Citation Nr: 21075152 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 14-10 748A DATE: December 17, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for right knee limitation of flexion prior to May 25, 2021, and in excess of 20 percent since May 25, 2021, is denied. Entitlement to an initial compensable rating for right knee limitation of extension prior to May 25, 2021, and a rating in excess of 30 percent since May 25, 2021, is denied. Entitlement to an increased initial rating for left knee limitation of flexion, currently rated as 10 percent disabling, is denied. Entitlement to an initial compensable rating for left knee limitation of extension prior to May 25, 2021, and a rating in excess of 30 percent since May 25, 2021, is denied. Entitlement to an increased initial rating for left knee instability, currently rated as 10 percent disabling, is denied. Entitlement to restoration of a 30 percent rating, but no greater, for right knee patellar subluxation, is granted. FINDINGS OF FACT 1. Prior to May 25, 2021, the Veteran's right knee disability was manifested by limitation of flexion to greater than 30 degrees. 2. Since May 25, 2021, the Veteran's right knee disability was manifested by limitation of flexion to greater than 15 degrees. 3. Prior to May 25, 2021, the Veteran's right knee disability was manifested by limitation of extension to less than ten degrees. 4. Since May 25, 2021 the Veteran's right knee disability was manifested by limitation of extension to less than 20 degrees. 5. The Veteran's left knee disability is manifested by limitation of flexion to greater than 30 degrees. 6. Prior to May 25, 2021, the Veteran's left knee disability was manifested by limitation of extension to less than ten degrees. 7. Since May 25, 2021 the Veteran's left knee disability was manifested by limitation of extension to less than 20 degrees. 8. The Veteran's left knee disability is manifested by slight lateral instability, without a medical provider prescribed assistive device or bracing for ambulation. 9. The evidence of record at the time of the rating reduction does not make it reasonably certain that any improvement to the Veteran's right knee patellar subluxation will be maintained under the ordinary conditions of life. The Veteran's right knee patellar subluxation is rated as 30 percent disabling, the schedular maximum. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee limitation of flexion prior to May 25, 2021, and in excess of 20 percent since May 25, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5258-5260. 2. The criteria for an initial compensable rating for right knee limitation of extension prior to May 25, 2021, and a rating in excess of 30 percent since May 25, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5003-5261. 3. The criteria for an initial rating for left knee limitation of flexion in excess of 10 percent disabling have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5003-5260. 4. The criteria for an initial compensable rating for left knee limitation of extension prior to May 25, 2021, and a rating in excess of 30 percent since May 25, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5003-5261. 5. The criteria for an initial rating for left knee instability in excess of 10 percent disabling have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, DC 5003-5257. 6. The decision to reduce the rating for right knee patellar subluxation from 30 percent to 20 percent, and then to non-compensable, was not proper, and restoration of a 30 percent rating, but no greater, is warranted. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 4.7, 4.21, 4.104, DC 5003-5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1973 to October 1977. The Veteran testified at an April 2018 Board hearing before the undersigned Veterans Law Judge, and a transcript of the hearing is of record. In June 2018, the Board remanded these matters to provide the Veteran with an updated VA examination of the left and right knees. In October 2019, the Board again remanded these matters to give the Veteran another opportunity to attend a VA knee examination, which he had declined to attend after the prior remand. Updated VA examinations were provided in December 2019 and January 2021. The Board most recently remanded these matters in April 2021 to provide an updated VA knee examination in light of updated rating criteria. As the VA examination was provided in May 2021, there has been substantial compliance with the prior remand directives and the matter is again before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, as is the case here, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). 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 actually 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. 