Citation Nr: 21006943 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 09-13 715 DATE: February 8, 2021 ORDER Entitlement to an evaluation in excess of 10 percent for left knee chondromalacia (left knee condition) is denied. Entitlement to an evaluation in excess of 10 percent for right knee chondromalacia (right knee condition) is denied. Entitlement to a separate evaluation of 10 percent for left knee instability from July 5, 2007 to June 23, 2011 is granted. Entitlement to a separate evaluation of 10 percent for right knee instability from July 5, 2007 to January 22, 2020 is granted. Entitlement to a rating higher than 10 percent for left knee instability for any time period on appeal is denied. Entitlement to a rating higher than 10 percent for right knee instability for any time period on appeal is denied. FINDINGS OF FACT 1. For the entire period on appeal, the left knee had range of motion no worse than limitation of flexion to 105 degrees, with normal extension, and complaints of painful motion. 2. For the entire period on appeal, the right knee had range of motion no worse than limitation of flexion to 100 degrees, with normal extension, and complaints of painful motion. 3. For the entire period on appeal, the evidence shows there is instability in the Veteran’s left knee and right knee with the use of knee braces, and that she falls when not using her braces or holding onto railings when climbing stairs, and has consistently reported locking and giving away of both knees, as well as flare-ups, which more nearly approximates slight instability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5014. 2. The criteria for a rating in excess of 10 percent for right knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5014. 3. The criteria for a separate evaluation of 10 percent for left knee instability from July 5, 2007 to June 23, 2011 have been met. 38 U.S.C. §§ 1155, 5103; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.20, 4.71a, DC 5257. 4. The criteria for a separate evaluation of 10 percent for right knee instability from July 5, 2007 to January 22, 2020 have been met. 38 U.S.C. §§ 1155, 5103; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.20, 4.71a, DC 5257. 5. The criteria for a rating in excess of 10 percent for left knee instability for any time period on appeal have not been met. 38 U.S.C. §§ 1155, 5103; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.20, 4.71a, DC 5257. 6. The criteria for a rating in excess of 10 percent for right knee instability for any time period on appeal have not been met. 38 U.S.C. §§ 1155, 5103; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.10, 4.20, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1981 to July 1996, from August 2000 to January 2001, and from July 2001 to October 2001. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a May 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing before a Veterans Law Judge (VLJ) in February 2011. A transcript of the hearing is of record. The VLJ who held the 2011 hearing has since retired from the Board. In September 2017, she was advised of this fact and given the opportunity to have another hearing. In correspondence received in October 2017, the Veteran indicated that she did not want an additional Board hearing. Therefore, the Board may proceed with adjudication of the issues on appeal, which includes consideration of the Veteran’s hearing testimony. This appeal was previously before the Board in December 2010, May 2011, January 2015, and June 2016 when the Board remanded the claims for additional development. Subsequently, in a February 2018 decision, the Board denied the Veteran’s claims for increased ratings for her bilateral knee disabilities. The Veteran appealed the Board’s 2018 decision to the United States Court of Appeals for Veterans Claims (Court). In a December 2018 Order, the Court granted a Joint Motion for Remand (JMR) vacating the Board’s February 2018 decision and remanded the matters for action consistent with the terms of joint motion. In September 2019, pursuant to the JMR, the Board remanded the claims to obtain VA medical records and obtain a new VA examination with an addendum opinion to consider the joint motion in prior examinations throughout the appeal period. Having fully reviewed the electronic claims file, the Board finds that the RO substantially complied with the Board’s prior remand directives to the extent possible. Stegall v. West, 11 Vet. App. 268, 271 (1998). While this appeal was pending, the RO issued an August 2015 rating decision that granted a separate rating for left knee instability, evaluated at 10 percent disabling effective June 24, 2011. Also, subsequent to the Board remand and following the January 2020 VA examination, in a July 2020 rating decision, the RO granted a separate rating for right knee instability, evaluated at 10 percent disabling effective January 23, 2020. Although the Veteran has not expressly appealed these ratings or effective dates, the Board finds the question of whether separate ratings should be assigned for instability is part and parcel of the pending appeal for higher ratings for the knee conditions. As discussed in more detail below, the Board finds she is entitled to separate 10 percent ratings for laxity/subluxation for the entire