Citation Nr: 21062610 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 17-31 060 DATE: October 8, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for left knee meniscus tear, post-operative for limitation of flexion and pain from July 24, 2015 to September 13, 2017 is denied. Entitlement to a separate disability rating of 10 percent for instability of the left knee from July 24, 2015 to September 13, 2017 is granted. Entitlement to a disability rating of 20 percent for left knee meniscus tear, post-operative for limitation of flexion and pain from December 1, 2017 is granted. FINDINGS OF FACT 1. From July 24, 2015 to September 13, 2017 for left knee meniscus tear, post-operative for limitation of flexion and pain the Veteran's most severe limitation of flexion was 30 degrees, and most severe extension was limited to less than 5 degrees. 2. Resolving reasonable doubt in the Veteran's favor, the Board finds that from July 24, 2015 to September 13, 2017 the Veteran's left knee meniscus tear, post-operative for limitation of flexion and pain has been manifested by recurrent lateral instability and subluxation and most nearly approximates slight instability. 3. From December 1, 2017, for left knee meniscus tear, post-operative for limitation of flexion and pain the Veteran's most severe limitation of flexion was 30 degrees, and most severe extension was limited to less than 5 degrees. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 20 percent for left knee meniscus tear, post-operative for limitation of flexion and pain from July 24, 2015 to September 13, 2017 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5260. 2. The criteria for entitlement to a separate disability rating of 10 percent for instability of the left knee from July 24, 2015 to September 13, 2017 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5257. 3. The criteria for entitlement to a disability rating of 20 percent for left knee meniscus tear, post-operative for limitation of flexion and pain from December 1, 2017 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2005 to March 2008 and from May 2008 to October 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Board remanded the issues on appeal for additional development. The Board finds that the Regional Office (RO) substantially complied with the Board's remand instructions and an additional remand to comply with the Board's directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). In the July 2020 rating decision, the Veteran was awarded a 20 percent disability rating for his service-connected left knee meniscus tear, post-operative for limitation of flexion and pain effective July 24, 2015. Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issues considered in this decision. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in this decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Increased ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). 1. Entitlement to a disability rating in excess of 20 percent for left knee meniscus tear, post-operative for limitation of flexion and pain from July 24, 2015 to September 13, 2017 2. Entitlement to a separate disability rating of 10 percent for instability of the left knee from July 24, 2015 to September 13, 2017 3. Entitlement to a disability rating of 20 percent for left knee meniscus tear, post-operative for limitation of flexion and pain from December 1, 2017 The Veteran seeks a higher rating for his left knee meniscus tear, post-operative for limitation of flexion and pain (left knee disability). The applicable rating period for the Veteran's left knee meniscus tear, post-operative for limitation of flexion and pain disability is July 24, 2014, one year prior to the receipt of the claim, through the present. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (discussing the one-year "look-back" period for non-initial increased rating claims). The Veteran's left knee disability was originally rated at 10 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5260. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The additional diagnostic code is shown after the hyphen. In this case, rating the Veteran's service-connected left knee disability under Diagnostic Code 5003, which pertains to degenerative arthritis, requires the use of Diagnostic Code 5260 which pertains to limitation of flexion. The Board notes that the Veteran was awarded a 100 percent total disability rating for treatment for s/p left knee meniscus tear and recurrent patellar dislocation from September 13, 2017 to December 1, 2017 for convalescence following the Veteran's left knee surgery. During the pendency of the appeal, the criteria for rating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's appeal 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. The amendments made effective February 7, 2021, did not affect the rating criteria under Diagnostic Codes 5003, 5260, and 5261. Diagnostic Code 5003 directs that a rating shall be awarded on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If noncompensable limitation of motion is demonstrated, a 10 percent rating is assigned for each major joint or group of minor joints affected. Further criteria for rating disabilities of the knees applicable in this case are found in 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5260, and 5261. Prior to the regulatory changes, under Diagnostic Code 5257, 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. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257 as in effect prior to February 7, 2021. Therefore, objective medical evidence cannot be categorically found more probative than lay evidence with respect to that diagnostic code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). As of February 7, 2021, under Diagnostic Code 5257, a 10 percent rating is warranted when there is a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; or where there is 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 when there is a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; or 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 when there is an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation; or there is 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. The regulatory changes did not affect Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees or greater. 