Citation Nr: 21021260 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 15-45 395 DATE: April 12, 2021 ORDER 1. Entitlement to a higher rating than 10 percent for right knee disability based on limitation of extension prior to August 9, 2016 is denied. 2. Entitlement to a higher rating than 10 percent for right knee disability based on limitation of flexion prior to August 9, 2016 is denied. 3. Entitlement to a higher rating than 30 percent beginning October 1, 2017 for right knee status post total knee replacement is denied. FINDINGS OF FACT 1. For the rating interval prior to August 9, 2016, the Veteran’s right knee disability was equivalent to knee extension limited to 10 degrees. 2. For the rating interval prior to August 9, 2016, the Veteran’s right knee disability was equivalent to knee flexion limited to 45 degrees. 3. For the rating interval prior to August 9, 2016, the preponderance of the evidence is against a finding that the Veteran’s right knee disability was manifested by recurrent subluxation or lateral instability, symptomatic semilunar cartilage dislocation or removal, malunion or nonunion of the tibia or fibula, genu recurvatum, or similar impairment to a disabling degree. 4. For the rating interval beginning October 1, 2017, the Veteran’s right knee replacement has been manifested by intermediate degrees of residual weakness, pain, or limitation of motion. The preponderance of the evidence is against a finding that the right knee replacement is manifested by instability. CONCLUSIONS OF LAW 1. The criteria for a higher rating for right knee disability prior to August 9, 2016 than 10 percent based on limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5261. 2. The criteria for a higher rating for right knee disability prior to August 9, 2016 than 10 percent based on limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. 3. The criteria for a separate, additional rating for right knee disability prior to August 9, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5258, 5259, 5262, 5263. 4. The criteria for higher rating than 30 percent beginning October 1, 2017, for the right knee status post total knee replacement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1983 to April 1984. The Department of Veterans Affairs is grateful for her service. Board development The Board remanded the appealed claims in January 2019 and again in September 2020 for additional examination findings addressing limitations of functioning of the right knee retrospectively over the claim periods for active and passive motion, with weight bearing and without, and with repetitive use and during flare-ups. As discussed below, the Board does not find that higher disability ratings are warranted for the right knee disability with limitation of flexion or extension for the rating interval prior to August 9, 2016. In so doing, the Board does not find that additional development is necessary. The November 2019 VA examiner was asked to provide supplemental findings retrospectively with respect to level of impairment with active and passive motion, with and without weight-bearing, and during flare-ups and with repetitive activity, and duration of flare-ups. However, the examiner concluded that this could not be done without mere speculation because not enough information was present to retrospectively address levels of impairment during those circumstances, either with regard to the November 2013 VA examination or the March 2016 VA examination or more generally over the pre-knee-replacement interval, due to insufficient information. The Veteran did not provide statements or testimony about greater symptomatology warranting a higher rating over the interval in question, and hence the Board concludes that there is no such retrospective information to be obtained to allow for medical findings or conclusions retrospectively. As the November 2019 VA examiner noted in an October 2020 addendum, a September 14, 2012 treatment observed right knee range of motion from 0 to 120 degrees as compared to 0 to 123 degrees on the left, with pain provoked with prolonged walking, standing, and sitting. The VA examiner noted that there was insufficient information to comment on passive motion, with and without weight-bearing, during flare-ups and with repetitive activity, at that time since treatment notes from 2010, 2011, and 2012 do not comment on this; the Board agrees, as the Veteran has also not provided requisite information from this interval to arrive at such conclusions, and it is exceedingly doubtful the Veteran could provide such highly specific information years later to any credible degree of accuracy. A claim can only reasonably be expected to encompass those symptoms or conditions which are of record at the time of its review. See Clemons v. Shinseki, 23 Vet. App. 1, 6-7 (2009) (finding that the scope of a claim includes any disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record); see Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992) ("The 'duty to assist' is not a license for a 'fishing expedition' to determine if there might be some unspecified information which could possibly support a claim). The Board accordingly proceeds to adjudicate based on the record before it. Rating claims The Veteran contends, in effect, that higher ratings are warranted for her right knee than those assigned prior to and following her total knee replacement in August 2016. The rating assigned during a temporary total rating period from August 19, 2016 through September 30, 2017 is not at issue, since a 100 percent rating is the maximum rating allowed. