Citation Nr: 21015755 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 15-24 626 DATE: March 18, 2021 ORDER Entitlement to service connection for right shoulder degenerative arthritis is granted. Entitlement to service connection for left shoulder degenerative arthritis is granted. Entitlement to service connection for left hand degenerative arthritis is granted. Entitlement to an increased disability rating higher than 20 percent for left knee limitation of motion during flexion is denied. Entitlement to a separate disability rating of 20 percent for dislocation of semilunar cartilage of the left knee is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to disability rating higher than 10 percent for left knee instability is denied. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s bilateral shoulder degenerative arthritis is related to his active duty service. 2. The evidence is at least evenly balanced as to whether the Veteran’s left hand degenerative arthritis is related to his active duty service. 3. Throughout the appeal period, the Veteran’s left knee symptoms manifested by pain and range of motion of flexion of no worse than flexion of 90 degrees and extension to 0 degrees when considering flare-ups and repeated use over time. 4. The Veteran’s left knee disability is manifested by dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 5. The evidence of record does not show that the Veteran’s left knee instability symptoms more nearly approximated moderate or severe lateral instability or subluxation. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for bilateral shoulder degenerative arthritis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for left hand degenerative arthritis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an increased disability rating higher than 20 percent for left knee limitation of motion during flexion are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.71a, Diagnostic Codes (DCs) 5010-5260. 4. The criteria for a separate disability rating of 20 percent for semilunar cartilage dislocation of the left knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.71a, DC 5258. 5. The criteria for a disability rating higher than 10 percent for left knee instability are not met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.3, 4.7, 4.10, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1968 to September 1970. This matter initially came before the Board of Veterans’ Appeals (Board) on appeal from March 2010 and November 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) that, among other things, continued the 20 percent evaluation for residuals of left knee meniscectomy and denied the claims of service connection for bilateral shoulder and left hand arthritis. The Veteran timely appealed these matters. In January 2019, the matters were remanded by the Board for further development, to include obtaining VA opinions, obtaining outstanding VA treatment records since October 2013, and requesting Social Security Administration (SSA) copies of documents issued in connection with the Veteran’s claim for benefits. The Agency of Original Jurisdiction (AOJ) has substantially complied with the Board’s January 2019 remand instructions by obtaining SSA documents and outstanding VA treatment records since October 2013 and, as demonstrated by the discussion below, obtaining a VA opinion in regard to the Veteran’s disability rating claims for the left knee that is adequate to decide the claims. Thus, no further action is necessary in this regard. As the Board is granting the claims of service connection for bilateral shoulder and left hand degenerative arthritis in full, discussion of compliance with the Board’s January 2019 remand instructions is unnecessary in regard to those claims. Stegall v. West, 11 Vet. App. 268 (1998). In a January 2020 rating decision, the AOJ granted an award of a separate disability rating for left knee instability with an evaluation of 10 percent, effective October 8, 2019. As the Veteran has not indicated satisfaction with this disability rating or the disability rating for left knee residuals of meniscectomy, the issues remain on appeal. Cf. AB v. Brown, 6 Vet. App. 35 (1993). Service connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in-service. 38 C.F.R. § 3.303(d) Entitlement to service connection for bilateral shoulder and left hand degenerative arthritis The Veteran contends his bilateral shoulder and left hand arthritis are related to an incident in service where a tank he was in blew up. He further reports that he has experienced continuous pain symptoms of these disabilities since his separation from service. During an October 2019 VA examination, the Veteran reported that he believed he injured both of his shoulders when he drove over a 50 pound basket mine in his tank while serving in Vietnam. He stated that he has experienced persistent bilateral shoulder problems since service, with progressively increasing bilateral shoulder pain and mobility problems over the last 10 years. The examiner found that the Veteran’s service treatment records were silent for diagnosis, treatment, and/or complaints of a left or right shoulder condition. Medical records following service showed complaints of bilateral shoulder pain in October 2009, and chronic shoulder pain was noted in July 2012. While it was accepted that the Veteran injured both of his shoulders during service, there was a 39-year gap in medical evidence showing treatment or care of a shoulder condition from separation of service in 1970 to 2009 when he first complained of shoulder pain. Therefore, the VA examiner found that the Veteran’s degenerative arthritis of bilateral shoulders, as well as the shoulder pain noted in 2009 and 2012, was less likely than not the result of the in-service