1. Entitlement to an initial rating in excess of 10 percent for right knee limitation of flexion prior to May 25, 2021, and in excess of 20 percent since May 25, 2021 2. Entitlement to an initial compensable rating for right knee limitation of extension prior to May 25, 2021, and a rating in excess of 30 percent since May 25, 2021 3. Entitlement to an increased initial rating for left knee limitation of flexion, currently rated as 10 percent disabling 4. Entitlement to an initial compensable rating for left knee limitation of extension prior to May 25, 2021, and a rating in excess of 30 percent since May 25, 2021 5. Entitlement to an increased initial rating for left knee instability, currently rated as 10 percent disabling 6. Entitlement to an increased rating for right knee patellar subluxation, initially rated as 30 percent disabling, and reduced to 20 percent disabling from July 1, 2014, and to a noncompensable evaluation effective May 25, 2021, to include consideration of whether it was appropriate to reduce the rating The Veteran contends that the severity of his service-connected left and right knee symptoms warrants ratings in excess of those assigned. The Veteran's right knee osteoarthritis, rated as limitation of flexion of the right knee, was rated as 10 percent disabling prior to May 25, 2021, and 20 percent disabling since May 25, 2021, under Diagnostic Code (DC) 5258-5260. The Veteran's right knee limitation of extension has been rated as noncompensable (zero percent disabling) prior to May 25, 2021, and a rated as 30 percent disabling since May 25, 2021, under DC 5003-5261. The Veteran's left knee limitation of flexion is rated as 10 percent disabling under DC 5003-5260. The Veteran's left knee limitation of extension has been rated as noncompensable prior to May 25, 2021, and 30 percent disabling since May 25, 2021 under 5003-5261. The Veteran's right knee patellar subluxation has been rated as 30 percent disabling prior to July 1, 2014, and was reduced to 20 percent disabling from July 1, 2014 to May 25, 2021, and reduced to noncompensable since May 25, 2021 under DC 5003-5257. The Veteran's left knee instability is rated as 10 percent under DC 5003-5257. A hyphenated DC may be used to identify the proper evaluation of a disability or a residual from disease. The first DC of a hyphenated code identifies the diagnosed disease or condition. The second DC of a hyphenated code identifies the criteria in the Schedule for Rating Disabilities used to evaluate the disability. Diagnostic Criteria for the Knee VA's Schedule for Rating Disabilities includes several Diagnostic Codes applicable to evaluating knee and leg disabilities. See 38 C.F.R. § 4.71a. The regulations pertaining to rating the musculoskeletal system were amended, effective February 7, 2021, per Final Rule AP88. Claims, such as this, pending prior to the effective date will be considered under both the old and new rating criteria from that date, and whatever criteria is more favorable to the Veteran will be applied from that date. Diagnostic Code 5003 provides that degenerative arthritis that is 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 there is some limitation of motion of the specific joint or joints involved that is non-compensable (zero percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent 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. Since February 7, 2021, Diagnostic Code 5003 applies to degenerative arthritis other than post-traumatic arthritis, and Diagnostic Code 5010 applies to post-traumatic arthritis. Under Diagnostic Code 5019, bursitis is evaluated as degenerative arthritis, on the basis of limitation of motion of the affected part. Diagnostic Codes 5260 and 5261 are used to rate limitation of flexion and of extension of the knee. Under Diagnostic Code 5260, limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating, and limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, limitation of extension of the knee to 5 degrees warrants a zero or non-compensable rating. Limitation of extension of the knee to 10 degrees warrants a 10 percent rating. Limitation of extension of the knee to 15 degrees warrants a 20 percent rating. Limitation of extension of the knee to 20 degrees warrants a 30 percent rating. Limitation of extension of the knee to 30 degrees warrants a 40 percent rating, and limitation of extension of the knee to 45 degrees warrants a 50 percent rating. Normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Prior to February 7, 2021, under Diagnostic Code 5257, a 10 percent rating is warranted for slight knee impairment, that is, recurrent subluxation or lateral instability. A 20 percent rating is assigned for a moderate degree of impairment, and a maximum rating of 30 percent is assigned for severe impairment. The words slight, moderate, moderately severe, marked, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence in reaching a decision that is "equitable and just." 38 C.F.R. § 4.6. Since February 7, 2021, under Diagnostic Code 5257, recurrent subluxation or instability is rated at 10 percent disabling for sprain, incomplete ligament tear, or complete ligament tear causing persistent instability, without a prescription from a medical provider for an assistive device. A 20 percent rating assigned for one of 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 device for ambulation, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is assigned for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Since February 7, 2021, under Diagnostic Code 5257, patellar instability is rated as 10 percent disabling for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is assigned 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 rating is assigned 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. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. Evidence The Veteran was provided with a VA knee and lower leg examination in January 2013. The examiner noted that the Veteran had been diagnosed with chondromalacia patella, osteoarthritis, and internal derangement of the bilateral knees. The Veteran reported that for two to six days out of the month he is unable to go anywhere or be up on his knees. Range of motion (ROM) testing found left and right knee flexion and extension from zero to 140 without objective evidence of painful motion. There was no additional limitation in ROM after repetitive use. However, more movement than normal and pain on movement were noted after repetitive use. The examiner noted extreme pain with patellar grind bilaterally, with laxity of the right medial collateral ligament. Pain on palpation was noted on the right knee. Muscle strength testing was normal. Joint stability testing was normal for the left knee, but there was medial-lateral instability of the right knee. Severe patellar subluxation/dislocation was noted in the right knee. The Veteran's residuals of meniscal tear with meniscectomy were found to cause frequent episodes of joint locking, joint pain, and joint effusion in both knees. The Veteran was noted to occasionally use brace(s) for locomotion. The Veteran was provided with a VA knee and lower leg examination in January 2014. The examiner listed the Veteran's medical history as left and right knee osteoarthritis, with multiple meniscectomy surgeries, and right knee severe patellar subluxation. The Veteran reported weekly flare-ups which last for days and cause pain in both knees and difficulty with walking or moving. Left and right knee ROM testing found flexion and extension from zero to 130 degrees, without objective evidence of painful motion. Repetitive use testing did not cause any loss of ROM, but did cause less movement than normal and pain on movement in both knees. Muscle strength testing was normal. Joint stability testing was normal in both knees for anterior instability, posterior instability, and medial-lateral instability. There was no evidence of recurrent patellar subluxation or dislocation. The Veteran's residuals of meniscal condition with meniscectomies were found to cause frequent episodes of joint pain. June 2017 private medical records show treatment for moderate bilateral knee arthritis. A physical examination found that the Veteran's right knee sits in 2 degrees valgus alignment and the left knee sits in three degrees varus alignment. The private physician noted the presence of effusion, crepitus, and patellofemoral grind. Diagnostic imaging from September 2017 and January 2018 revealed advanced degenerative changes of the bilateral knees, as well as a moderate to high-grade partial tear of the medial meniscus in the left knee. At the February 2018 hearing, the Veteran testified that his bilateral knee conditions have worsened since the last examination. The Veteran testified that his knee disabilities caused him to stumble, slip, and fall three to four times per week, and he rated his pain as seven out of ten. Pursuant to a Board remand, the Veteran was provided with another VA knee and lower leg examination in December 2019. The examiner noted the Veteran's diagnoses to include right knee tendonitis/tendonosis, bilateral meniscal tear, bilateral knee joint osteoarthritis, right knee recurrent subluxation, bilateral knee cartilage restoration surgery, bilateral chondromalacia patellae, and right knee bursitis. The examiner also noted that the Veteran suffered a left knee high-grade partial MCL tear in 2018. The Veteran reported that three to four times per month he has a flare-up of severe pain requiring virtually no ambulation or standing. This lasts for one to two days, and is treated with pain medical and ice. The Veteran also reported that he can spend no more than an hour at a time standing, walking and no more