Citation Nr: 1753521 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 09-37 422 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for the right knee. 2. Entitlement to an additional evaluation in excess of 20 percent from June 6, 2016 for instability of the right knee. 3. Entitlement to an evaluation in excess of 10 percent from June 6, 2016 for the left knee. 4. Entitlement to an additional evaluation in excess of 10 percent prior to June 6, 2016, and in excess of 20 percent thereafter, for instability of the left knee. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Associate Counsel INTRODUCTION The Veteran had active duty service in the U.S. Army from November 1986 to November 1989. This matter initially came before the Board of Veteran's Appeals (Board) on appeal from an October 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In May 2013 and March 2016, the Board remanded the appeal for additional development and an August 2016 rating decision granted partial increased ratings. In March 2017, the Board again remanded the appeal for additional development. It is once again before the Board. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this appellant's case should take into account the existence of these electronic records. FINDINGS OF FACT 1. Throughout the entire appeal period, the Veteran's left and right knee disabilities have each more nearly approximated extension limited to 10 degrees but not extension limited to 15 degrees or flexion limited to 45 degrees. 2. From June 9, 2008 through June 5, 2016, the Veteran's left and right knee disabilities each more nearly approximated slight lateral instability but not moderate lateral instability or recurrent subluxation. 3. From June 6, 2016, the Veteran's left and right knee disabilities each more nearly approximated moderate lateral instability but not severe lateral instability or recurrent subluxation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent based on limitation of motion of the right knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260, 5261 (2017). 2. The criteria for a separate 10 percent rating, but no higher, from June 9, 2008 through June 5, 2016, for right knee instability have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257 (2017). 3. The criteria for a rating in excess of 20 percent from June 6, 2016 for right knee instability have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257. 4. The criteria for a 10 percent rating, but no higher, from June 9, 2008 through June 5, 2016, based on limited extension of the left knee have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5261. 5. The criteria for a rating in excess of 10 percent from June 6, 2016, based on limitation of motion of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260, 5261. 6. The criteria for a rating in excess of 10 percent prior to June 6, 2016, and in excess of 20 percent thereafter, for instability of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. In June 2008, VA notified the Veteran of the information and evidence needed to substantiate her claims, to include notice of what part of that evidence is to be provided by the claimant, and notice of what part VA will attempt to obtain. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. In May 2013, the appeal was remanded for a Board hearing, the request for which the Veteran subsequently withdrew. In March 2016, the Board remanded the appeal for outstanding records and a current VA examination and in March 2017, the Board remanded the appeal for additional outstanding records and another VA examination which addressed the factors outlined in 38 C.F.R. § 4.59 and Correia v. McDonald, 28 Vet. App. 158 (2016). Pursuant to these remands, outstanding records were obtained and VA examinations were obtained in June 2016 and April 2017, as discussed in further detail below, the most recent examination complied with the factors outlined in 38 C.F.R. § 4.59 and Correia to the extent feasible. As such, the Board finds that additional examinations are not warranted and that there has been substantial compliance with the prior remands. Stegall v. West, 11 Vet. App. 268 (1998). Legal Principles and Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2017). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. By way of background, prior to the Veteran's June 2008 claim for an increased rating which gave rise to the present appeal, each knee was evaluated as 10 percent disabling for chondromalacia under Diagnostic Codes 5299-5262. 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 (2017). In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. The use of the "99" series and a hyphenated diagnostic code reflects that there is no specific diagnostic code applicable to chondromalacia, and it must be rated by analogy. 