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Because varying, distinct degrees of disability may have been experienced over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Id. at 505. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability over the rating period in question. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. See 38 C.F.R. § 4.14. However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable diagnostic code. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 1. Entitlement to a higher rating than 10 percent for right knee disability based on limitation of extension prior to August 9, 2016 2. Entitlement to a higher rating than 10 percent for right knee disability based on limitation of flexion prior to August 9, 2016 The Veteran's right knee disability for the rating interval prior to August 9, 2016 is currently rated as 10 percent disabling based on limitation of flexion and is assigned a separate 10 percent based on limitation of extension. Under Diagnostic Code 5260, limitation of flexion of a knee to 60 degrees is noncompensable, limitation of flexion to 45 degrees warrants a 10 percent disability rating, limitation of flexion to 30 degrees warrants a 20 percent disability rating, and limitation of flexion to 15 degrees warrants a maximum schedular 30 percent disability rating. Under Diagnostic Code 5261, a 10 percent disability rating is allowed when knee extension is limited to 10 degrees, a 20 percent disability rating is allowed when extension of the leg is limited to 15 degrees, a 30 percent disability rating is warranted for extension limited to 20 degrees, and a maximum schedular 40 percent disability rating is warranted for extension limited to 30 degrees. 38 C.F.R. § 4.71a. With regards range of motion, for rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. Id., Plate II. Upon VA examination addressing the right knee in November 2013, the Veteran’s history was noted of injuring the knee in a fall during training exercises in 1983, and of subsequently having three surgeries on the knee, the first in 1999 and the last in 2001, followed by physical therapy. The Veteran reported current right knee symptoms including chronic pain, weakness, swelling, and stiffness, as well as frequent instability, with symptoms worse during the winter. She also reported worsening pain with prolonged walking, standing, climbing stairs, and weather changes. She also did a lot of prolonged sitting, which increased pain and stiffness in the knee. The Veteran reported using a right knee brace for knee pain and took over-the-counter Aleve, with the medication helping with pain and inflammation. Objectively, range of motion of the right knee was to 60 degrees in flexion with pain beginning at 60 degrees, and to 0 degrees in extension without objective evidence of painful motion in extension, as compared to 90 degrees flexion and 0 degrees extension in the left knee without pain. Range of motion was unchanged with repetitive use testing. Repetitive use was found to produce less movement than normal and pain with movement in both knees. Full 5/5 strength was found in both knees in both flexion and extension. No instability was found in either knee. A meniscal tear was present in the right knee for which the Veteran had not undergone surgery. The examiner found no residuals of the past knee surgeries. X-rays supported the presence of degenerative changes in the knee. The examiner noted that the Veteran’s prior work was as a paralegal though she was currently unemployed. The examiner did not indicate that her unemployment was related to her knee. The examiner recommended against the Veteran performing significant physical labor but noted that her knee disability did not impose a restriction on the Veteran performing moderate physical work such as in a grocery or department store or more sedentary work activities. The examiner diagnosed right knee arthritis with residual pain and decreased range of motion. In February 2014 the Veteran was seen at VA requesting specialist treatment for her knees. She reported being told that she needed a knee replacement. She then informed that her right knee was worse than her left with arthritis on the right. She also then reported that her knees swelled all the time and that her right knee locked and popped. She was noted to have been seen by VA orthopedics one-and-a-half years ago and to have last received physical therapy two years ago. She reported taking one to two tables of Advil twice daily, and she was requesting Celebrex. She also reported previously having had steroid injections, adding that they did not work, and she would not repeat them. An October 2014 VA visit reflects that the Veteran again sough orthopedic specialist treatment for