than two to four hours total in a day on his feet. He has to avoid uneven surfaces, impact activities, and any turning or twisting motions. He can rarely climb stairs. He cannot kneel at all, and has limited flexion, making bending over very difficult. During the December 2019 examination, ROM testing found right knee flexion and extension from zero to 90 degrees, and left knee flexion and extension from 0 to 80 degrees. Pain was noted on examination which caused functional loss. There was pain with weight bearing and severe pain to palpation to the patella, and moderate pain to palpation over the medical and lateral joint lines. There was no additional functional loss or ROM after three repetitions. The examiner found that, during flare-ups, the Veteran's right knee ROM would be limited to flexion and extension of five to 50 degrees, and left knee ROM would be limited to flexion and extension from five to 40 degrees. Bilateral muscle strength testing found active movement against some resistance. There was no muscle atrophy and no ankylosis. The examiner found a history of slight right knee recurrent subluxation, and slight left knee lateral instability. Joint stability testing was normal except for left knee medial instability. The Veteran's history of meniscal tear was found to cause frequent episodes of joint locking, joint pain, and joint effusion. The Veteran was noted to occasionally use brace(s) as an assistive device. However, there was no indication that an assistive device was prescribed by a medical provider. The Veteran was provided with another VA knee and lower leg examination in January 2021. The examiner noted that the Veteran's medical history contained diagnoses of left and right knee osteoarthritis, with multiple meniscectomy surgeries and right knee severe patellar subluxation. The Veteran reported flare-ups described as increased pain and discomfort which will also occur with change of the weather. The Veteran reported functional loss including increased pain, which limits ROM and activity, especially with deep knee bending. ROM testing found right knee flexion and extension from zero to 95 degrees, and left knee flexion and extension from zero to 85 degrees. Pain on motion caused functional loss, including being unable to fully squat. Mild localized pain around the left and right anterior knee joint was noted. There was no additional loss of ROM or function after three repetitions. Muscle strength testing was normal, and there was no muscle atrophy. There was no ankylosis. Joint stability testing was normal and there was no joint instability in either the left or right knee. The examiner noted a history of meniscal tear with multiple surgeries to both knees to repair menisci. Pursuant to the most recent Board remand, the Veteran was provided with a VA knee and lower leg examination on May 25, 2021. The examiner noted a medical history of instability, left knee osteoarthritis with bursitis, tendonitis and chondromalacia patellae; patellar subluxation, right knee; left knee osteoarthritis; limitation of extension, left knee osteoarthritis with bursitis, tendonitis and chondromalacia patellae; limitation of extension, right knee osteoarthritis with bursitis, knee tendonitis and chondromalacia patellae. The Veteran reported moderate flare-ups after repeated use over time, causing increased knee pain and alleviated by rest. These flare-ups negatively impact his ability to perform occupational tasks, including prolonged periods of walking. ROM testing found right and left knee flexion and extension from 10 to 130 degrees. There was no additional loss of function or ROM after three repetitions. After repetitive use, and during flare-ups, the examiner found right and left knee estimated flexion and extension would be from 20 to 120 degrees. The examiner also found that disturbance of locomotion would also be a contributing factor to disability. There was no muscle atrophy or ankylosis. The examiner noted recurrent subluxation or persistent instability in the left knee but not the right knee. The examiner found that the Veteran was not prescribed an assistive device for walking. The examiner found no recurrent patellar instability. The examiner found that the Veteran's meniscus condition would cause frequent episodes of joint pain and effusion. Analysis Regarding the Veteran's right knee limitation of flexion prior to May 25, 2021, the evidence does not show that a rating in excess of 10 percent is warranted. To warrant a higher rating under DC 5260, the evidence would have to show limitation of flexion of the knee to 30 degrees or less during this period. As none of the VA examinations or other medical evidence of record shows such a limitation of flexion, a rating in excess of 10 percent prior to May 25, 2021 under DC 5260 is not warranted. Regarding the Veteran's right