for long periods for long periods. Lessened with rest and Ibuprofen. Bilateral knee frequent effusions 2 to 3 times weekly with a duration of 8 hours, the effusions are mild. The Veteran reports frequent flare-ups in the right knee about 2 to 3 times per day lasting about 30 to 60 minutes with severity of 9/10; and in the left knee about 2 to 3 times per week lasting about 1 to 2 hours with a severity of 10/10. He reports difficulty with walking, sitting, standing for short periods of time. Range of motion reveals right knee flexion to 95 degrees and extension to 3 degrees with pain on both flexion and extension; as well as weight bearing, non-weight bearing, active motion and passive motion. Left knee range of motion reveals flexion to 110 degrees and extension to 3 degrees with pain on both flexion and extension; as well as weight bearing, non-weight bearing, active motion and passive motion. Passive range of motion is the same as active range of motion in both knees. Repeated use over time reveals estimated right knee flexion is 90 degrees and extension is 4 degrees; and left knee flexion is 105 degrees; extension is 4 degrees. Estimated range of motion during flare-ups reveal right knee flexion is 90 degrees and extension is 5 degrees; left knee flexion is 100 degrees and extension is 5 degrees. The Veteran experiences locking, joint pain, effusion for bilateral meniscal conditions.

In a January 2023 retrospective opinion, the examiner provided estimated range of motion for the bilateral knees for repetitive use over time and flare-ups. In regards to the July 2016 VA examination, active range of motion right knee flexion 110 degrees; extension 0 degrees; left knee flexion 80 degrees and extension 0 degrees; passive range of motion the same as active range of motion; repetitive use over time right knee flexion is 110 degrees and extension is 0 degrees; left knee flexion is 60 degrees and extension is 0 degrees. Did not provide estimated range of motion for flare-ups for either knee. September 2019 VA examination reveals estimated range of motion for repetitive use over time for right knee is flexion to 85 degrees and extension to 0 degrees; left knee flexion is to 80 degrees and extension is to 20 degrees. Flare-ups is right flexion to 80 degrees and extension to 0 degrees; left knee flexion is 75 degrees and extension is 20 degrees.

In a November 2024 retrospective opinion, the examiner estimates that the Veteran's loss of bilateral knee motion during flare-ups as reflected in the July 2016 VA examination report that right knee is 85 degrees of flexion and 5 degrees of extension; and left knee flare up would be 100 degrees of flexion and 5 degrees of extension.

Further review of the record shows that the Veteran receives VA treatment and private treatment for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported knee symptoms or range of motion measurements that are worse than those noted
flexion to 80 degrees and extension to 0 degrees; left knee flexion is 75 degrees and extension is 20 degrees.

With regards to the Veteran's left knee traumatic arthritis for the appeal period prior to September 5, 2019, the Board finds that a rating in excess of 10 percent is not warranted under Diagnostic Codes 5010 and 5261. The July 2016 VA examination demonstrated left knee extension to zero degrees at its worst, even in contemplation of a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements. In this regard, there is no evidence that the Veteran experienced extension limited to 15 degrees during this period to warrant a 20 percent rating. Therefore, the Board finds that such factors do not result in functional loss more nearly approximating extension limited to 15 degrees in the left knee. See DeLuca v. Brown, supra; Mitchell v. Shinseki, supra.

Pursuant to VAOPGCPREC 9-04, the Board has considered whether the Veteran is entitled to a separate rating for limitation of flexion. Under Diagnostic Code 5260, a 20 percent rating is warranted for limitation of extension of the leg to 30 degrees. The evidence does not show that the Veteran's left knee traumatic arthritis was limited to 30 degrees even in contemplation of a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements. At its worst, during pain, the Veteran's flexion was limited to 60 degrees. Therefore, a higher rating of 20 percent is not warranted for limitation of flexion.