her knees but was uncooperative in releasing private records, allowing lab tests, and undergoing scans for her knees. The Veteran reported having 7 out of 10 pain which was present in her knees and thighs. Impairment solely due to the right knee was not addressed. A February 2015 VA treatment MRI of the right knee resulted in assessments of mild patellar tendon tendinosis, severe tear or destruction of the lateral meniscus, grade 2 sprain or partial tear of the medial collateral ligament, multiple foci of bone infarct in the distal femur, probable small focal bone infarct in the proximal tibia, and moderate osteoarthritis of the knee with grade 3 chondromalacia patella. Upon VA examination in March 2016 addressing the right knee, the examiner diagnosed osteoarthritis of the knee and noted a history of the knee gradually getting worse over time, with pain, limping, and swelling. The Veteran did not report flare-ups of the knee condition, but she had pain and stiffness with use, and at times the knee swelled. Objectively, range of motion was from 5 to 80 degrees flexion and from 80 to 5 degrees extension. Pain was noted on examination including with weight bearing, though repetitive use did not result in additional loss of range of motion. The examiner could not say without speculation whether repetitive use over time resulted in more limited functioning due to pain, weakness, fatigability, or incoordination. Muscle strength was 5/5 in flexion and extension. The examiner found no joint instability upon testing. A history of meniscal tear was noted, with the knee condition currently manifested by arthritis. The Veteran regularly used a knee brace and occasionally used a cane due to knee pain. The examiner assessed that the Veteran’s right knee disability would not preclude the Veteran from performing light manual or sedentary work. The March 2016 examiner noted the presence of a one-centimeter surgical scar, but this was not tender or unstable and was not found to otherwise affect functioning. The Board finds that the balance of the evidence of record is generally consistent with and supportive of the findings of the VA examiners in November 2013 and March 2016 with respect to the level of disability present in the right knee prior to the Veteran’s knee replacement in August 2016. The Board accordingly finds that with due consideration of pain on use and pain and increased limitation of functioning with prolonged sitting, standing, or walking, the Veteran’s right knee disability warrants a 10 percent rating for limitation of extension as equivalent to extension limited to 10 degrees under Diagnostic Code 5261, and warrants a 10 percent rating for limitation of flexion, as equivalent to flexion limited to 45 degrees under Diagnostic Code 5260. In the absence of such considerations of pain on use and pain and increased limitation of functioning with prolonged sitting, standing, or walking, the Veteran’s knee disability would be rated noncompensable for flexion and extension prior to August 2016. Because the Veteran is already assigned these 10 percent ratings, the Board finds the preponderance of the evidence against the Veteran’s right knee disability warranting a higher level of disability than the 10 percent assigned for limitation of flexion or than the 10 percent assigned for limitation of extension prior to knee replacement in August 2016. The VA examination reports all show the Veteran has full muscle strength in her right lower extremity with both flexion and extension which is evidence against weakness in that lower extremity that would warrant a rating in excess of 20 percent (the combined rating for limitation of flexion and extension). The Board also concludes that the weight of the evidence is against the Veteran’s right knee disability warranting a separate rating on other bases prior to the knee replacement in August 2016. Neither treatment records nor examination reports over the claim period reflect findings of symptomatic semilunar cartilage dislocation or removal, malunion or nonunion of the tibia or fibula, genu recurvatum, or other impairment to warrant a disability rating under Diagnostic Codes 5258, 5259, 5262, or 5263. In the VA Form 9, Appeal to the Board, received in December 2015, the Veteran alleged she had instability in the right knee and that the 2013 VA examiner was wrong in finding no instability. The Board acknowledges that the Veteran as a layperson is competent to testify to factual matters of which he has first-hand knowledge such as experiencing pain, perceiving instability in a joint, or witnessing actually observed symptoms such as swelling. See Washington v. Nicholson, 19 Vet. App. 362, 368 (discussing competence to report experienced or witnessed symptoms versus incompetent to offer render a medical diagnosis or identify the etiology of disease or injury that require medical knowledge). With respect to lateral instability, the Board has considered the Veteran’s statement that she has instability in the right knee. The Board recognizes that when considering whether lay evidence is competent, the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence may be competent. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, the Board finds the Veteran is competent to describe many symptoms of her right knee disability, such as perceived instability and pain. See Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). To the extent, however, that VA medical personnel used specific clinical tests to assess the stability of the Veteran’s right knee, the Board finds the objective medical evidence is more probative than the lay evidence on the issue of instability because the clinical assessment of knee instability made by performing particular joint stability tests falls outside the realm of common knowledge of laypersons. Here, since receipt of the increased rating claim in 2010, competent medical evidence has consistently documented that the Veteran’s right knee joint was stable to anterior testing, posterior testing, medial testing, and lateral testing. In Jandreau v. Nicholson, 492 F.3d 1372 (2007), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when…lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau, 492 F.3d at 1977. The issue of whether the Veteran’s perceived symptom of right knee instability is competent and sufficient to establish that she has actual instability of the knee sufficient to warrant a separate disability rating under Diagnostic Code 5257 is analogous to the situation described here in Jandreau. In this case, the Veteran has described her perception of right knee instability. However, numerous medical professionals have tested her right knee for instability during the pendency of her appeal and none has found even slight instability on anterior, posterior, medial, or lateral stability testing. Because the Veteran’s perceived symptom of right knee instability has repeatedly been refuted or confirmed on clinical testing by numerous, independent medical professionals, her lay statement that she had instability is insufficient to establish the presence of anterior, posterior, medial, or lateral instability sufficient to warrant separate disability rating. In English v. Wilkie, 30 Vet. App. 347 (2018), the United States Court of Appeals for Veterans Claims held that the Board cannot find objective medical evidence categorically more probative than lay evidence without explaining why that is the case. To be clear, the Board finds the objective medical evidence more probative than the Veteran’s report of perceived right knee instability for two reasons. First, the clinical findings by the May 2011, December 2013, and March 2016 examiners, where examiners included either two or four forms of stability testing; none of the examinations demonstrated right knee instability. The thorough, repeated stability testing, which did not reveal instability, supports the conclusion that the Veteran’s perceived knee instability is not due to anterior, posterior, medial, or lateral knee joint laxity. Second, the three examinations conducted over five years were performed by three, different medical professionals, each performed joint stability testing, and each documented the right knee was stable to stability testing. The internal consistency among the three independent examiners bolsters the conclusion that their findings of no right knee joint instability were accurate. For these reasons, the Board finds that the clinical findings of no right knee instability are more probative. Therefore, a separate rating for instability of the right knee is not warranted. For all the above reasons, the Board finds that higher ratings for the right knee are not warranted. 3. Entitlement to a higher rating of 60 percent beginning October 1, 2017, for the right knee status post total knee replacement A review of pertinent treatment and examination records as well as the Veteran’s own statements and testimony informs that the weight of the evidence is against a higher rating than the 30 percent assigned for right total knee replacement. Diagnostic Code 5055 provides for a 30 percent rating as a minimum rating for knee replacement. With intermediate degrees of residual weakness, pain, or limitation of motion, the disability is rated by analogy to Diagnostic Codes 5256, 5261, or 5262. A 60 percent rating is warranted for knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. A maximum rating of 100 percent is warranted for one year following implantation of prosthesis, which was assigned from May 19, 2015, to June 30, 2016. 38 C.F.R. § 4.71a, Diagnostic Code 5055. A February 2018 private rehabilitation note, as contained within private treatment records added to the claims file in October 2019, documents that the Veteran then had difficulty with her right lower extremity on steps. Impairment of right knee flexion also resulted in difficulties sitting, stand, and squatting. Negotiating stairs, heavy exertion, lifting, and physical activities were also noted to be affected. The physical therapist did report that the Veteran was making progress toward goals of better functioning. The Veteran reported significant progress in subsequent treatment. At a September 2019 physical therapy visit, the Veteran reported having a level 1 out of 10 pain in the right hip and right knee, and a 2 out of 10 pain in the low back. The