Citation Nr: 21072645 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 15-06 385 DATE: December 3, 2021 ORDER Service connection for a back disability, to include degenerative disc disease of the lumbar spine and lumbosacral strain is denied. A rating in excess of 10 percent for service-connected left knee patellofemoral syndrome is denied. A separate 10 percent disability rating for service-connected instability of the left knee from May 23, 2012 is granted. FINDINGS OF FACT 1. The Veteran's back disability, to include degenerative disc disease of the lumbar spine and lumbosacral strain did not have its onset during active service, did not manifest to a compensable degree within one year of service discharge, and is not otherwise related to any disease or injury in service, to include as secondary to his service-connected left knee and/or depressive disorder. 2. The preponderance of the evidence shows that the flexion of the left knee was not limited to 30 degrees or less with consideration of reduced function on repetitive motion or during flare-ups at any time during the appeal period; or, extension limited to 10 degrees or more even with consideration of reduced function on repetitive motion or during flare-ups. 3. The evidence is evenly balanced as to whether the Veteran's left knee patellofemoral syndrome is manifested by slight instability. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for a rating in excess of 10 percent for service-connected left knee patellofemoral syndrome, on the basis of painful limited motion, have not all been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 3. The criteria for a separate 10 percent disability rating, but no higher, for service-connected left knee instability from May 23, 2012, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1982 to November 1986 and November 1987 to October 1990. This appeal comes before the Board of Veterans' Appeals (Board) from a November 2012 and November 2013 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In the November 2012 rating decision, the RO, in pertinent part, denied a rating in excess of 10 percent for service-connected left knee patellofemoral syndrome. In the November 2013 rating decision, the RO, in pertinent part, denied service connection for a lower back disability. The Veteran's notice of disagreement (NOD) was received in November 2013. The RO issued the statement of the case (SOC) in February 2015, and the Veteran's VA Form 9, substantive appeal was received in February 2015. In September 2018 and September 2020, the Board remanded the case to the RO for further development and adjudicative action. In August 2016, the Veteran submitted a VA 21-8940 Veterans Application for Increased Compensation Based on Unemployability wherein he stated that depression, knee pain and lower back pain prevent him from securing or following any substantially gainful occupation. Thus, an inferred claim for TDIU was raised as part and parcel of his increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). During the pendency of the appeal, in November 2016, the RO issued a rating decision granting TDIU effective August 17, 2016. The Veteran has an appeal pending pursuant to the Appeals Modernization Act (AMA), which addresses entitlement to a total disability rating based on individual unemployability (TDIU) for the period on appeal prior to August 17, 2016. As the Veteran specifically opted the issue of entitlement to TDIU into AMA and his AMA appeal follows separate procedural guidelines in addition to the application of regulations specific to the adjudication of AMA claims, a separate decision will be promulgated addressing that claim. Finally, relevant evidence has been associated with the claims file following the most recent Supplemental Statement of the Case. However, in July 2021 correspondence, the Veteran waived his right to have his case remanded to the agency of original jurisdiction for review of the additional evidence and requested that the Board proceed with the adjudication of his appeal. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases may also be established based upon a legal "presumption" by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. 1. Entitlement to service connection for a back disability to include degenerative disc disease of the lumbar spine and lumbosacral strain. The Veteran generally contends that he has a back disability that is secondary to his service-connected left knee and service-connected depressive disorder. See May 2012 Supplemental Claim, August 2012 VA examination report and February 2015 correspondence and medical treatise. VA treatment records reflect current diagnoses of lumbosacral strain and degenerative disc disease of the lumbar spine. See e.g. November 2020 VA examination, VA treatment records dated in December 2017 and private treatment records dated in November 2018 (MRI report). Service treatment records (STRs) reflect that the Veteran was treated in February 1983 and July 1983 for muscle spasms of the upper back. The rest of the Veteran's STRs are silent for complaints, treatment, or diagnoses pertaining to a back disability. On Reports of Medical History completed in April 1987 and May 1989, the Veteran affirmatively denied ever experiencing recurrent back