Citation Nr: 21063597 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 16-03 404 DATE: October 14, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for left knee strain is denied. FINDING OF FACT Throughout the entire appeal period, flexion in the Veteran's left knee was not limited to 30 degrees, including upon clinical examination, or as determined to result after repeated use over time or during flare-ups, and she had no incapacitating exacerbations. CONCLUSION OF LAW The criteria for entitlement to an initial rating in excess of 10 percent for left knee strain have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5260. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 2004 to February 2012. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision issued by a VA Regional Office (RO). This rating decision granted service connection for left knee strain with a 10 percent rating effective from March 1, 2012. Subsequently, the Veteran filed a timely appeal and the claim was previously remanded by the Board in September 2018 and November 2019. In a September 2020 Board decision, the Veteran's claim for an increase rating was once again denied. Afterwards, the Veteran appealed the decision to the Court of Appeals for Veterans' Claims (CAVC), which resulted in a Joint Motion for Remand (JMR) in June 2021 vacating the prior Board decision. The parties to the JMR found the Board's September 2020 decision did not fully address the Veteran's subjective reports of left knee instability. During the pendency of the appeal, the Veteran filed a Supplemental Claim under the AMA in July 2021 again seeking an increased disability rating for her left knee condition. In response, the RO afforded her a new VA knee examination in August 2021 and then issued a new rating decision later that same month continuing the denial of an increase. The Board wishes to note, that the claims file does not contain a Legacy system Supplemental Statement of the Case (SSOC) after the Veteran had been afforded the new August 2021 VA examination. However, the Board finds there has already been AOJ consideration of this evidence in the first instance because there was a new rating decision issued after the new examination was obtained. To delay adjudication by the Board for the issuance of an SSOC would do nothing more than create an unnecessary delay for the Veteran. As such, the Board will proceed to consider all evidence now of record and adjudicate the Veteran's claim as indicated below. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Court, in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court's holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Further, in evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. at 592. Additionally, the Court has stated that flare-ups must be factored into an examiner's assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Here, the Veteran was granted service connection for left knee strain at 10 percent disabling effective March 1, 2012, under 38 C.F.R. § 4.71a, DC 5260, pertaining to limitation of flexion. As noted in the introduction, this appeal stems from the Veteran's initial claim seeking service connection for her left knee strain. Thus, the Board will consider all evidence of record dating back to the filing of her initial claim including all evidence considered by the RO that issued the original August 2012 rating decision. The Veteran's current 10 percent rating is based on painful limitation of flexion of the left knee. See 38 C.F.R. § 4.59, 4.71a, DC 5260. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). 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 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 Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the AOJ. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claim. Under the pre-amended criteria, degenerative arthritis as shown by x-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5003. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Under DC 5260, flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. Also relevant to any discussion of knee disabilities are the criteria under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Under DC 5256, favorable ankylosis of the knee, in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent disability rating; ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent disability rating; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent disability rating. Under DC 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling, moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. Under DC 5258, a claimant is entitled to a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5261, extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Under DC 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. Under DC 5263, a 10 percent rating is warranted for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Effective February 7, 2021, DC 5257 was amended to provide ratings for recurrent subluxation or lateral instability. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. DC 5257 also provides for ratings based on patellar instability. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 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. Note [1] to DC 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to DC 5257 states 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. Also, effective February 7, 2021, DC 5262 is amended to provide for a 40 percent rating for nonunion of the tibia and fibula, with loose motion, requiring brace. Malunion of the tibia and fibula are to be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Separate ratings are also provided for medial tibial stress syndrome (MTSS) or shin splints. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Turning to the evidence of record, the Veteran was afforded a VA examination in June 2012. At which time, the Veteran reported flare-ups with cold weather and prolonged walking during which times she ices the knee and rests. Flexion of the left knee was to 70 degrees, with painful motion beginning at 70 degrees; extension was to 0 degrees with no evidence of painful motion. She was able to perform repetitive use testing with no additional loss of range of motion. Functional loss was described as less movement than usual and pain on movement. Muscle strength testing was 5/5 throughout. Joint stability tests were normal and there was no objective evidence of left knee instability. In June 2015, the Veteran was afforded another VA examination of her left knee. At this examination the Veteran denied having flare-ups. She did report constant knee pain with weather changes and prolonged walking/standing. She used Ibuprofen for pain and rated her knee pain as a 5 to 9 out of 10 on the pain scale. Range of motion (flexion/extension) was entirely normal on objective examination. The examiner did note pain on flexion but found that it did not result in a functional loss. There was no pain with weightbearing. There was no crepitus. The Veteran was able to perform repetitive use testing with no additional loss of range of motion. Joint stability tests were normal and there was no objective evidence of left knee instability. Muscle strength testing of the left lower extremity was 5/5 throughout. In July 2019, the Veteran was afforded another VA examination. The Veteran endorsed flare-ups "sometimes" with cold weather and riding in a car for a long time. She stated that her knee cramps and buckles sometimes when she walks. She endorsed occasional swelling and use of a brace. On objective examination, flexion of the left knee was to 42 degrees and extension was to 0 degrees. Pain was noted on examination on rest/non-movement with flexion and there was evidence of pain with weightbearing. The medial side of the left patella was tender. There was no crepitus. The Veteran was unable to perform repetitive use testing with both knees due to the fact that she was 27 weeks pregnant at the time of the examination. With repeated use over time, the examiner estimated that pain, fatigue, weakness, lack of endurance, and incoordination would limit flexion to 37 degrees (extension to 0 degrees). With flare-ups, the examiner estimated that pain, fatigue, weakness, lack of endurance, and incoordination would limit flexion to 42 degrees (extension to 0 degrees). Joint stability testing was performed, and no instability was found. Muscle strength testing was 5/5. Recurrent effusion was reported depending on activity level. The Veteran used a left knee brace on a regular basis. Diagnostic testing revealed arthritis of the left knee. Functional impact was noted as exertional and postural limitations at postpartum. The examiner noted that range of motion testing was performed only seated and was limited due to the Veteran being 27weeks pregnant and that any additional range of motion testing was contraindicated due to pregnancy. Another, VA examination was conducted in December 2019, at which time the Veteran reported experiencing intermittent left knee pain up to 70 percent of the time. It was described as dull, reaching a 3 out of 10 on the pain scale. She used 800 milligrams of Ibuprofen, up 10 per week, for her left knee pain. She stated that her left knee pain was precipitated by cold weather and nothing alleviates it. She reported having left knee flare ups up to four times per month, lasting for up to 24 hours with sharp to dull pain (10 out of 10 on the pain scale). She stated that she loses 30 percent of the motion of her left knee with a flare-up. Functional loss or impairment was described as being unable to get down on the floor with her 3-month-old baby and walking up to one-half of a mile. Left knee flexion was to 80 degrees, extension was to 0 degrees. The range of motion itself contributed to a functional loss to the extent that the Veteran reported that she was unable to run due to the range of motion of her knees. Pain was noted on flexion and extension. There was pain with weightbearing. There was tenderness on the left patella and on the medial aspect of her left knee joint. There was evidence of crepitus. The Veteran was able to perform repetitive use testing, but flexion was limited to 60 degrees due to pain after three repetitions. The Veteran reported having intermittent swelling of her left knee. Left knee muscle strength testing was 3/5. There was no history