appeal period. Therefore, as the RO already assigned the 10 percent rating for the left knee from June 24, 2011, the Board will grant that rating from July 5, 2007 (date of claim for an increase) until June 23, 2011, so that she will have the 10 percent rating for the entire appeal period. Similarly, as the RO already assigned the 10 percent rating for the right knee from January 23, 2020, the Board will grant that rating from July 5, 2007 (date of claim for an increase) until January 22, 2020. However, in a July 2020 rating decision, the RO reduced the evaluation for the service-connected left knee instability from 10 percent to noncompensable, effective October 1, 2020. Rating reductions claims are separate from increased ratings claims. Dofflemeyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992); Peyton v. Derwinski,1 Vet. App. 282, 286(1991). The reduction in rating was not included in any subsequent Supplemental Statement of the Case, so the Veteran has not been led to believe it was part of her pending appeal. The Veteran has not yet appealed the rating reduction, although she is still within the time period for doing so. She is advised that if she disagrees with that reduction, she should file a notice of disagreement. The Board acknowledges that the record contains additional medical evidence that was associated with the claims file after the August 2020 supplemental statement of the case (SSOC). However, the evidence is not pertinent to the claims on appeal; rather the evidence is related to the Veteran’s separate claims. Because that evidence is not pertinent to this appeal, the Board may proceed to the merits of the claims before it. See 38 C.F.R. § 20.1304(c). Finally, the Veteran also filed a higher-level review application for her increased rating claims for her bilateral knees following the August 2020 SSOC. However, as stated in the October 2020 letter from the RO to the Veteran, this application cannot be considered as she did not explicitly withdrew these issues from the current legacy system into the modernized appeals system. Therefore, the issues on appeal remain in the legacy system and the Board may proceed. The Veteran has not raised any issues with the duty to notify or duty to assist in obtaining documentary evidence. Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Further, neither the Veteran nor her representative has alleged any deficiency with the conduct of his Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens, 814 F.3d at 1361, that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott, 789 F.3d at 1381. Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to active service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the reports into a consistent picture so that the current rating may accurately reflect the elements of disability. See 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. See 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. See 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. see 38 C.F.R. § § 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as in the present case, entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Evidence obtained during, or leading up to, the appeal period may indicate that the degree of disability increased or decreased during the pendency of the appeal. In such circumstances, VA’s determination of the “present level” of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the rating claim has been pending, and “staged” ratings may be assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is a balance of positive and negative evidence regarding any material issue, the benefit of the doubt shall be given to the claimant. See 38 U.S.C. § 5107(b). Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. See 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert, 1 Vet. App. at 54. The Board has reviewed all the evidence of record. Although the Board has an obligation to provide adequate reasons and bases supporting its decisions, there is no requirement that the Board discuss every piece of evidence in the record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence, as deemed appropriate, and the Board’s analysis will focus on what the evidence shows, or fails to show, as to each claim. The Veteran is seeking higher disability ratings for her service-connected left knee and right knee disabilities. The pertinent regulations for rating knee conditions were provided to the Veteran in the Statement of the Case and will not be repeated. Here, both the Veteran’s left knee and right knee conditions were not more than 10 percent disabling due to painful limitation of motion at any time during the appeal period. The probative evidence includes VA examination reports from March 2008, June 2011, August 2016, and January 2020. The Veteran’s VA and private treatment records were also considered. "Chondromalacia" is not listed in the disability ratings schedule. Chondromalacia is a "softening of the articular cartilage, most frequently in the patella." Dorland's Illustrated Medical Dictionary 1930 (32nd ed. 2012). The conditions were rated under Diagnostic Code 5014, analogous to osteomalacia, which is rated based on limitation of motion of the joint. Here, Diagnostic Code 5260 for limited flexion and Diagnostic Code 5261 for limited extension apply to knee conditions. 