While the Veteran has essentially stated that he has reduced motion in his left knee, he has not described a range of motion less than that found of record. In this regard, he reported that he experienced pain and tenderness. The Veteran's statements do not show the requisite limitation of motion necessary for higher or additional separate ratings. Treatment records do not show greater limitations of motion than the above examination findings. Given the above, even when considering the impact of the Veteran's knee pain on physical activities, higher or separate ratings are not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260.

With regards to the Veteran's left knee traumatic arthritis for the appeal period from September 5, 2019 to May 18, 2020; and from July 1, 2021 to March 17, 2022, the Board finds that a rating in excess of 30 percent is not warranted under Diagnostic Code 5055. The September 2019 VA examination does not show that the Veteran had chronic residuals of severe pain and weakness or that the symptoms manifested to the degree of a prosthetic replacement to warrant a 60 percent rating. Further, a November 2020 post-operative treatment record for the left knee documents mild to moderate symptoms in the left knee. Therefore, a higher rating of 60 percent is not warranted for his left knee replacement warranted for this time period.

With regards to the Veteran's left knee traumatic arthritis, the Board finds that a rating in excess of 60 percent is not warranted, under Diagnostic Code 5055 for the appeal period beginning on March 17, 2022. The March 2022 and December 2022 VA examinations indicates chronic residuals consisting of severe painful motion or weakness after his left knee replacement surgery. The evidence does not show that the Veteran had additional replacement surgery after March 17, 2022, to warrant a 100 percent rating for convalescence after surgery.

The Board notes that a rating in excess of 60 percent for residuals of left knee status post arthroplasty cannot be awarded due to the amputation rule. The amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. 38 C.F.R. § 4.68. Amputations of the lower extremity are rated under 38 C.F.R. § 4
consisting of severe painful motion or weakness after his left knee replacement surgery. The evidence does not show that the Veteran had additional replacement surgery after March 17, 2022, to warrant a 100 percent rating for convalescence after surgery.

The Board notes that a rating in excess of 60 percent for residuals of left knee status post arthroplasty cannot be awarded due to the amputation rule. The amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. 38 C.F.R. § 4.68. Amputations of the lower extremity are rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5160-5173. Diagnostic Code 5163 allows for a 60 percent rating for amputation of the leg with a defective stump and thigh amputation recommended. Diagnostic Code 5164 allows for a 60 percent rating for amputation of the leg not improvable by prosthesis controlled by natural knee action. For a rating higher than 60 percent, there must be amputation up to the upper third of the thigh. 38 C.F.R. § 4.71a, Diagnostic Code 5161.

The 60 percent rating for the period on appeal represents the maximum schedular rating available for all other applicable knee and leg codes under 38 C.F.R. § 4.71a. The knee and leg regulations do not provide for a rating in excess of 60 percent. Accordingly, a rating in excess of 60 percent for the residuals of left knee status post arthroplasty is not warranted. In reaching this conclusion, the Board observes that higher ratings are warranted under Diagnostic Codes 5160 and 5161 for amputation of the upper third of the thigh or amputation of thigh with disarticulation and loss of extrinsic pelvic girdle muscles. 38 C.F.R. § 4.68. However, at no time during the course of the appeal has the Veteran's left knee resulted in symptoms analogous to such amputation. Therefore, any further award is not permitted as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

In regards to right knee traumatic arthritis with limitation of extension and limitation of flexion, the Board finds that a rating in excess of 10 percent is not warranted under Diagnostic Code 5261 and a compensable rating is not warranted under Diagnostic Code 5260. The medical evidence demonstrated limitation of extension to 4 degrees and limitation of flexion to 55 degrees at its worst, even in contemplation of a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran's lay statements. In this regard, there is no evidence that the Veteran experienced extension limited to 15 degrees during this period or limited flexion to 30 degrees to warrant a 20 percent rating. Therefore, the Board finds that such factors do not result in functional loss more nearly approximating flexion limited to 30 degrees or extension limited to 15 degrees in the right knee. See DeLuca v. Brown, supra; Mitchell v. Shinseki, supra.