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 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). 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). Summary of the Evidence Relevant to the Increased Left Knee Ratings Claim The Veteran's treatment records reflect that he has received ongoing care for his left knee. In November 2015, the Veteran was afforded a VA examination for his left knee. The examiner noted that the Veteran had a diagnosis of a left knee meniscal tear, recurrent patellar dislocation, knee instability, and degenerative arthritis. The Veteran's most recent surgery occurred in 2010. The examiner indicated that the Veteran's September 2015 "Ortho note" revealed that the Veteran's main problem is left patellar instability and is being referred to an outside ortho for a patellar realignment procedure. The Veteran reported that his knee has slippage about two times per week. The examiner noted that the Veteran's limitation of motion of the left knee is limited to 76 degrees flexion, and 0 degrees extension. The examiner indicated there is evidence of pain with weightbearing. There was no additional limitation of motion after repetitive range of motion testing. The examiner indicated he was unable to determine if pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time or during flare-ups. There is some tenderness on the subpatellar of the knee on palpitation. The examiner indicated that the Veteran has muscle atrophy 10 cm below the knee. The examiner indicated that there was no evidence of crepitus or ankylosis. Diagnostic testing revealed degenerative arthritis. The examiner indicated that there is no history of recurrent subluxation or lateral instability but there is a history of recurrent effusion. The examiner indicated that the Veteran's joint stability was tested, and all of the tests were normal. However, the examiner indicated that the Veteran had severe recurrent patellar dislocation. The examiner stated that the Veteran had a meniscus (semilunar cartilage condition including a meniscal tear and frequent episodes of joint effusion) in around 2005. The examiner indicated that the Veteran's surgeries included a lateral release and two arthroscopies with residuals including patellar instability. The Veteran reported he regularly uses braces as assistive devices. The examiner noted that the functional impact of the Veteran's left knee condition includes limitations of prolonged standing, twisting movements and squatting. In a January 2016 clinic note, the Veteran's private doctor indicated that the Veteran complains that his knee is giving way now. The Veteran stated that he feels like it is through his patellofemoral joint and it feels like it is sliding or subluxing and making him give way. The private doctor stated that the Veteran has had therapy and there has been substantial improvement, and the Veteran has used a brace over the years as well. In the March 2016 and September 2016 clinic notes, the Veteran's private doctor indicated that the Veteran has a history of recurrent patellar dislocations and the Veteran has a medical meniscal tear. In a November 2016 clinic note, the Veteran's private doctor indicated that the Veteran has chronic patellar instability and meniscal pathology. The MRI revealed a medial meniscal tear. The Veteran was treated with an injection of Marcaine and Celestone. In a June 2017 clinic note, the Veteran's private doctor indicated that the Veteran is still having pain and instability. The Veteran was treated with an injection of Marcaine and Celestone. The private doctor indicated that the Veteran was having limited flexion and extension today. "At a resting period, his flexion was at 68 to 70 with extension at 30 to 35, very, very limited. The private doctor indicated that if there is no improvement within two weeks, that they will see him back at that point. In July 2017, the Veteran was afforded a VA examination for his right knee condition. The examiner noted that the Veteran had a diagnosis of degenerative arthritis in the right knee and left knee s/p lateral release and debridement. The examiner noted that the Veteran's initial range of motion testing revealed that the left knee is limited to 130 degrees flexion, and 0 degrees extension. There was pain noted on the exam but does not result in/cause functional loss. There was no additional limitation of motion after repetitive range of motion testing. The examiner indicated that there was no objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue, not pain with weight bearing, and no evidence of crepitus. There is no evidence of pain on passive range of motion testing or on non-weight bearing testing of the left knee. During repeated use over time testing the examiner indicated that pain, weakness, fatigability or incoordination does not significantly limit functional ability. The examiner indicated that during flare-ups the Veteran is expected to have additional loss of range of motion (ROM) when suffering from pain, the loss in ROM will depend on the activity and severity of pain experienced however today's degrees in ROM may be suggestive findings one may experience during flare-ups. The examiner indicated that the Veteran does not have muscle atrophy or ankylosis. The examiner indicated that there is no history of recurrent subluxation or lateral instability or a history of recurrent effusion. The examiner indicated that the Veteran's joint stability was tested, and all of the tests were normal. The examiner indicated that the Veteran has not had recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. The