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. As to limited extension, a compensable rating requires evidence of extension limited to at least 10 degrees. This has not been shown by the record. See 38 C.F.R. § 4.71a, DC 5261. Considering the pertinent evidence in light of the governing legal authority, the Board finds the preponderance of the evidence is against the assignment of a higher rating for the left knee and right knee conditions at any time on appeal. First, in the March 2008 VA examination, she reported pain, weakness, swelling, locking, and giving away with stiffness, and flareups were noted as moderate 2-3 times a week in the left knee, and twice a month in the right knee, and both knees were opined to have a 40 percent loss of motion during a flare-up. There was no evidence of abnormality with weight bearing. Her right knee flexion was limited to 100 degrees with normal extension and her left knee range of motion was normal with no pain; both knees did not have additional loss after repeated use, and she had no ankylosis. She reported her knees swell after prolonged standing and walking and stated that her left knee is weaker and sometimes gives away with frequent pain in both knees. The examiner noted that her left knee had some giving way but no instability. Both knees had pain, stiffness, weakness, and locking episodes about once a month, but no dislocation or subluxation or effusion. In the June 2011 VA examination, it was noted that she had a history of falls and that her knees give out, especially when squatting to attend to children [the Board notes that she is a school principal]. It was noted that she had unstable knees (the right stronger than the left), and that both knees had giving away and instability with constant pain, stiffness, weakness, swelling, crepitus, guarding, and decreased speed of joint motion. It was also noted that both knees had episodes of subluxation and occasional swelling and locking several times a week. The Veteran’s knees had flare-ups that she reported were severe and occurred every other month for a day or two after overuse and she is unable to walk. The range of motion showed that left knee flexion was limited to 120 degrees, with no further limitation after repetitive motion testing with evidence of pain, and right knee flexion limited to 130 degrees with pain, but extension was normal bilaterally. The examiner opined additional limitation following repetitive use in the left knee would be flexion to 105 degrees and 120 degrees in the right. She did not have ankylosis. The examiner considered the 2007 finding of a left knee meniscal tear and the 2007 X-ray found effusions, but the June 2011 X-rays revealed no effusions. The August 2016 VA examination noted that the Veteran’s flare-ups of the right knee were described as swelling and increased pain after standing for over 20-30 minutes and when she walks for more than 20-30 minutes and flare-ups of the left knee were described as swelling, increased pain and stiffness after 20 minutes of walking and standing. She also stated that her muscles tighten or give way and her knees give out during walking. She stated that when swelling occurs, she has to rest for three to five days and her knees cannot fully bend and when they do bend a little, they hurt, especially the left knee. Both knees range of motion was tested and noted to be normal with pain on flexion and pain with weight bearing. There was no evidence of crepitus or tenderness or pain on palpation. Repetitive testing revealed no limited loss of function or limitations, though it was noted that she had pain, fatigue, and lack of endurance with repeated use over time and with flare-ups (though no range of motion was provided). There was no reduction in muscle strength, no muscle atrophy, and no ankylosis. The examiner also noted that there was no history of recurrent subluxation or instability, and all joint stability testing revealed normal findings and no instability was found. She reported using a knee brace occasionally. Finally, in the January 2020 VA examination, she reported having increased pain with pain most days and that there is pain on use with swelling and instability and she had tried injections with temporary relief. She stated that currently, she has swelling, stiffness, limited motion when bending and kneeling, with weakness in both knees, and buckling and locking. The examiner noted that she has limited prolonged walking/standing, cannot squat, and has limited ROM. Her right knee flexion was limited to 130 degrees with normal extension, with pain noted on flexion and evidence of tenderness and pain on palpation. The examiner noted pain with weight bearing, but no crepitus. Her left knee had normal range of motion, with pain noted during flexion testing and evidence of pain on palpation; but no pain with weight bearing. The examiner did note there was evidence of crepitus as to the left knee. The Veteran was able to perform repetitive testing with no additional loss of motion. As for repeated use over time and flare-ups, although the examination was not being conducted during a flare-up, the examiner considered the Veteran’s contentions as to functional loss over time and noted that pain and a lack of endurance would cause