38 C.F.R. § 4.20 (2017). The narrative portion of an August 2002 rating decision reflects that the 10 percent ratings were assigned for chondromalacia in each knee which were manifested by painful motion with grinding and crepitus. Each knee was rated by analogy to Diagnostic Code 5262, applicable to impairment of the tibia and fibula. Following the Veteran's June 2008 claim for an increased rating, the October 2008 rating decision denied ratings in excess of 10 percent for each knee; however, the codesheet reflects that diagnostic codes were changed. In this regard, the right knee was now rated under Diagnostic Codes 5003-5262, therefore indicating that degenerative arthritis of the knee under Diagnostic Code 5003 was the service-connected disability and that impairment of the tibia and fibula under Diagnostic Code 5262 was the residual disability. The evaluation of the left knee was changed to Diagnostic Codes 5003-5257, therefore indicating that degenerative arthritis of the knee under Diagnostic Code 5003 was the service-connected disability and the residual disability was recurrent subluxation or lateral instability of the left knee. Thereafter, the August 2016 rating decision continued the 10 percent rating for the right knee but changed the diagnostic code again; this time to Diagnostic Codes 5003-5261, therefore indicating that the residual disability is limitation of extension. The rating decision also granted a separate 20 percent rating for right knee instability under Diagnostic Codes 5003-5257. As to the left knee, the rating decision increased the evaluation of left knee instability to 20 percent from June 6, 2016. It also granted a separate 10 percent rating for limitation of extension of the left knee under Diagnostic Code 5261, effective June 6, 2016. As noted above, Diagnostic Codes 5260 and 5261 pertain to limitation of knee motion. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. In this regard, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A limitation of leg flexion allows for a 10 percent evaluation when it is limited to 45 degrees, and a 20 percent evaluation when flexion is limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A limitation of leg extension is assigned a 10 percent evaluation when it is limited to 10 degrees, and a 20 percent evaluation when extension is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings for knee disabilities may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. Under Diagnostic Code 5259, a 10 percent rating can be assigned for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent evaluation can be assigned for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. Id. A veteran may also receive a separate evaluation for recurrent subluxation or lateral instability under Diagnostic Code 5257, which can be rated as slight (10 percent), moderate (20 percent) or severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. Evaluations for knee impairment can also be assigned due to ankylosis or genu recurvatum, but as the Veteran has not at any time been found to have ankylosis or genu recurvatum, these diagnostic codes are not applicable. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5263 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.40, 4.45. In DeLuca, it was held that when the pertinent diagnostic criteria provide for a rating on the basis of loss of range of motion, determinations regarding functional losses are to be "'portray[ed]' (38 C.F.R. § 4.40) in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups." Id. at 206. The evidence in this case shows that in a June 2008 correspondence, the Veteran reported pain and swelling in her knees. At a June 2008 VA examination, the Veteran reported that her knees had progressively worsened since she injured them while on active duty. She reported bilateral giving way, instability, pain, stiffness, weakness, locking one to three times per month, effusion once, as well as severe flare-ups occurring weekly for hours which resulted in decreased ability to ambulate. There was no deformity, dislocation, or subluxation. The right knee exhibited 30 degrees of flexion, with pain beginning at the same, to include in passive range of motion, and against strong resistance; after repetitions, there was 25 degrees of flexion. The right knee exhibited extension limited to 10 degrees, with pain beginning at the same, to include in passive range of motion, against strong resistance and after repetitions. The left knee exhibited 30 degrees of flexion, with pain beginning at the same, to include in passive range of motion, and against strong resistance; after repetitions, there was 25 degrees of flexion. The left knee exhibited extension limited to 10 degrees, with pain beginning at the same, to include in passive range of motion, against strong resistance and after repetitions. The examiner additionally noted that neither knee exhibited Osgood-Schlatter Disease, crepitation, mass behind knee, clicking or snapping, grinding, instability, patellar abnormality or meniscus abnormality. The examiner estimated that the knee conditions prevented exercise and sports, had a severe effect on chores, shopping, recreation and travelling but did not affect feeding, bathing, dressing, toileting, or grooming. She also noted that the knee pain was incapacitating with flare-ups. In a February 2009 correspondence, the Veteran reported spasms in her knees as well as right knee locking. At an August 2009 VA examination, the examination request noted that the June 2008 VA examination showed almost no range of motion in her knees and was inconsistent with the other medical evidence in her claims file which showed that she was on narcotics for pain control but did not show any mention of severely limited motion or an inability to perform all routine activities of daily living. The examination request asked for clarification of these inconsistencies. The examiner summarized the right knee joint symptoms as involving giving way, pain, stiffness, weakness, incoordination, decreased speed of joint motion, but no deformity or episodes of dislocation or subluxation. There was one episode of locking. There were moderate flare-ups two times per month lasting up to one day which were alleviated with medication, ice and rest. The examiner