knee limitation of flexion since May 25, 2021, the evidence does not show that a rating in excess of 20 percent is warranted. To warrant a higher rating under DC 5260, the evidence would have to show limitation of flexion of the knee to 15 degrees or less during this period. As none of the VA examinations or other medical evidence of record shows such a limitation of flexion, a rating in excess of 20 percent since May 25, 2021 under DC 5260 is not warranted. Regarding the Veteran's right knee limitation of extension prior to May 25, 2021, the evidence does not show that a compensable rating is warranted. To warrant a higher rating under DC 5261, the evidence would have to show limitation of extension of the knee to 10 degrees or greater during this period. As none of the VA examinations or other medical evidence of record shows such a limitation of extension, a compensable rating prior to May 25, 2021 under DC 5261 is not warranted. Regarding the Veteran's right knee limitation of extension since May 25, 2021, the evidence does not show that a rating in excess of 30 percent is warranted. To warrant a higher rating under DC 5261, the evidence would have to show limitation of extension of the knee to 20 degrees or greater during this period. As none of the VA examinations or other medical evidence of record shows such a limitation of extension, a rating in excess of 30 percent since May 25, 2021 under DC 5261 is not warranted. Regarding the Veteran's left knee limitation of flexion, the evidence does not show that a rating in excess of 10 percent is warranted. To warrant a higher rating under DC 5260, the evidence would have to show limitation of flexion of the knee to 30 degrees or less during this period. As none of the VA examinations or other medical evidence of record shows such a limitation of flexion, a rating in excess of 10 percent throughout the appeal period under DC 5260 is not warranted. Regarding the Veteran's left knee limitation of extension prior to May 25, 2021, the evidence does not show that a compensable rating is warranted. To warrant a higher rating under DC 5261, the evidence would have to show limitation of extension of the knee to 10 degrees or greater during this period. As none of the VA examinations or other medical evidence of record shows such a limitation of extension, a compensable rating prior to May 25, 2021 under DC 5261 is not warranted. Regarding the Veteran's left knee limitation of extension since May 25, 2021, the evidence does not show that a rating in excess of 30 percent is warranted. To warrant a higher rating under DC 5261, the evidence would have to show limitation of extension of the knee to 20 degrees or greater during this period. As none of the VA examinations or other medical evidence of record shows such a limitation of extension, a rating in excess of 30 percent since May 25, 2021 under DC 5261 is not warranted. Regarding the Veteran's left knee lateral instability, prior to February 7, 2021, to warrant a rating in excess of 10 percent under Diagnostic Code 5257, the evidence would have to show a moderate or greater degree of impairment. Joint stability testing was normal for the left knee during VA examinations conducted in January 2013 and January 2014. The December 2019 examiner found slight left knee lateral instability. Joint stability testing was normal in January 2021. While the May 2021 examiner noted peristent instability in the left knee, it was not noted to be moderate or severe. While the Veteran reported using a knee brace, the medical evidence of record does not show that it was prescribed by a medical provider. As the evidence of record does not show a moderate or greater degree of impairment due to left knee instability, and that an assistive device or bracing was not prescribed by a medical provider, the evidence does not support a rating in excess of 10 percent under DC 5257 throughout the period on appeal under either the new or old criteria. Restoration of Right Knee Subluxation Rating There are required procedures when a rating is reduced. Specifically, the provisions of 38 C.F.R. § 3.105(e) allow for the reduction in evaluation of a service-connected disability when considered warranted by the evidence but only after following certain procedural guidelines. Several general regulations apply to all rating reduction cases, regardless of how long the rating has been in effect. Specifically, the United States Court of Appeals for Veterans Claims (Court) has stated that certain regulations "impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon a review of the entire history of the veteran's disability." Brown v. Brown, 5 Vet. App. 413, 420 (1993). A rating reduction requires an inquiry as to "whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations." Id. at 421. A claim as to whether a rating reduction was