additional loss and that there would be a limitation of flexion to 120 degrees in the right knee, but normal left knee. Further, the examiner noted the Veteran’s bilateral knees had swelling, but no muscle atrophy, normal muscle strength, and no ankylosis. It was noted that both knees had slight recurrent subluxation and lateral instability but no effusion; though joint stability testing revealed medial and lateral instability in the right knee ONLY and left knee had normal instability testing. The examiner opined she was functionally impacted in that she is limited with standing/walking less than 30 minutes at a time or less than 4 hours a day and no repetitive squatting. As part of the 2019 remand instructions and pursuant to the JMR, the Board asked the examiner to provide an opinion based on the entirety of the record as to the severity, frequency, and duration of any flare-ups, and an estimation of the loss of range of motion during flare-ups at the time of the prior VA examinations. Specifically, the remand instructions requested the examiner to comment on the examinations from March 2008, June 2011, and August 2016. The Veteran was examined, and this retrospective opinion was provided in January 2020. The examiner stated that he reviewed the previous examinations and opined that “the Veteran’s range of motion seems to be fairly well preserved.” The examiner noted that the 2011 and 2016 examinations revealed normal range of motion in both knees and the 2008 range of motion documented “is likely to be her presumed range of motion at that time.” The examiner opined that the Veteran’s condition has progressed over time, but that the current January 2020 examination is the first time that testing noted a loss of range of motion to a mild degree, though the examiner opined that it is likely she experienced pain with her normal range of motion findings in the 2016, 2011, and 2008 examinations. The examiner further opined that she has had progressive symptoms and based on MRI findings, that the Veteran’s prior examinations “adequately show her range of motion with the fact that she likely had pain with range of motion,” though where the pain began is unable to be determined for those past examinations. The examiner stated the Veteran will “likely have increased pain with use and possibly occasionally with flareups...as documented...however, this would not change her range of motion but only increase her symptoms.” The Veteran’s VA treatment records also do not show symptoms warranting a rating higher than 10 percent for either knee based on limitation of motion for the period on appeal. For example, in August 2007, she reported occasional knee pain. In August 2008, she reported the pain in her knees were rated 7/10 and she had bilateral crepitus that was worse in the right knee than the left, with tenderness on palpation. In November 2009, she reported knee pain whenever she tried to stand up or when kneeling or squatting. She reported that her knees give away at times and that they swell if she walks or stands for long. In December 2010, she reported knee discomfort when walking up stairs and that her knees will buckle but she has had no falls. In June 2011, she reported her knees give out. In August 2011, the doctor noted the results of the June 2011 X-rays, noting that she had bilateral minimal degenerative spurring with minimal medial compartment joint space loss. In September 2012 she reported “that her knee problems are unchanged.” In October 2013, she reported “some pain” in her knees and that the pain was rated 8/10 and that this pain has been off and on over the years. In December 2016, she reported chronic knee pain but denied stiffness or weakness. In March 2019, she reported chronic knee pain which she iced and rested and has had three injections recently. Her private medical records showed that in June 2017 she reported that her right knee has been buckling and she has had increased pain and instability. She reported constant pain which is exacerbated with weight bearing, stairs, and range of motion, and that the knee pops. She also reported that she is attending physical therapy. Although these physical therapy records are not part of the evidence in her file, in the 2019 Board remand, the instructions included for the Veteran to identify or submit any pertinent evidence in support of her claims, to include records of any private treatment. As she did not respond or submit these records, the remand directives were complied with to the extent possible. As discussed in Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), “[t]he duty to assist is not always a one-way street” and if the Veteran desires help with her claims, she must cooperate with VA’s efforts to assist her. To the extent the evidence is incomplete, that is a direct result of her failure to either submit the records or authorize VA to obtain them. The private doctor in 2017 noted that she had full range of motion with pain with palpation, and she received a knee injection. In July 2017, she reported that her knee was doing better following the injections and her range of motion was noted to be good with moderate pain (no degrees listed). She reported only using Ibuprofen and icing. In December 2018, she reported right knee pain with grinding and difficulty with