of recurrent subluxation or lateral instability. Joint stability tests were normal. She occasionally used a left knee brace. The Veteran was currently employed on a full-time basis. The examiner stated that, per the Veteran's report, flexion of the left knee would be limited to 57 degrees with a flare-up (extension to 0 degrees). She endorsed left knee pain with passive range of motion. She also reported pain in a non-weightbearing status. The Veteran was afforded her last and most recent VA knee examination in August 2021. At which time the examiner confirmed her diagnosis of a left knee strain. The Veteran reported experiencing constant moderately severe pain with limited range of motion in her left knee. She also reported no flare-ups and no current treatment other than taking 800 milligrams of ibuprofen. Functionally, the Veteran reported that her left knee condition affects her ability to walk, knee, or stand for long periods of time as well as affects her ability to drive and climb stairs. The examiner reported there was no history or current reports of instability or recurrent subluxation. Upon initial range of motion testing flexion was limited to 85 degrees with normal extension both noted with pain. The examiner noted there was objective evidence of pain with active motion and upon weight bearing. There was evidence of crepitus and localized tenderness or pain upon palpation around the left knee joint. Neither passive nor repeated use over time testing was able to be performed due to the Veteran's fear of pain and belief by the examiner that further testing may cause injury. However, the examiner considered the medical evidence of record as well as the lay statements of the Veteran and opined that there was evidence of functional impact to include pain, fatigability, weakness, lack of endurance and incoordination upon repeated use over time. The examiner estimated the resulting range of motion to be 80 degrees of flexion with normal extension, a decrease of 5 degrees with repeated use over time. Additional factors contributing to her left knee disability noted by the examiner included interference with standing and sitting, swelling, weakened movement, less movement than usual, and "instability of station". The examiner explained that the Veteran's left knee pain and limited range of motion are the cause of her feelings of instability. Upon further examination, muscle strength testing was normal with no ankylosis. Joint stability testing was normal for all ligaments with no ligament tears nor recurrent patellar instability. No tibial or fibular impairments were noted nor any meniscal conditions. The examiner noted that the Veteran did use a left knee brace constantly, but this was not noted or reported as being prescribed by a physician. Lastly, the examiner noted that the Veteran is currently employed as a Social Security Department Claims Specialist and that due to her left knee disability it was estimated that she would lose 2-4 weeks of work over a 12 month period. VA treatment records dated throughout the appeal period reflect ongoing complaints of left knee pain. For instance, an April 2018 VA treatment record documented full range of motion of the left knee; no crepitus; pain on medial and lateral sides; no laxity or deformity; and no edema. The Veteran reported a feeling of instability, pain with standing or sitting (8 out of 10 on the pain scale). Physical therapy notes from June 2021 further indicate the Veteran's continued reports of pain and impaired function. During the consultation, flexion in her left knee was noted as 108 degrees with normal extension. The Board notes at the outset that the VA examinations of record, taken in conjunction with records of medical treatment, are an adequate basis upon which to determine the extent and severity of the Veteran's left knee disability. Given the totality of the information, including the Veteran's own descriptions of her limitations, the Board finds that the requirements of DeLuca, Sharp, and Correia have been adequately addressed. DeLuca v. Brown, 8 Vet. App. At 202; Sharp v. Shulkin, 29 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158. A rating in excess of 10 percent for left knee strain is denied. The Board notes that the criteria under which the Veteran's right knee is currently rated, 38 C.F.R. § 4.71a, DC 5260, was not affected by the February 7, 2021, amendments. Under the criteria of DC 5260, the Veteran's right knee disability did not warrant a rating in excess of 10 percent at any time during the appeal period. Flexion was not limited to 30 degrees, including upon clinical examination, or as determined to result after repeated use over time or during flare-ups, thereby warranting a 20 percent rating under the criteria of DC 5260. See 38 C.F.R. § 4.59; Mitchell v. Shinseki, 25 Vet. App. at 32. Although flexion was not limited to a compensable degree during the appeal period, the Veteran had evidence of painful motion, warranting a 10 percent rating under 38 C.F.R. § 4.59. However, she had no incapacitating exacerbations meriting a 20 percent rating under the criteria of DC 5003. Accordingly, a rating in excess of 10 percent for left knee strain under DC 