The Board finds that a rating of 10 percent for right knee traumatic arthritis with instability is warranted for the appeal period beginning on March 17, 2022 under Diagnostic Code 5257. In this regard, the March 2022 VA examiner noted that the Veteran experienced right knee recurrent subluxation, although a cane was shown to be prescribed for the left knee, the Board finds reasonable that the cane is used for instability for knee disorder. Nevertheless, for a 10 percent rating to be warranted, the use of an assistive device prescribed by a medical provider does not need to be shown. However, the Board notes that a higher rating is not warranted as the Veteran had not undergone any prior surgical repairs to his right knee during the appeal period. Therefore, a separate 10 percent rating for right knee traumatic arthritis with instability is warranted.

The Board has also considered whether any additional higher or separate ratings are warranted under alternative diagnostic codes for either knee. However, the clinical evidence does not establish, and the Veteran has not alleged ankylosis, functional impairment consistent with ankylosis, subluxation, instability in the left knee, a meniscus condition, a meniscotomy, malunion and nonunion of the tibia or fibula, or genu recurvatum. Although the VA examinations suggests instability, objective evidence of instability was not found on examination prior to the total left knee replacement. The Board observes VA reports document meniscus condition with symptoms of pain and effusion into the joint. The Board notes that the current ratings encompass these symptoms for the appeal
.

Here, the Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the United States Court of Appeals for Veterans Claims (Court) holdings in Correia and Sharp. See Correia v. McDonald, supra and Sharp v. Shulkin 29 Vet. App. 26, 33 (2017). The Board notes that the Veteran is service connected for both the right knee and left knee; hence, there is no uninjured joint to test. The Board notes that the July 2016 VA examination was conducted prior to these holdings and therefore contain only partial information. Collectively, the September 2019, March 2022, December 2022 VA examinations as well as January 2023 and November 2024 retrospective opinions measured active and passive range of motion and range of motion on repetitive use testing as well as range of motion on weight-bearing and non-weight bearing; the effects of pain on range of motion is described above. Estimated range of motion was provided for repeated use over time as well as during flare-ups. Therefore, the VA examinations are adequate for adjudication purposes.

The Board notes that Diagnostic Codes 5260, 5261 and 5055 does not contemplate the use of medication. The Board is cognizant of the recent Court decision in Ingram v. Collins, in which the Court reaffirmed prior holdings that in rating disabilities, the Board must discount the beneficial effects of medication when the relevant rating criteria do not contemplate medication use. Ingram v. Collins, 38 Vet. App. 130 (2025); see also Jones v. Shinseki, 26 Vet. App. 56 (2012); McCarroll v. McDonald, 28 Vet. App. 267 (2016). Here, the Veteran reported that he used Ibuprofen to treat his knee disorders. However, the Veteran did not report that the use of any medication ameliorated his symptoms in any way, and the Board has thus discounted the ameliorative effects of medication in reaching its determination in this case.

The Board acknowledges the Veteran's belief that his right and left knee disorders are more severe than the current rating reflects. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board also acknowledges that the Veteran's VA treatment records note complaints of and treatment for his right and left knee disorders. However, these records do not address the specific rating criteria necessary to determine an increase in severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment.

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The Board has considered whether a staged rating under Hart v. Mansfield, supra, is warranted, and confirms that the Veteran's symptomatology is consistent with each rating throughout each appeal period. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017).

Accordingly, the Board finds that a rating of 10 percent, but no higher, for right knee traumatic arthritis with instability is warranted for the appeal period beginning on March 17, 2022. To that extent, the appeal is granted. The Board finds that ratings in excess of 10 percent for left knee traumatic arthritis with limitation of extension prior to September 5, 2019; in excess of 30 percent from September 5, 2019 to May 18, 2020 and from July 1, 2021 to March 17, 2022; and in excess of 60 percent thereafter for residuals of total left knee replacement is not warranted. In addition, the Board finds that a rating in excess of 10 percent for right knee traumatic arthritis with limitation of extension and a compensable rating for right knee traumatic arthritis with limitation of flexion are not warranted at any time. To that extent, the appeals are denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, supra.

KRISTY L. ZADORA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board M. McPhaull, 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.

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