examiner noted that in February 2007 the Veteran had a lateral release and medial reefing procedure; in June 2007 an arthroscopic debridement; in October 2009 a debridement and lateral release. The described residuals include recurring knee pain and discomfort with overuse and pain. The Veteran did not report using an assistive device. The examiner indicated that the Veteran's knee conditions would impact his ability during flare-ups to limit his ability for prolonged standing and walking as well as climbing stairs due to discomfort and pain with overuse. In September 2018, the Veteran was afforded a VA examination for his left knee condition. The examiner indicated that the Veteran had a diagnosis of traumatic arthritis. The Veteran reported that his left knee hurts continuously. He avoids walking on it whenever possible and even avoids walking around a store due to pain. The Veteran treats his leg with ice, a TENS unit, and takes antiinflammatory medicines and still has severe pain. The Veteran reported having flare-ups about twice a month and it has been so severe that he has taken off time from work to avoid weightbearing and ices his knees and uses a TENS unit. The Veteran reported not being able to walk more than 100 yards or sit or stand for more than 20 minutes. The examiner noted that the Veteran's initial range of motion testing revealed that the left knee is limited to 90 degrees flexion, and 0 degrees extension. The examiner noted that the Veteran was unable to bend. The examiner indicated that there is evidence of pain with weightbearing. There was no additional limitation of motion after repetitive range of motion testing. The examiner indicated that there would be pain and lack of endurance that would significantly limit the Veteran's functional ability with repeated use over a period of time but is unable to describe the terms of range of motion. The examiner indicated that there would be no change during flare-ups and that there would be pain and a lack of endurance. There is objective evidence of localized tenderness or pain on palpitation of the media joint line. There is no objective evidence of crepitus or ankylosis. The examiner indicated that the Veteran has muscle atrophy 12 cm below the patella. The examiner indicated that there is no history of recurrent subluxation or lateral instability or a history of recurrent effusion. The examiner indicated that the Veteran's joint stability was tested, and all of the tests were normal. The examiner indicated that the Veteran has not had recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. The examiner noted that the Veteran has had a meniscus (semilunar cartilage) condition and had at least three surgeries. The Veteran reported regularly using a brace. The examiner noted that the Veteran has degenerative or traumatic arthritis in his left knee. Specifically, there is advanced degenerative change of the femorotibial compartment, medial greater than lateral. The functional impact includes not being able to perform work that requires prolonged standing or walking. In January 2020, the Veteran was afforded a VA examination for his left knee condition. The examiner indicated that the Veteran had a diagnosis of status post left knee meniscus tear and recurrent patellar dislocation and left knee strain status post left knee reconstruction surgery. The Veteran reported that he had flare-ups daily that were moderate to severe, that may last all day depending on the activities of the day. The Veteran reported that his flare-ups were precipitated by prolonged walking, standing, and climbing steps. The flare-ups are alleviated by rest and medication for pain. The Veteran reported that the functional loss includes limited range of motion. The examiner noted that the Veteran's initial range of motion testing revealed that the left knee was limited to 60 degrees flexion, and 0 degrees extension, with objective evidence of pain. The examiner indicated that during observed repetitive use testing the Veteran was able to perform testing with at least three repetitions, but his left knee was limited to 50 degrees flexion and 0 degrees extension. The repeated use over time testing revealed the Veteran was limited to 40 degrees flexion and 0 degrees extension. The examiner estimated that during flare-ups the Veteran would be limited to 30 degrees flexion and 0 degrees extension. The examiner noted that the factors causing functional loss during repetitive use, repeated use over time and flare-ups testing were caused by pain and lack of endurance. The examiner indicated that pain, weakness, fatigability or incoordination significantly limit the Veteran's functional ability with flare ups. The examiner indicated that there was objective evidence of pain on passive, weightbearing and non-weight bearing range of motion testing of the left knee. The examiner indicated that the Veteran does not have crepitus, muscle atrophy, or ankylosis. The examiner stated that there is no history of recurrent subluxation or lateral instability or a history of recurrent effusion. The examiner indicated that the Veteran's joint stability was tested, and all of the tests were normal. The examiner indicated that the Veteran does not have a history of recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. The examiner indicated that the Veteran has had a meniscal tear and frequent episodes of joint pain. The examiner noted that the Veteran had arthroscopic and reconstructive surgery in 2017 with residuals including limited range of motion and pain. The Veteran did not report using any assistive devices. The examiner stated that the impact on the Veteran's work would include knee pain, stiffness, limited range of motion, difficulty with bending, prolonged standing more than 10 minutes, walking more than 12 mile, or climbing more than two flights of stairs. Analysis of the Evidence Relevant to the Increased Left Knee Ratings Claim The