injury. The Veteran’s degenerative arthritis of bilateral shoulders was the result of the aging process and normal wear and tear associated with aging. During an October 2019 VA examination, the VA examiner noted that the Veteran’s service treatment records were silent for diagnosis, treatment, and/or complaint of a left wrist and/or hand condition. Medical records following service showed treatment and/or complaints of a left wrist and/or hand condition in 2008, 2009, and 2010. While it was accepted that Veteran injured the left hand and wrist during service, there was a 38-year gap in medical evidence showing treatment or care of a left wrist and/or hand condition from separation of service in 1970 to 2008 when he first complained of a left hand and wrist condition. Therefore, the VA examiner found that the Veteran’s degenerative arthritis of left hand and wrist, as well as the left hand condition noted in 2008, 2009, and 2010, was less likely than not the result of the in-service injury. For the following reasons, entitlement to service connection for bilateral shoulder and left hand degenerative arthritis is warranted. An October 2019 VA examination noted the Veteran’s diagnoses of bilateral shoulder and left hand degenerative arthritis. Thus, the Veteran meets the current disability requirement. The Veteran’s DD Form 214 shows that the Veteran’s military occupational specialty was armored reconnaissance specialist. The Veteran’s statements in regard to being involved in an incident in Vietnam where his tank was blown up are therefore competent, credible, and consistent with the circumstances of his service. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303 (a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service records). Thus, the Veteran meets the in-service injury or disease requirement. The October 2019 VA opinions are afforded little probative value as they relied on the lack of contemporaneous medical evidence without considering the Veteran’s lay statements regarding continuous bilateral shoulder and left hand pain symptoms since his separation from service. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (VA’s examiner’s opinion, which relied on the absence of contemporaneous medical evidence, “failed to consider whether the lay statements presented sufficient evidence of the etiology of [the Veteran’s] disability such that his claim for service connection could be proven without contemporaneous medical evidence”).    The Veteran is competent to report on the Veteran’s continuous bilateral shoulder and left hand pain symptoms in the years since service. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan, 451 F.3d at 1337 (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). There is nothing to explicitly contradict the Veteran reports, thus, they are credible and competent. To the extent that the grant of service connection in these matters are based primarily on lay evidence, “nothing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself.” Id. at 1335. At this point, the Board could remand the claim for a VA examination or opinion.  However, a request for an opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible.  38 C.F.R. § 3.304(c) (“The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination”); Gardner-Dickson v. Wilkie, No. 19-4765, 2020 U.S. App. Vet. Claims LEXIS 1927 (Panel Order), at *20 (denying petition for a writ of mandamus challenging a remand, but agreeing “with the petitioner that it ‘would not be permissible for VA to undertake... additional development if a purpose was to obtain evidence against an appellant’s case.’” (citing Mariano v. Principi, 17 Vet. App. 305, 312 (2003) and Hart v. Mansfield, 21 Vet. App. 505, 508 (2007)). For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran’s bilateral shoulder and left hand degenerative arthritis are related to his active duty service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for bilateral shoulder and left hand degenerative arthritis is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Applicable law and rating criteria for knee disabilities Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities.  38 C.F.R. Part 4.  The Board determines the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations.  38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10.  Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.   Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition.  The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required.  38 C.F.R. §§ 4.1, 4.2, 4.10.  DC 5260, limitation of flexion of a leg, provides a 20 percent rating if flexion is limited to 30 degrees. A maximum 30 percent rating is warranted for knee flexion that is limited to 15 degrees. 38 C.F.R. § 4.71a; DC 5260. DC 5261, limitation of extension of a leg, provides a noncompensable disability rating when extension is limited to 5 degrees, a 10 percent rating when it is limited to 10 degrees, a 20 percent rating when it is limited to 15 degrees, a 30 percent rating when limited to 20 degrees, a 40 percent rating when limited to 30 degrees, and a 50 percent rating when limited to 45 degrees. Id. Normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71; Plate II. Separate ratings may be warranted for limitation of flexion and extension when the criteria for compensable ratings are met for such limitation under DCs 5260 and 5261. See VAOPGCPREC 9-2004. VA General Counsel provided guidance in VAOPGCPREC 23-97 (July 1997) that a veteran who has instability of the knee may be rated separately under DC 5257, provided that a separate rating must be based upon additional disability. The schedular criteria for rating knee instability was amended effective February 7, 2021.  See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5257).  