pain. In February 2001, private treatment records indicate that the Veteran began experiencing back pain after pulling a muscle in his back while operating a welding robot. In August 2012, the Veteran underwent a VA examination for his claim. The VA examiner found that the Veteran did not have a diagnosis of a back disability. The examiner noted that the Veteran has been complaining of low back pain for years now, that he relates to his prior left knee injury. Following the examination and records review, the VA examiner concluded that it is less likely as not that the Veteran's back pain is caused by or the result of the Veteran's left knee disability. The examiner stated that injury to the left knee would not cause his current complaints of back pain and explained that there is no causal relationship between chronic left knee pain and back pain. On a December 2013 claim for benefits from the Social Security Administration (SSA), the Veteran reported that his low back pain began in 1995. During an April 2016 VA Mental Disorder examination, the Veteran reported that his "back and knees hurt all the time from being on the concrete" during his career as a welder from approximately 1992 to 2010. An October 2016 VA treatment note indicates that imaging of the Veteran's lumbosacral spine was normal. The Veteran most recently underwent a VA examination in November 2020. He was diagnosed with lumbosacral strain. The Veteran reported that he began experiencing lower back pain in 2010. Following the examination and records review, the VA examiner concluded that it is less likely as not that the Veteran's back disability was incurred in or caused by the claimed in-service injury, event or illness. The examiner stated that no records indicate that an in-service injury or event caused his current chronic back pain/strain. The examiner noted that the Veteran was seen for upper back pain/strain twice in 1983 but stated that there were no chronic or recurrent complaints of back pain to support a nexus. Regarding secondary service connection, the examiner concluded that it is less likely as not that the Veteran's back disability is proximately due to or the result of his service-connected depressive disorder or left knee disability. The examiner explained that no current, good studies, rationale, or the Veteran's history support or conclude that the Veteran's current back disability is at least as likely as not proximately due to or the result of his service-connected depressive disorder or left knee disability. The examiner similarly stated that no current, good studies, rationale, or the Veteran's history support or conclude that the Veteran's current back disability was at least as likely as not aggravated beyond its natural progression by the service-connected depressive disorder or left knee disability. The examiner stated that he reviewed the articles submitted by the Veteran and that it is nothing new to postulate that depression and/or anxiety may increase perceptions of pain. However, he stated that no current, good studies or rationale can conclude how much, if any, in an individual case. The examiner explained that no good current studies conclude that anxiety/depression specifically cause strains or arthritis and there is no real way in this Veteran to estimate a baseline of which to quantitate any aggravation, if any. After a careful review of the record, the most probative evidence of record is against the Veteran's claim. As such, service connection for back disability, degenerative disc disease of the lumbar spine and lumbosacral strain, to include as secondary to the Veteran's service-connected left knee disability and depressive disorder is denied. The Veteran's back disability did not have its onset in service and did not manifest to a compensable degree within one year of discharge. While the Veteran was treated for muscle spasms of the upper back twice during service in 1983, the rest of his STRs are silent for complaints, treatment, or diagnosis pertaining to a back disability and on separation the Veteran affirmatively denied experiencing recurrent back pain. The first documented post-service complaint of back pain is in 2001, more than 10 years after service. Notably, the Veteran has not stated that his back pain began in service and has continued since service. Instead, he has variously reported that his back pain began in 1995 and 2010. Compare December 2013 SSA Application with November 2020 VA examination report. Accordingly, the Veteran's degenerative disc disease of the lumbar spine and lumbosacral strain did not have its onset in service and did not manifest to a compensable degree within one year of discharge. With respect to the issue of nexus, the November 2020 VA examination report indicates that there is no nexus between the Veteran's back disability and his service, to include his service-connected left knee disability and depressive disorder. Regarding direct service connection, the November 2020 VA examiner noted that the Veteran was treated for muscle spasms of the upper back during service but determined that it is less likely as not that the Veteran's current back disability was incurred in or caused by the claimed in-service injury, event or illness. Regarding secondary service connection, the