Board finds that a rating in excess of 20 percent for the Veteran's left knee meniscus tear, post-operative for limitation of flexion and pain from July 24, 2015 to September 13, 2017 under Diagnostic Code 5003-5260 is not warranted. The Veteran's most severe limitation of flexion was 30 degrees, which reflects a 20 percent rating under Diagnostic Code 5260. The Veteran's most severe extension was limited to less than 5 degrees and is thus noncompensable under Diagnostic Code 5261. The Board acknowledges that the AOJ resolved reasonable doubt in the Veteran's favor and used the January 2020 VA examination in awarding the Veteran a 20 percent rating during the July 24, 2015 to September 13, 2017 time period. The Board notes that the prior examinations showed that the Veteran's most severe limitation of flexion was 68-70 degrees, and the most severe extension was 0 degrees. The Board acknowledges that a June 2017 clinic note stated "at a resting period, his flexion was at 68 to 70 with extension at 30 to 35, very, very limited. The private doctor indicated that if there is no improvement within two weeks, that they will see him back at that point." The Board is not clear if the private examiner was indicating that the Veteran's extension to 30 to 35 degrees is "0 to 30-35" or limited to "30-35 degrees. However, the Veteran's medical records do not reflect that the Veteran has had an extension worse than 0 degrees throughout the appeal period. In addition, the Veteran had a VA examination a month later and the Veteran's left knee was limited to 130 degrees flexion, and 0 degrees extension. Thus, the Board concludes that the Veteran's limitation of extension was most severe to 0 degrees, which is consistent with the Veteran's treatment records. However, the Board finds that a separate rating for instability under Diagnostic Code 5257 from July 24, 2015 to September 13, 2017 is warranted. VA General Counsel has interpreted that, if a musculoskeletal disability is rated under a specific diagnostic code predicated upon limitation of motion - Diagnostic Code 5260, as applicable here, for limitation of flexion - assigning a separate rating under a diagnostic code that does not appear to involve limitation of motion (e.g., Diagnostic Code 5257) would not constitute pyramiding. See VAOPGCPREC 23-97, 9-98. Here, the Veteran is currently in receipt of a 20 percent rating under Diagnostic Code 5260 for limitation of flexion to 30 degrees. Review of the evidence of record reflects that the Veteran's left knee meniscus tear, post-operative for limitation of flexion and pain has been manifested by recurrent lateral instability and subluxation and more nearly approximates slight instability. The Veteran has consistently reported that his knee has had slippage. See November 2015 VA examination, January 2016 clinic note, June 2017 clinic note. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257. As such, objective medical evidence cannot be found categorically more probative than lay evidence with respect to Diagnostic Code 5257. See English, 30 Vet. App. at 352-53. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence supports the Veteran's contention that he has slight instability in his left knee and a 10 percent rating, but no higher, from July 24, 2015 to September 13, 2017 is warranted. The Board notes there is no evidence of instability after the Veteran's more recent surgery. The Veteran's left knee instability is considered slight in severity because objective testing has had conflicting results and, more importantly, while the Veteran has indicated that he has had instability, there is no indication in the record that the instability caused falls, caused other injuries, or was otherwise moderate or severe in terms of the pain or harm it caused. The Board also notes that the Veteran has used braces as assistive devices. As such, the Board finds that a separate rating for the Veteran's left knee instability is warranted at a 10 percent rating, and no higher, under Diagnostic Code 5257 as in effect prior to February 7, 2021. A separate rating under Diagnostic Code 5257 for 10 percent instability of the knee does not violate the prohibition against pyramiding as instability is not contemplated by the 20 percent disability rating currently assigned under Diagnostic Code 5260 for limitation of flexion. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). As such, a separate 10 percent rating under Diagnostic Code 5257 is supported by the evidence of this case. VAOPGCPREC 23-97, 9-98; 38 C.F.R. § 4.71a. In addition, the Board finds that a 20 percent disability rating for the Veteran's left knee meniscus tear, post-operative for limitation of flexion and pain disability is warranted from December 1, 2017 to the present. The January VA examination revealed that, the Veteran's most severe limitation of flexion was 30 degrees (during flare-ups), which reflects a 20 percent rating under Diagnostic Code 5260. The Veteran's most severe extension was limited to less than 5 degrees and is thus noncompensable under Diagnostic Code 5261. There is no evidence of instability post-surgery under Diagnostic Code 5257. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). In conclusion, resolving reasonable doubt in the Veteran's favor, the Board finds that from July 24, 2015 to September 13, 2017 a separate 10 percent disability rating for instability is warranted. In addition, the Board finds that a 20 percent rating but no higher for the Veteran's left knee meniscus tear, post-operative for limitation of flexion and pain from December 1, 2017 to the present is warranted. The Board also concludes that the preponderance of evidence is against the claim for an increased rating for left knee meniscus tear, post-operative for limitation of flexion and pain from July 24, 2015 to September 13, 2017, and the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Quist Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.