proper must be resolved in the veteran's favor unless the Board concludes that a fair preponderance of evidence weighs against the claim. Id. Regarding the Veteran's right knee patellar subluxation, a January 2013 VA examination noted severe patellar subluxation dislocation in the right knee. In January 2014, the VA examiner found no evidence of patellar subluxation. June 2017 private medical records show treatment for moderate bilateral knee arthritis, and that the Veteran's right knee sits in 2 degrees valgus alignment. At the February 2018 hearing, the Veteran testified that his bilateral knee conditions have worsened since the last examination. The Veteran testified that his knee disabilities cause him to stumble, slip, and fall three to four times per week, and he rated his pain as seven out of ten. A December 2019 VA examination found a history of slight right knee recurrent subluxation. In January 2021, a VA examiner noted a history of right knee severe patellar subluxation. A VA examiner again noted a history of right knee patellar subluxation in May 2021. The medical evidence of record does not present a picture of an improving disability but rather one with symptoms that vary in their severity, including periods of more severe symptoms consistent with a 30 percent rating. The Board finds that the medical evidence of record at the time of the reduction does not show a sufficient sustained improvement in the Veteran's disability, particularly under the conditions of ordinary life. Accordingly, restoration of the 30 percent rating for the Veteran's right knee patellar subluxation, the maximum under the rating schedule, is warranted. Additional Considerations The record does not contain evidence of impairment of the tibia and fibula or genu recurvatum noted in any of the lay or medical evidence of record, evaluation of the right and left knees under Diagnostic Codes 5262, or 5263, respectively, is not warranted. With respect to Diagnostic Code 5258, the Board notes that while the Veteran had a history of dislocation of the semilunar cartilage, as indicated below, the Veteran subsequently underwent removal of semilunar cartilage in both knees. Therefore, there is no evidence that his knee disabilities were manifested by meniscal tears to warrant a separate rating under Diagnostic Code 5258. See 38 C.F.R. § 4.71a, Diagnostic Code 5258. Regarding Diagnostic Code 5259, which contemplates symptomatic removal of the semilunar cartilage, the Board notes that the Veteran underwent multiple meniscectomies of both knees. However, the Veteran may not be assigned separate ratings under both Diagnostic Code 5257 and Diagnostic Code 5259 as to do so would constitute pyramiding. The Veteran is already in receipt of a 30 percent rating under Diagnostic Code 5257 for right knee patellar subluxation and a 10 percent rating under Diagnostic Code 5257 for left knee instability. The Board finds that the symptomatic residuals associated with the bilateral knee meniscectomies are already contemplated in the assigned 30 percent rating for right knee patellar subluxation and 10 percent rating for left knee instability pursuant to DC 5257. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The left knee instability and right knee patellar subluxation that are symptomatic residuals of the meniscus removals overlap with the symptomatology upon which the ratings under DC 5257 have been based. Therefore, the Board finds that assigning separate compensable ratings under DC 5259 would constitute pyramiding prohibited by 38 C.F.R. § 4.14 because it would compensate the Veteran twice for the same knee symptomatology, here, instability and subluxation. The Board has considered whether higher ratings should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria but determines that higher ratings are not warranted for the Veteran's disability picture. The Board acknowledges that the Veteran has scars associated with his service-connected left and right knee disabilities. However, these scars are already appropriately contemplated by the award of separate non-compensable ratings for scars of the left and right knee under DC 7805. As discussed above, the preponderance of the evidence is against the claims for higher ratings than those assigned for left and right knee limitation of flexion, limitation of extension, and left knee instability. Therefore, the doctrine of reasonable doubt is not for application for the claims. However, reasonable doubt has been considered in restoring the Veteran's 30 percent rating, but no greater, under Diagnostic Code 5257 for right knee patellar subluxation. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.71a, DC 5010-5260, 5256, 5257; Gilbert, 1 Vet. App. at 54-56. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Casey, 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.