5260 is not established. The Board has considered whether rating the knee disability under additional or alternative diagnostic codes pertaining to the knees would be more appropriate or advantageous to the Veteran. However, rating the disability under DC 5256 is not indicated as there is no evidence of ankylosis. Further, the Veteran does not have any meniscal conditions warranting rating under DC 5258 or DC 5259. Extension has not been limited to 5 degrees such that additional rating might be available under DC 5261. Finally, there is no malunion or nonunion of the tibia and fibula and no genu recurvatum indicating rating under DC 5262 and DC 5263. The Board has considered whether an additional rating is warranted under the pre-amended or amended criteria of DC 5257 but finds that an additional rating is not merited under either diagnostic criterion. The Veteran has reported subjective complaints of feelings of instability in her left knee. She also currently reported the use of knee braces on a constant basis. However, objective evidence of instability in the left knee is not reflected during the appeal period, as joint, ligament, and meniscus stability tests have consistently been normal during clinical evaluation. Further, knee braces were noted by the Veteran to be used for left knee pain and feelings of instability. Based on the Veteran's lay statements alone, there appears to be a lack of steadiness during ambulation. However, there does not appear to be functional instability based on the medical evidence of record. Functional instability is the "inability of a joint to maintain support during use." See Dorland's Illustrated Medical Dictionary 958 (31st ed. 2007). As noted above, clinical testing did not indicate that the left knee joint could not maintain support such that instability was found. As such, lateral instability for purposes of rating under pre-amended DC 5257 has not been demonstrated during the appeal period. Nor was there any evidence of recurrent subluxation throughout the appeal period. In addition, the Board has considered whether the Veteran's subjective reports of instability alone warrant a disability rating under DC 5257. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018) (finding objective medical evidence is not required to establish lateral knee instability under DC 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code). However, here, the Veteran's reports of instability throughout the appeal period were explained by the August 2021 examiner. It was noted that the Veteran's reported instability was caused by her left knee pain and limited range of motion. In other words, the feeling of instability the Veteran has experienced is a symptom of the pain and limited range of motion in her left knee. Structurally, instability tests throughout the appeal period have confirmed there is no objective indication of instability in the joint nor ligaments of the Veteran's left knee. Furthermore, as the Veteran is already in receipt of a 10 percent rating for painful motion of her left knee with limited range of motion, the Board finds a separate 10 percent rating under DC 5257 for instability caused by pain and limitation of motion would constitute pyramiding as the symptoms are not separate and distinct. 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). As such, under the pre-amended criteria of DC 5257, an additional rating is not warranted. While the Board acknowledges that separate ratings are permitted under DC 5260 and DC 5257 if and when they are compensating differing symptomatology, in this particular case, the Board finds no separate and distinct manifestations of the knee. Rather, the Veteran has no objective ligament instability or recurrent subluxation. Her subjective feelings of instability stem from the pain and limitation of motion of her knee, which is already compensated under DC 5260. Thus, under this particular circumstance, the Board finds separate ratings under DC 5257 and DC 5260 to accommodate subjective complaints of feelings of instability due to pain and limited motion would constitute impermissible pyramiding. Further, the Board considered the amended criteria of DC 5257, but the Veteran does not have a ligament tear warranting a rating for recurrent subluxation or lateral instability. There is no evidence of patellar instability involving the patellofemoral complex, as no instability has been demonstrated involving the quadriceps tendon, the patella, and the patellar tendon. Clinical testing has specifically demonstrated no instability within the left knee itself. As such, under the amended criteria of DC 5257, an additional rating is not warranted. As outlined above, the left knee disability is most appropriately rated under DC 5260 and no additional ratings are indicated. The Board recognizes the Veteran's belief that her left knee strain merits a higher rating. However, an application of the relevant diagnostic codes and consideration of the DeLuca factors indicates that a higher evaluation is not warranted based on the evidence of record. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. F. Minnitte, Attorney Advisor 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.