bending and standing. However, it was noted she had full range of motion and stable stress testing. She received another injection. Finally, in October 2019, she reported bilateral knee pain that was worse in the right than the left. It was noted the bilateral knees demonstrated moderate tenderness to palpation with full range of motion with crepitus but good overall strength. The assessment was mild to moderate osteoarthritis. While the Veteran has clearly experienced pain and functional loss, the Board cannot find that either knee approximated the level of severity as described by the next higher rating with flexion limited to 45 degrees and/or extension limited to 10 degrees. On each of the VA examinations, repetitive motion did not cause any additional loss of motion to the extent that would warrant a higher rating. While she has reported severe pain at times, the additional loss of motion caused during these episodes has not been quantified. The Board thus finds that pain and functional loss has already been considered in awarding the current ratings. The 10 percent ratings contemplate some limitations in motion – here, flexion – that are not otherwise compensable, painful motion, and some functional impairment due to that pain. Extension was within normal limits at all the aforementioned VA examinations, even after repetitive motion and considering pain. As such, the Veteran’s left knee and right knee conditions based on painful motion are both properly rated 10 percent disabling for the entire period on appeal. Without further limitations of motion, higher ratings cannot be assigned under Diagnostic Code 5260 or 5261. The Board has also considered all other diagnostic codes pertaining to the knee. As ankylosis was not shown on any examination, DC 5256 is not applicable. Because the file contains no indication of a meniscal condition in the right knee, and the Veteran’s left knee meniscal tear did not amount to “frequent locking, pain, and effusion into the joint” as required for a separate rating (specifically, the Board notes that the Veteran had effusion in the 2007 MRI, and all VA examination reports and X-rays subsequent to the 2007 MRI revealed no effusions and that she only had effusion that one time); malunion or nonunion of the tibia or fibula; or genu recurvatum, DCs 5258, 5259, 5262 and 5263, respectively, are not applicable. However, as discussed below, the Veteran’s bilateral knees did show instability, and the reported locking was considered as part of this grant. For all the foregoing reasons, the Board finds that the preponderance of the evidence is against a higher rating for the Veteran’s left knee and right knee conditions based on painful, limited motion. The preponderance of the evidence is also against the assignment of any further separate ratings for the knee disabilities other than that assigned herein and below. As such, an evaluation in excess of 10 percent for left knee chondromalacia and in excess of 10 percent for the right knee chondromalacia at any time during the appeal period is denied. As to the bilateral knee instability, the Veteran is currently assigned a 10 percent disability rating for the right knee, effective January 23, 2020, and 10 percent in the left knee from June 24, 2011 through October 1, 2020, and noncompensable thereafter. As discussed above, the Veteran has not appealed that reduction in rating. Under DC 5257, a separate rating is warranted for a showing of recurrent subluxation or lateral instability; the code states that slight recurrent subluxation or lateral instability, is rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability warrants a 20 percent rating, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. See 38 C.F.R. § 4.71a, DC 5257. Here, the Board notes that the evidence indicates that there was instability in both the left knee and right knee for the entire period on appeal. The Board has considered the Veteran’s lay reports of falls due to the knees giving out, buckling, and locking, and that she has worn knee braces and finds that the ratings being granted herein contemplate such symptoms. As discussed above, as the RO already assigned the 10 percent rating for the left knee from June 24, 2011, the Board will grant that rating from July 5, 2007 (date of claim for an increase) until June 23, 2011, so that she will have the 10 percent rating for the entire appeal period. Similarly, as the RO already assigned the 10 percent rating for the right knee from January 23, 2020, the Board will grant that rating from July 5, 2007 (date of claim for an increase) until January 22, 2020. Specifically, as discussed in detail above, the Veteran consistently reported in the 2008, 2011, 2016, and 2020 VA examinations that both of her knees felt unstable, that she had giving away and locking in both knees, and that her knees would buckle, especially when walking up stairs. She also reported locking and her knees giving out in her VA and private medical records. She consistently reported swelling, and that her flare-ups exacerbated all of these symptoms. As noted in the prior Board remand and the JMR, although the prior examinations did not fully articulate the full limitations caused by her flare-ups when it came to the loss of degrees (and discussed by the 2020 VA examiner