November 2020 VA examiner considered the Veteran's lay statements and the submitted medical treatise evidence but determined that it is less likely as not that the Veteran's current back disability is proximately due to or the result of his service-connected depressive disorder or left knee disability and that it is less likely as not that the Veteran's current back disability was aggravated beyond its natural progression by the service-connected depressive disorder or left knee disability. The November 2020 VA medical opinion is persuasive and probative as the examiner provided a clear explanation for the medical opinions based on a review of the claims file, evaluation of the Veteran, consideration of the Veteran's lay statements, and general medical expertise as a physician. Additionally, there is no competent medical opinion establishing an etiological relationship between the Veteran's active service or service-connected left knee disability and depressive disorder and his current back disability. Thus, the preponderance of the evidence of record weighs against finding that the Veteran's degenerative disc disease of the lumbar spine and lumbosacral strain is related to his active service, to include as secondary to service-connected left knee disability and depressive disorder. The Board acknowledges that the November 2020 opinion used the phrase "beyond natural progression" in providing its conclusion regarding aggravation. In Ward v. Wilkie, 31 Vet. App. 233 (2019), the Court clarified that secondary service connection does not require "permanent" worsening of a claimed disability by the service-connected disability and requires considering whether there has been any worsening, no matter how incremental, even if not above and beyond the condition's natural progression. Here, the rationale provided by the November 2020 examiner makes clear that the examiner did not find any association between the Veteran's current degenerative disc disease of the lumbar spine and lumbosacral strain and his service-connected left knee disability and depressive disorder. There is no suggestion that anything other than the natural progression of the disability contributed to or aggravated the back disability The Veteran's belief that his back disability was caused by or aggravated by his service-connected left knee disability and depressive disorder is no doubt sincere. However, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the musculoskeletal system and laboratory testing. Therefore, it is outside the competence of the Veteran because the record does not show that he has the skills or medical training necessary to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). In sum, the Veteran's back disability did not have its onset in service, did not manifest to a compensable degree within one year of service, and the preponderance of the evidence is against a finding that the back disability is otherwise causally related to the Veteran's service, to include secondary to his service-connected left knee disability and depressive disorder. Accordingly, as the preponderance of the evidence is against the claim, service connection for degenerative disc disease of the lumbar spine and lumbosacral strain is not warranted. Increased Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 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."). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion (ROM) testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with ROM measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Effective February 7, 2021, the regulations governing disability ratings for musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, although not all of the diagnostic criteria were affected. Any changes to the criteria that are applicable to the claims on appeal are indicated below. 2. Entitlement to a rating in excess of 10 percent for service-connected left knee patellofemoral syndrome. 3. Entitlement to a separate compensable rating for service-connected instability of the left knee. The Veteran contends that he is entitled to a higher rating for his service-connected left knee patellofemoral syndrome. The assigned Diagnostic Code 5257 suggests that the left knee patellofemoral syndrome is rated based on slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. However, a review of the evidence and past rating decisions reflects that the left knee patellofemoral syndrome has also been evaluated based on painful noncompensable limitation of motion under 38 C.F.R. § 4.59, and that patellofemoral syndrome of the left knee has manifested in painful but not compensable limitation of motion throughout the relevant rating period. Notably, the February 1990 rating decision which granted service connection for left knee patellofemoral syndrome mentions left knee pain but no instability. Therefore, the Diagnostic Code assigned could have been Diagnostic Code 5299-5260, to show that the patellofemoral syndrome is being rated based on noncompensable limitation of motion that is painful. For this reason, the Board will change the Diagnostic Code for left knee patellofemoral syndrome to reflect the actual rating already assigned. 38 C.F.R. § 4.71a. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For purpose of rating a disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, (limitation of flexion), a 10 percent disability rating is warranted for flexion limited to 45 degrees. Limitation of flexion to 30 degrees warrants a 20 percent disability rating. A 30 percent disability rating is assigned for flexion limited to 15 degrees or less. In order for the Veteran to receive a 10 percent rating under Diagnostic Code 5261 (limitation of leg extension), the evidence must show that his knee disability is manifested by leg extension limited to 10 degrees. A 20 percent rating under Diagnostic Code 5261 is warranted if the evidence shows leg extension limited to 15 degrees. The Veteran is entitled to a 30 percent disability rating for leg extension limited to 20 degrees. A veteran who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (September 17, 2004). A November 2013 VA examination reveals that flexion of the left knee was to 110 degrees and extension was to zero degrees. There was pain on flexion and extension. There was no additional limitation in range of motion following repetitive use testing but the examiner did not assess whether the joint function of the left knee was additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use or during flare-ups. Joint stability testing was normal. The Veteran underwent another VA examination in November 2020. The Veteran reported constant aching in both knees and pain with squatting. He denied flare-ups. He reported functional loss or functional impairment in that he cannot perform repetitive squatting or climb stairs or ladder. Physical examination revealed 120 degrees of flexion and normal extension in the left knee. The range of motion itself did not contribute to functional loss. There was pain on flexion, objective evidence of localized tenderness over the lateral knee, pain with weight-bearing and objective evidence of crepitus. There was no additional functional limitation following repetitive use. The examiner noted that the Veteran was not examined immediately after repeated use over time and stated that pain significantly limits functional ability with repeated use over a period of time. The examiner estimated that range of motion would be to 120 degrees of flexion and 0 degrees of extension after repeated use over time. Additional factors contributing to the Veteran's left knee disability were described as disturbance of locomotion. Muscle strength testing was within normal limits. There was no atrophy. There was no ankylosis. Joint stability testing was normal for the left knee and there was no history of recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The examiner stated that the Veteran had a meniscal tear and subsequent meniscectomy in 2010 and experiences frequent episodes of joint pain. The examiner stated that the residuals of the meniscectomy are continued knee pain. The Veteran did not use any assistive devices as a normal mode of locomotion. Diagnostic imaging was performed which revealed degenerative arthritis in both knees. The Veteran reported functional impact in the form of inability to repetitively kneel, squat, and climb ladders and stairs. There was objective evidence of pain on passive range of motion testing and on non-weightbearing testing of the left knee. Passive range of motion was the same as active range of motion, including consideration of pain. The Veteran most recently underwent a VA examination in March 2021. The Veteran reported flare-ups of the left knee which occur weekly, are moderate in severity, and last hours to days. The flare-ups are precipitated by standing, bearing weight, and walking and are alleviated by rest, elevation and over the counter pain medication. The Veteran reported functional loss or functional impairment in the form of decreased flexion. He also reported that his knees give out from under him and swell several times a week. Physical examination revealed 120 degrees of flexion and normal extension in the left knee. The range of motion itself did not contribute to functional loss. Passive range of motion was the same as active range of motion. There was pain on flexion and extension during both passive and active range of motion. There was pain on weight-bearing, nonweight-bearing and on rest/non-movement. Pain did not result in or cause functional loss. There was objective evidence of moderate localized tenderness along the anterior and posterior. There was objective evidence of crepitus. There was no additional functional limitation following repetitive use. The examiner noted that the Veteran was not examined immediately after repeated use over time and stated that pain and weakness significantly limit functional ability with repeated use over a period of time. The examiner estimated that range of motion would be to 120 degrees of flexion and 0 degrees of extension after repeated use over time. The examiner noted that the Veteran was not examined during a flare-up and stated that pain, fatigability, incoordination, lack of endurance and weakness significantly limit functional ability during flare-ups. The examiner estimated that range of motion would be to 60 degrees of flexion and 0 degrees of extension during a flare-up. Additional factors contributing to the Veteran's left knee disability were described as interference with