summarized the left knee joint symptoms as involving, pain, stiffness, weakness, incoordination, decreased speed of joint motion, but no giving way, deformity, episodes of dislocation or subluxation, or locking. There were severe monthly flare-ups lasting up to one day which were alleviated with medication, ice and rest. As to the right knee, physical examination revealed tenderness of the medial and lateral knee, pain at rest, swelling, subpatellar tenderness and tenderness over patellar tendon but no increased warmth, bumps consistent with Osgood-Schlatter Disease, crepitation, mass behind knee, clicking or snapping, grinding, instability, meniscus abnormality or other abnormality. As to the left knee, physical examination revealed tenderness over the popliteal fossa, medial and lateral knee, pain at rest, mild swelling, subpatellar tenderness, and tenderness on palpation of patellar tendon but no bumps consistent with Osgood-Schlatter Disease, crepitation, mass behind knee, clicking or snapping, grinding, instability, or meniscus abnormality. The right knee exhibited 110 degrees of flexion and normal extension to zero degrees. The left knee exhibited 112 degrees of flexion and normal extension to zero degrees. The examiner noted that there was objective evidence of pain with active motion and after repetitions bilaterally; however, there was no additional limitation of motion following repetitions. The examiner estimated that the knee conditions prevented shopping and recreation, had a severe effect on chores (because she was not able to do prolonged standing), exercise and driving, moderate to severe effect on bathing, moderate effect on traveling and dressing, and no effect on feeding, toileting, or grooming. She did not play sports. As to the inconsistencies identified in the examination request, the examiner stated that she was unable to comment on the June 2008 examination which took place more than one year ago because the Veteran was seen by another examiner at that time and therefore it was unknown whether she was having a flare-up or other problem with may have resulted in a more abnormal examination. In her September 2009 substantive appeal, the Veteran reported popping and grinding in her knees and that she was told she needs a brace. A September 2009 VA treatment record shows that a rheumatologist found that there was no effusion in the knees, no crepitus, and normal motion. An October 2010 VA treatment record shows that the Veteran reported twisting her right knee and going to the emergency room. A January 2011 VA treatment record shows that the Veteran was told that she needed knee stabilizers after falling three times in two weeks. At that time she was not using a cane although she had one. She also reported frequent edema of the knees. At a June 2016 VA examination, the Veteran reported that she had been in a 2003 motor vehicle accident which had resulted in a distal left tibia fracture but which did not involve injury to the bilateral knees and proximal lower legs; however, this accident resulted in an open fracture of the left tibia which required surgical treatment. As to the current severity of her knees, she reported pain that was aching, throbbing, burning, dull, grinding and popping, sharp, locking and soreness. She reported flare-ups in both knees which occurred secondary to activities of daily living, which resulted in "continuous pain" on the right and a two to ten hour flare on the left, and which was partially relieved by ceasing the aggravating activity, ice, rest, and medication. The right knee exhibited flexion from 10 to 60 degrees and extension from 60 to 10 degrees and which contributed to a functional loss. There was pain in both flexion and extension and in weight bearing. There was global right knee pain and tenderness and objective evidence of crepitus. Although the examiner noted that there was additional functional loss after repetitions and with repeated use over time, he noted that range of motion was unchanged. The left knee exhibited flexion from 10 to 70 degrees and extension from 70 to 10 degrees and which contributed to a functional loss. There was pain in both flexion and extension and in weight bearing. There was global left knee pain and tenderness and objective evidence of crepitus. Although the examiner noted that there was additional functional loss after repetitions and with repeated use over time, he noted that range of motion was unchanged. Although the examination was not conducted during a flare-up, the examiner noted that pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups bilaterally. Strength was 3/5 in both flexion and extension bilaterally although there was no muscle atrophy. There was no history of recurrent subluxation or lateral instability in either knee. Although there was no anterior or posterior instability, there was medial and lateral instability of 2+ in both knees. There were meniscal conditions which resulted in frequent episodes of joint locking, pain and effusion in both knees. The Veteran used a cane constantly for assistance. A March 2017 VA treatment record shows that the Veteran was involved in a motor vehicle accident in December 2016 and suffered a lot of bruising and knee and back injuries. At an April 2017 VA examination, the Veteran reported pain and swelling. She reported flare-ups four times per month lasting one to two days which involved increased pain and swelling. The Veteran described her knee disorders as involving problems with prolonged walking, sitting and standing, as well as problems