The amendments apply to claims, such as the Veteran’s, that were pending before VA as of that date, with the provision that the more favorable of the old and new criteria are to be applied. If application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation.  38 U.S.C. § 5110(g). Prior to the effective date of the change in the regulation, the Board can apply only the original version of the regulation. Prior to February 7, 2021, DC 5257 provided a 10 percent rating for slight recurrent subluxation or lateral instability of the knee, a 20 percent rating for moderate recurrent subluxation or lateral instability of the knee, and a 30 percent rating for severe recurrent subluxation or lateral instability of the knee. The terms slight, moderate, 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. 38 C.F.R. § 4.6. It should also be noted that use of terminology such as severe by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under the amended criteria, DC 5257 provides for recurrent subluxation or instability with a 30 percent rating that is 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, a 20 percent rating that is (a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation (b) an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation, and a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. DC 5257 also provide for patellar instability with a 30 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker, a 20 percent rating 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, and a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note (1) of the rating provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon, and Note 2 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). As discussed further below, the evidence of record reflects that the schedular criteria of DC 5257 in effect prior to February 7, 2021 are more favorable to the Veteran and are for application here. The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint’s functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time, functional loss due to flare-ups, fatigability, incoordination, and pain on movement. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. Furthermore, 38 C.F.R. § 4.59 recognizes that painful motion is an important factor of disability. Joints that are painful, unstable, or misaligned, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id. Pain that does not result in additional functional loss does not warrant a higher rating. Mitchell v. Shinseki, 25 Vet. App. 32, 42-43 (2011). The Board notes that there are additional DCs that pertain to the knee. However, as shown in the VA examinations, the service-connected left knee disability symptoms in this case have not either manifested as or been attributed to ankylosis, removal of symptomatic semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. Therefore, separate or higher ratings under the additional knee DCs do not merit further consideration. 38 C.F.R. §§ 4.14, 4.71a; DCs 5256, 5259, 5262, 5263. Left knee background During a November 2009 VA examination, the Veteran stated that after release from service in 1971 he underwent a left knee meniscectomy at the Loch Raven VA. The Veteran reported that he had not received any further operations or any specific treatment for the left knee since that surgery. There were no episodes of dislocation, subluxation, or locking. The Veteran did not report flare-ups. The Veteran carried a cane, but he was able to walk without the cane. There was no functional limitation on standing or walking. Left knee range of motion was 0 degrees extension and 130 degrees flexion. There was no pain in range of motion and no loss of motion on repeated maneuvers. There was no mediolateral instability. There was no evidence of additional loss of range of motion after repetitive use due to pain, fatigue, weakness, lack of endurance, or incoordination. In November 2018, a VA treatment note indicated the Veteran reported left knee chronic pain that the VA physician found was secondary to osteoarthritis. During an October 2019 VA examination, the Veteran reported increased left knee pain and swelling in the last month with constant moderate left knee pain and intermittent swelling. His left knee pain increased with prolonged walking, repetitive squatting, heaving lifting, running, and using stairs. The Veteran did not report flare-ups of the left knee. He reported functional loss or functional impairment of problems with walking, squatting, and an inability to run or use stairs. Examination revealed left knee flexion and extension was 110 to 0 degrees. Abnormal range of motion did not contribute to functional loss of the left knee. Pain was noted on examination of the left knee and resulted in functional loss. There was pain on weight-bearing of the left knee and pain on passive range of motion and on non-weight-bearing. The Veteran was able to perform repetitive use testing with at least three repetitions in the left knee with range of motion estimated at 100 degrees flexion and 0 degrees extension. Pain, weakness, and lack of endurance caused functional loss. The Veteran was not examined immediately after repetitive use over time.  The examination was medically consistent with the Veteran’s statements describing functional loss repetitive use over time.  Pain, weakness, and lack of endurance caused functional loss with repetitive use over time. This was described in terms of range of motion as 90 degrees flexion to 0 degrees extension. Additional contributing factors of disability were less movement than normal, weakened movement, disturbance of locomotion, and less movement than normal. There was no history of recurrent subluxation or lateral instability in the left knee. Anterior and lateral instability were each 1+, while posterior and medial instability was normal. The Veteran had a left meniscal tear with left knee meniscectomy in 1971 and experienced frequent episodes of joint pain. The Veteran reported he used a cane regularly. Left knee limitation of motion during flexion The Veteran is in receipt of a 20 percent disability rating for left knee residuals of meniscectomy under DCs 5010-5260 from November 26, 2002. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § § 4.27. DC 5010 pertains to arthritis, due to trauma that is substantiated by x-ray findings, and is rated by analogy under DC 5260 for limitation of leg flexion. For the following reasons, an increased disability rating higher than 20 percent for left knee limitation of motion during flexion is not warranted. In addition, a separate disability rating for the left knee under DC 5258 (dislocation of semilunar cartilage) is warranted. Given the Veteran’s statements regarding flare-ups, and the evidence of record, to include range of motion, at worst, of 90 degrees flexion to 0 degrees extension, the Veteran’s left knee disability did not result in limitation of motion more nearly approximating flexion of 15 degrees warranting a 30 percent rating under DC 5260 throughout the entire appeal period. Moreover, the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran’s left knee disability symptoms have not been shown to have been so disabling to actually or effectively result in limitation of knee extension more nearly approximating 10 degrees, which is the requirement for a compensable (10 percent) rating for limitation of knee extension under DC 5261. 38 C.F.R. § 4.59 creates range of motion testing requirements with which VA must comply. Correia, 28 Vet. App. at 158. 38 C.F.R. § 4.59 provides, “The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint.” Here, the October 2019 VA examiner complied with Correia, noting evidence of pain on active and passive range of motion testing and on weight bearing and non-weight bearing. Likewise, the VA examiner in 2019 opined that repetitive use over time would result in left knee range of motion of flexion to 90 degrees and extension to 0 degrees. The Board has also considered whether the Veteran is entitled to a separate disability rating for the left knee under DC 5258, which provides a 20 percent rating for dislocation of semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. Here, the Veteran experienced a left meniscal tear for which he underwent a left knee meniscectomy in 1971 and endorsed frequent episodes of joint pain during the October 2019 VA examination. Moreover, separate ratings under DCs 5258 and 5260 do not constitute “pyramiding” under 38 C.F.R. § 4.14. In the case of DC 5258, the schedular criteria include pain, locking, and effusion or swelling in the joint, while in the case of DC 5260, limitation of motion is encompassed by the limitation of flexion, including limitation of motion due to pain. While both DCs list criteria of symptoms of pain, the Board finds the “pain” associated with torn semilunar cartilage under DC 5258 is distinct from that associated with the arthritis and painful limitation of motion under DC 5260. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). Separate disability ratings under DC 5258 and 5260 are therefore permissible in this instance and do not amount to impermissible pyramiding. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Thus, resolving reasonable doubt in the Veteran’s favor, a separate disability rating of 20 percent under 38 C.F.R. § 4.71a, DC 5258 dislocated semilunar cartilage for the left knee is warranted. This is the maximum schedular rating for this disability. For the foregoing reasons, as a preponderance of the evidence is against an increased disability rating higher than 20 percent for left knee limitation of motion during flexion, the benefit of the doubt doctrine is not otherwise for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Left knee instability The Veteran is currently assigned a 10 percent disability rating for left knee instability under DC 5257, effective October 8, 2019. As discussed previously in the applicable law section, a veteran who has instability of the knee may be rated separately under DC 5257, provided that a separate disability rating must be based upon additional disability. As also noted previously, the evidence of record reflects that the schedular criteria of DC 5257 in effect prior to February 7, 2021 are more favorable to the Veteran and are for application here. For the following reasons, a disability rating higher than 10 percent for left knee instability is not warranted. The October 2019 VA examination noted anterior and lateral instability was 1+, while posterior and medial instability was normal. However, the November 2009 VA examination report revealed normal clinical findings for left knee stability. Moreover, the Veteran did not indicate in his lay statements that his left knee instability symptoms more nearly approximated moderate instability or recurrent subluxation. In light of the specific and normal stability findings on the November 2009 VA examination and a lack of indication in the evidence of record that the instability was more than slight, the preponderance of the evidence is against a finding that the symptoms more nearly approximated moderate instability. For the foregoing reasons, the preponderance of the evidence is against a disability rating higher than 10 percent for left knee instability. Thus, the benefit of the doubt doctrine is not otherwise for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Board has considered the Veteran’s claims and decided entitlement based on the evidence. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Styer, 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.