standing, interference with sitting, swelling, disturbance of locomotion, instability of station, weakened movement, pain and inflammation. There was no muscle atrophy. There was no ankylosis. There was no history of recurrent subluxation or persistent instability, ligament tear (sprain) or patellar instability. The examiner noted that the Veteran had an incomplete/partial ligament tear which has not been repaired. The Veteran did not require a prescription of an assistive device for ambulation due to his left knee disability. There was no evidence of recurrent patellar instability. The examiner stated that the Veteran does not currently and has never had a meniscal condition or tibial and/or fibular impairment affecting his left knee. However, the examiner noted that the Veteran underwent arthroscopic surgery in 2010 to clean up bone fragments. The examiner stated that the Veteran wears knee sleeves regularly for comfort, stability and support to stand. The VA examiner stated that the Veteran's bilateral knee symptoms of pain, muscle spasms, stiffness, weakness with pain, numbness, tingling and burning down the bilateral legs result in difficulty sitting, standing, bearing weight longer than 30 minutes, walking further than a quarter of a mile, bending over longer than 10 minutes and picking up or carrying heavy objects greater than 25 pounds. The examiner stated that there is a history of slight lateral instability of the left knee and findings of joint instability of the left knee. The 10 percent disability rating for the Veteran's left knee patellofemoral syndrome was assigned based on painful but noncompensable limitation of motion. As noted above, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003 for degenerative arthritis. In order to meet the criteria for the next higher 20 percent disability rating under Diagnostic Code 5260, there would have to at least be an indication of flexion limited to 30 degrees. This is clearly not the case as flexion in the Veteran's left knee has consistently been shown to be 60 degrees or more even when considering functional loss due to flare-ups and repeated use over time. Given the range of motion findings and the lack of significant functional loss, frequency, and severity with flareups, or other motion including repetitive motion, it cannot be said that range of motion would more nearly approximate flexion limited to 30 degrees as required for a 20 percent rating under DC 5260. In this regard, while the Veteran has been noted to have painful motion on extension of the left knee, this extension has consistently been documented as normal (0 degrees). Thus, a separate initial compensable disability rating based on DC 5261 is not warranted as the Veteran does not meet the criteria for even a noncompensable rating. VAOPGCPREC 9-2004 (2004) (separate ratings may be assigned under DCs 5260 and 5261, where there is compensable limitation of flexion and extension). 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). To this end, the Veteran reported in the November 2013 and March 2021 VA examinations that his left knee would occasionally give way. The March 2021 VA examiner noted that the Veteran has a history of slight lateral instability in the left knee and that additional factors contributing to his left knee disability included instability of station. 38 C.F.R. § 4.71a, Diagnostic Code 5257 evaluates recurrent subluxation or lateral instability of the knee. Prior to February 7, 2021, under this diagnostic code, slight recurrent subluxation or lateral instability warrants a 10 percent disability rating. A 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability. Severe recurrent subluxation or lateral instability warrants a 30 percent disability rating. The United States Court of Appeals for Veterans Claims has held that nothing in Diagnostic Code 5257 provides that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee. English v. Wilkie, 30 Vet. App. 347, 349 (2018). In this case, there is no objective evidence of instability of the left knee until the March 2021 VA examination. Nonetheless, the Veteran reported experiencing his left knee giving way during the November 2013 VA examination and the March 2021 VA examiner indicated that the Veteran had a history of slight lateral instability in the left knee and that the anterior instability test for the left knee was 1+. Furthermore, there is nothing in the claims to indicate that the Veteran's lay statements regarding the symptoms he experiences are not credible. Thus, the credible lay evidence supports a finding that, in addition to painful motion, the Veteran also experienced symptoms more nearly approximating slight instability in the left knee throughout the appeal period, warranting a separate compensable rating under Diagnostic Code 5257 from May 23, 2012. Resolving reasonable doubt in favor of the Veteran, entitlement to a separate 10 percent rating for slight lateral instability of the left knee under Diagnostic Code 5257 is warranted. However, the preponderance of the evidence does not support a separate rating higher than 10 percent. As discussed above, the only objective evidence of joint instability was during anterior instability testing during the March 2021 VA examination. The grant of 10 percent rating is