with bending, squatting and lifting. Both knees exhibited flexion from zero to 110 degrees and extension from 110 to zero degrees and which contributed to a functional loss which involved inability to perform routine maneuvers requiring full range of motion in the knees. There was pain in both flexion and extension and in weight bearing. There was mild to moderate pain in the subpatellar areas bilaterally. There was no objective evidence of crepitus. The Veteran was unable to perform repetitive-use testing in either knee due to pain. The examination was not conducted immediately after repetitive use over time and was not conducted during a flare-up. There was normal strength in flexion and extension bilaterally and no atrophy. There was no history of recurrent subluxation or lateral instability in either knee but there was recurrent effusion about five times per week. Joint stability testing was not conducted due to the Veteran's knee conditions not being suspicious for instability. The examiner noted that the Veteran never had a meniscal condition. The Veteran regularly used a walker for her knees. The examiner estimated that the functional impact of her conditions would result in difficulties with prolonged standing, walking and sitting as well as squatting, bending and lifting. In addition, the examiner noted that there was no objective evidence of pain in non-weight bearing, that passive range of motion was the same as active range of motion and that although there was pain in passive range of motion, it did not additionally limit range of motion. Based on the above, the Board finds that there is no basis to grant an increased rating based on limitation of flexion. Although the June 2008 VA examination showed significantly impaired range of motion, these results do not appear to be representative of the limited range of motion she generally experienced, including when considering the effect of flare-ups. In this regard, while the June 2008 VA examination found 25 degrees of knee flexion in both knees, by August 2009, there was 110 degrees of right knee flexion and 112 degrees of left knee flexion without additional limitation of motion following repetitions and a September 2009 VA treatment record noted normal range of motion. While the June 2016 VA examination revealed more limited flexion with the right knee limited to 60 degrees and the left limited to 70 degrees, this still translates to a noncompensable rating under Diagnostic Code 5260. Although it is significant that the Veteran was unable to perform range of motion testing after repetitions due to pain at the April 2017 VA examination, even assuming that such pain would result in some additional limitation of motion, because initial testing revealed nearly normal range of motion in knee flexion at 110 degrees in both knees, it is unreasonable to conclude that any additional limited range of motion would more nearly approximate flexion limited to 45 degrees. Indeed, the examiner there noted that there was no objective evidence of pain in non-weight bearing, that passive range of motion was the same as active range of motion and that although there was pain in passive range of motion, it did not additionally limit range of motion. As to limited extension, the evidence shows that the both knees have varied between normal knee extension and extension limited to 10 degrees. While the June 2008 VA examination showed both knees limited to 10 degrees, the August 2009 VA examination showed normal range of motion as did the September 2009 VA treatment record. While the June 2016 VA examination again revealed bilateral knee extension limited to 10 degrees, by the April 2017 VA examination, there was normal knee extension again although the Veteran was unable to perform range of motion testing after repetitions due to pain. Resolving all reasonable doubt in favor of the Veteran, and considering that she was unable to perform range of motion testing after repetitions at the April 2017 examination, the Board finds that the evidence throughout the appeal period more nearly approximates bilateral knee extension limited to 10 degrees in both knees. As to the right knee, such limited motion is already contemplated under the Veteran's 10 percent rating under Diagnostic Codes 5003-5262 prior to June 6, 2016 and 10 percent rating under Diagnostic Codes 5003-5261 from June 6, 2016. Since the Veteran's rating for left knee limitation of extension begins on June 6, 2016, the Board finds that a 10 percent rating, but no higher, under Diagnostic Code 5261 for the period from June 9, 2008 through June 5, 2016 is warranted. Regarding instability, at the June 2008 VA examination, the Veteran reported giving way and instability, at the August 2009 VA examination, she reported giving way, and in January 2011, she reported that she had been told that she needs to wear "knee stabilizers" to prevent her from falling. Although the examiners at the June 2008 and August 2009 examinations did not find objective evidence of lateral instability, the Veteran is competent to report symptoms she has observed through her senses, and such reports were later supported by the June 2016 VA examiner's finding of medial and lateral instability of 2+ in each knee. With reasonable doubt resolved in favor of the Veteran, therefore, the Board finds that for the period prior to June 6, 2016, each knee more nearly approximated slight, but not moderate, lateral instability. While the Board finds the Veteran's reports of giving way to be competent and credible, prior to June 6, 2016, such