physical therapist noted some continued greater weakness in the right lower extremity compared to the left but continued progressive strengthening. At a November 2019 VA knee examination, the Veteran’s history of right knee arthritis status post total knee replacement was noted. The Veteran reported that her knee disability currently was manifested by increased pain with prolonged weight bearing. Objectively, range of motion was to 70 degrees flexion and 5 degrees extension. This compared with range of motion in the left knee to 120 degrees flexion and 0 degrees extension. Pain and not range of motion itself was noted to contribute to functional impairment. There was evidence of pain with weight bearing as well as pain on palpation. The examiner did not observe additional range of motion loss with repetitive use. Strength in the right knee was 4/5 in extension and 5/5 in flexion, compared to 5/5 in flexion and extension in the left knee. Joint testing revealed no instability. The examiner assessed that the Veteran’s right total knee replacement was best characterized as intermediate degrees of residual weakness, pain, or limitation of motion. The Veteran regularly used a cane for assistance with locomotion. In addenda to the examination it was indicated that the Veteran regularly used both a brace and a cane for right knee support. Surgical scars from the knee replacement were not tender or unstable and were not found to otherwise affect functioning. The examiner commented that she would not recommend significant physical labor such as construction work due to the Veteran’s right knee impairment, but that the knee would not preclude more moderate physical labor such as in a department store, light office work, or more sedentary employment. In an October 2020 and December 2020 addenda, the November 2019 VA examiner was able to provide a revised estimate that status-post total knee replacement based on the Veteran’s self-report upon the examiner contacting her. The examiner concluded that the Veteran lost 50 percent of range of motion of the right knee after repetitive activity and lost 75 percent of range of motion of the right knee with flare-ups. The Veteran had range of motion of the right knee from 5 to 70 degrees flexion and from 70 to 5 degrees extension; but that with repetitive use pain, weakness, fatigability, and incoordination additionally limited such range of motion to 5 to 35 degrees flexion and 35 to 5 degrees extension. During flare-ups the Veteran’s range of motion was further limited due to pain, weakness, fatigability, and incoordination to 5 to 20 degrees flexion and 20 to 5 degrees extension. Based on these recent findings regarding the status of the Veteran’s right knee status post total knee replacement, the Board concludes that the Veteran’s disability has been equivalent to that which would warrant a 30 percent rating under Diagnostic Code 5260 based on disability equivalent to flexion limited to 20 degrees, and would warrant a 0 percent rating under Diagnostic Code 5261 based on disability equivalent to extension limited to 5 degrees. The Veteran’s post-knee-replacement pain and limitations combine to equate to intermediate degrees of residual weakness, pain, or limitation of motion, and hence a 30 percent rating under Diagnostic Code 5055 for knee replacement. The preponderance of the evidence is against a higher rating than the 30 percent assigned for the entire rating interval beginning October 1, 2017, and intervals of greater disability are not indicated as to warrant staged ratings. At the time of the November 2019 VA examination, the examiner documented that the Veteran had 5/5 motor strength with right knee flexion and 4/5 motor strength with right knee extension, which is evidence against a finding of more than moderate limitation of function to warrant a higher rating. In the November 2017 Notice of Disagreement, the Veteran wrote that she was still having problems with her knee “shifting” when she walks more than a block and has to use a cane if she is walking more than one block from her home. It is unclear if the Veteran’s allegation of her knee “shifting” is her alleging that the right knee has instability. The Veteran underwent a VA examination in November 2019, where the examiner performed four tests to determine if the Veteran’s right knee had instability, and all four tests were normal. The Board accords more probative value to the November 2019 VA examiner’s findings of no instability based on specific clinical tests than to the Veteran’s allegation of her knee “shifting,” as joint stability tests falls outside the realm of common knowledge of laypersons. Additionally, the physical therapy records that the Veteran submitted do not show a finding of instability. Therefore, a separate rating for instability of the right knee is not warranted. Benefit of doubt The Board finds the preponderance of the evidence against entitlement to higher ratings than those assigned by the agency of original jurisdiction, and hence the benefit of the doubt is not applicable to this extent. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Schechter 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.