based on the Veteran's probative reports of his left knee occasionally giving way. The description of his left knee occasionally giving way is not consistent with moderate impairment as he did not describe symptoms occurring on any consistent basis nor did he report a history of falls due to instability. He consistently denied experiencing any falls. See VA treatment records dated in December 2017, December 2018, and October 2019. Finally, there is no objective evidence to support a finding of moderate instability. Diagnostic Code 5257 was amended, effective February 7, 2021. Under the amended criteria, Diagnostic Code 5257 evaluates other impairment of the knee of recurrent subluxation or instability or recurrent patellar instability. With respect to recurrent subluxation or instability, a 20 percent disability rating is warranted for the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability and a medical provider prescribes a brace and/or assistive decide (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 prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent disability rating is warranted for 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. Regarding recurrent patellar instability, a 20 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent disability 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. In this case, while the March 2021 VA examination report shows that the Veteran's left knee disability was manifested by an incomplete/partial ligament tear, the examiner found that there was no recurrent subluxation, persistent instability, recurrent patellar instability, repaired complete ligament tear, unrepaired complete ligament tear, or failed repair of complete ligament tear. This is consistent with the medical and lay evidence. Notably, even assuming arguendo that the Veteran has persistent instability, the examiner noted that the Veteran does not require a prescription by a medical provider for any assistive devices for ambulation as required for a higher, 20 percent rating. Similarly, although the Veteran has a diagnosed condition involving the patellofemoral complex of the left knee, the medical evidence shows that he has not had surgical repair of the patellofemoral complex. Thus, the Veteran is not entitled to a disability rating in excess of 10 percent for instability of the left knee as of February 7, 2021 under the amended criteria. Disabilities of the knee and leg may also be evaluated under Diagnostic Codes 5256, 5258, 5259, 5262 or 5263. The medical and lay evidence does not show that the Veteran's left knee disability was manifested by ankylosis, any impairment of the tibia and fibula, or genu recurvatum at any time during the appeal period. While the November 2013 VA examination report indicates that the Veteran had asymptomatic shin splints affecting both knees, this is contrary to and outweighed by all other medical evidence of record, including VA treatment records and the September 2012, November 2020 and March 2021 VA examination reports, which do not reveal shin splints. Thus, Diagnostic Codes 5256, 5262 and 5263 are not applicable in this case under the prior criteria or as of February 7, 2021 under the amended criteria. Notwithstanding, the Veteran has a recorded history of meniscal conditions in the left knee. Under Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint warrants a maximum 20 percent evaluation. Under Diagnostic Code 5259, the symptomatic removal of semilunar cartilage warrants a maximum 10 percent evaluation. The medical evidence indicates that the Veteran suffered a left knee meniscal tear and underwent a meniscectomy in 2010. However, the residuals of both the meniscal tear and subsequent meniscectomy have been most consistently described as either joint pain with range of motion or no residuals. See November 2020 VA examination report and March 2021 VA examination report. While the November 2013 VA examination indicates frequent episodes of joint effusion, the examiner also stated that there were no residuals of the 2010 meniscectomy. See November 2013 VA examination report. Similarly, while the Veteran reported experiencing knee swelling several times a week during the March 2021 VA examination, the VA examiner did not attribute this swelling to the Veteran's left knee meniscal tear or meniscectomy. Moreover, the medical evidence of record does not reflect that the Veteran experiences frequent episodes of joint locking as required for a rating under Diagnostic Code 5258. Finally, as the Veteran's residual joint pain with range of motion is already contemplated by his current 10 percent rating under Diagnostic Code 5260, it would be pyramiding to assign an additional separate rating under Diagnostic Code 5259. In conclusion, the evidence is evenly balanced with respect to a separate 10 percent disability rating for slight instability of the left knee under Diagnostic Code 5257, effective May 23, 2012. However, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the service-connected left knee patellofemoral syndrome the entire appeal period. In denying such a rating, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. N. RIPPEL Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Modesto, Victor 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.