above); the Board notes that the Veteran did also report that flare-ups and overuse cause swelling, instability and locking per her statements in the examination reports and medical records. Additionally, in the February 2011 Board hearing, the Veteran testified that going up and down stairs is hard, and that if she does not have a railing to hold onto, she will fall. She stated that she feels her knees buckling and giving away and this causes excruciating pain. She also stated that her knees lock and give away when going down steps, otherwise she has to walk with a straight leg until she can bend it again without pain. She further testified that her knee issues cause her to fall. However, the 2008, 2011, and 2016 VA examiners all opined that the Veteran did not have instability in her right knee following testing; and the 2008, 2016, and 2020 VA examiners opined she did not have instability in her left knee following testing (though noted instability in other parts of the report). That notwithstanding, the Board acknowledges that the Veteran is competent to report knee instability as this is within the realm of her personal perception. Layno v. Brown, 6 Vet. App. 465, 469; see also English v. Wilkie, 30 Vet. App. 347 (2018) (suggesting that lay evidence of knee instability is generally competent). The Board is cognizant that objective medical evidence is not categorically more probative than lay evidence when it comes to determining the degree of knee instability the Veteran has experienced during the appellate period. English, supra. As discussed above, the Board has considered that the Veteran’s VA medical records show she has instability and that she wears knee braces and must use support when using steps or stairs. Her VA medical records showed she reported giving away and locking of her knees, that her knees will buckle and stiffen, and that overuse and flareups cause her knees to swell and cause her to feel unstable. She also has needed physical therapy and injections. However, at no time during the appellate time period has the Veteran’s bilateral knee instability resulted in greater than slight impairment. The Board reaches this conclusion based on the objective testing results of record. This is not an instance where the Board is negating the probative value of the Veteran’s lay statements simply because they are unaccompanied by supporting contemporaneous medical evidence, which would be in contravention of Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). To the contrary; the medical evidence of record, to include all VA examinations, are inconsistent with and contradict anything more than slight severity of the Veteran’s knee instability as presented in her lay statements issued during the course of these proceedings. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (finding the Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). DC 5257 expressly refers to lateral instability, a specific type of joint instability demonstrated by clinical test for ligament laxity, such as Lachman’s and drawer tests. As discussed above, the 2008, 2011, and 2016 examiners marked “no” to history of instability or recurrent subluxation as to the right knee, and the 2008, 2016, and 2020 examiner “no” to history of instability or recurrent subluxation after the Veteran underwent instability and laxity testing. Although the Veteran is competent to report her symptoms, and all reasonable doubt is being resolved in her favor by granting the ratings for the entire appeal period, the fact remains that the medical evidence indicates that different VA examinations over the years have shown no instability or subluxation of the bilateral knees except as noted above. Accordingly, her statements are afforded less evidentiary weight as to the severity of her instability. As such, the Board ultimately finds that the preponderance of the evidence of record, lay or medical, simply does not demonstrate that her service-connected right knee and left knee disabilities manifested with recurrent subluxation or lateral instability that is at least moderate in severity at any time during the appeal period, so a rating higher than 10 percent is not warranted. The Board notes that the benefit of the doubt has been applied, where applicable, and acknowledges that the Veteran believes her bilateral knee instability to be of greater severity. However, the Board finds that her statements are most supportive of a 10 percent rating. The Veteran primarily has described her symptoms as feeling unstable and needing to wear a brace or use support, that she has the potential for falls, and that she has fallen on several occasions when she does not have support, or during a flare-up. Such symptomatology is consistent with 10 percent evaluations for both knees, and some of her reported symptoms were considered as part of the separate 10 percent evaluations discussed above. In sum, the evidence indicates that a separate rating of 10 percent, but no higher, for left knee instability was warranted from July 5, 2007 until June 23, 2011, and a separate rating of 10 percent, but no higher, for right knee instability was warranted from July 5, 2007 until January 22, 2020. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.Hoy, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.