instability was not so severe as to be manifest upon examination in June 2008 and August 2009. Accordingly, a rating in excess of 10 percent prior to June 6, 2016 for left knee instability is denied; however, a separate 10 percent rating for mild right knee lateral instability from June 9, 2008 through June 5, 2016, is warranted. Beginning June 6, 2016, the Board finds that each knee more nearly approximated moderate, but not severe, lateral instability. While the June 2016 VA examiner found medial and lateral instability of 2+ in each knee, the April 2017 VA examiner indicated that there was no objective evidence to suggest any lateral instability of the knees. In addition, throughout the entire period on appeal, the Veteran has denied experiencing subluxation and there has been no objective evidence indicating such symptoms. Accordingly, ratings in excess of 20 percent for left and right knee instability are denied. Finally, the Board acknowledges that the June 2016 examiner indicated that she had a meniscal condition which resulted in frequent episodes of locking, pain and effusion. This appears to be undercut, however, by the fact that the June 2008, August 2009 and April 2017 VA examiners all found that the Veteran does not have any meniscal condition. Further, even though the June 2016 examiner indicated that there was "frequent" effusion into the joints, the imaging studies cited in the same examination found "no joint effusion" in both knees. Similarly, the Veteran herself has not indicated that the locking occurred frequently; in June 2008, she reported locking one to three times per month and effusion once, and in August 2009, she reported one episode of locking in the right knee and none in the left. Hence, the preponderance of the evidence shows that the Veteran has not had dislocated or removed semilunar cartilage and to the extent there are symptoms of locking, this has not occurred frequently. Moreover, the functional impact of any symptoms of locking, pain and effusion is limited motion which the currently assigned ratings already contemplate. The Board acknowledges that the Veteran's VA treatment records, VA examination reports, and lay statements indicate that she has chronic knee pain, and has considered 38 C.F.R. § 4.59 regarding painful motion. Under 38 C.F.R. § 4.59, with any form of arthritis, actually painful joints are entitled to at least the minimum compensable rating. See also Petitti v. McDonald, 27 Vet. App. 415, 425 (2015) ("Under 38 C.F.R. § 4.59, the trigger for a minimum disability rating is an 'actually painful, unstable, or malaligned joint [].'"). In this case, however, the Veteran has already been assigned at least the minimum compensable rating, 10 percent, for each knee for the entire period on appeal. See Petitti, 27 Vet. App. at 425. The 10 percent evaluations already take into account the Veteran's limitation of motion hampered by pain, repetitive motion, and flare ups, as these symptoms were evaluated on examination to the extent feasible. Furthermore, pain, by itself, does not constitute functional loss. Rather, there must be actual limitation of motion that is caused by pain. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). The Board has considered the Veteran's lay statements regarding the functional impact of her bilateral knee disabilities, including difficulty with prolonged walking, sitting and standing, as well as problems with bending, squatting and lifting. The Veteran is competent to report her own observations with regard to the severity of her disability, including reports of pain and decreased mobility. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Her statements are consistent with the ratings assigned. The occurrence of pain and increased difficulty while performing physical activities are not additional symptoms, but rather the practical effect of the symptoms of pain and limited range of motion which have been clinically observed and measured in the Veteran's medical records. To the extent that the Veteran argues her symptomatology is more severe than shown on evaluation, her statements must be weighed against the other evidence of record. Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran's more general lay assertions. Based on the foregoing, the Board finds that 10 percent ratings, but no higher, from June 9, 2008 through June 5, 2016, for right knee instability and limited extension of the left knee are warranted. To this extent, the appeal is granted. The preponderance of the evidence is against the remaining claims. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; as the preponderance of the evidence is against assignment of any other higher ratings, it is not applicable. See 38 U.S.C.A. § 5107. (CONTINUED ON NEXT PAGE) ORDER Entitlement to an evaluation in excess of 10 percent for the right knee is denied. Entitlement to a separate 10 percent rating, but no higher, from June 9, 2008 through June 5, 2016, for right knee instability is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 20 percent from June 6, 2016 for right knee instability is denied. Entitlement to a 10 percent rating, but no higher, from June 9, 2008 through June 5, 2016, based on limited extension of the left knee is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 10 percent from June 6, 2016 for the left knee is denied. Entitlement to an evaluation in excess of 10 percent prior to June 6, 2016, and in excess of 20 percent thereafter, for instability of the left knee is denied. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs