Citation Nr: 21032346 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 16-32 535 DATE: May 26, 2021 ORDER Prior to November 13, 2018, a disability rating in excess of 10 percent for degenerative joint disease (DJD) of the right knee joints with instability (and painful motion) ("right knee DJD") is denied. From January 1, 2020, entitlement to a disability rating in excess of 30 percent for right knee total knee replacement ("TKR") is denied. A disability rating in excess of 10 percent for DJD of the left knee joints with instability and painful motion ("left knee painful motion") under Diagnostic Code (DC) 5260 is denied. Prior to November 13, 2018, a compensable disability rating for right knee total knee replacement, previously rated as degenerative arthritis of the right knee joints with instability ("right knee instability") under DC 5257 is denied. A compensable disability rating for degenerative arthritis of the left knee joints with instability ("left knee instability") under DC 5257 is denied. FINDINGS OF FACT 1. Prior to November 13, 2018, the Veteran's right knee DJD manifested with x-ray evidence of arthritis; flexion limited to, at worst, 100 degrees; extension limited to, at worst, 0 degrees; painful motion; and symptoms including pain; inability to sit, stand, walk, or squat for prolonged periods; and sleep disturbance. 2. From January 1, 2020, the Veteran's right knee TKR manifested with x-ray evidence of arthritis; flexion limited to, at worst, 105 degrees; extension limited to, at worst, 0 degrees; painful motion; and symptoms including pain; inability to sit, stand, walk, or squat for prolonged periods; and sleep disturbance. 3. Left knee painful motion manifested by subjective complaints of painful motion and difficulty ambulating; objective testing did not show flexion limited to 30 degrees. 4. Prior to November 13, 2018, right knee instability did not result in slight recurrent subluxation or lateral instability. 5. During the period on appeal, left knee instability did not result in recurrent subluxation, lateral instability, or patellar instability, including that requiring the use of assistive devices. CONCLUSIONS OF LAW 1. Prior to November 13, 2018, the criteria for a rating in excess of 10 percent for right knee DJD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5260. 2. From January 1, 2020, the criteria for a rating in excess of 30 percent rating for right knee TKR have not been met. 38 U.S.C.§ 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5055. 3. The criteria for a rating in excess of 10 percent for left knee painful motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5260. 4. Prior to November 13, 2018, the criteria for a compensable rating for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257. 5. The criteria for a compensable rating for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1972 to November 1974 and April 1975 to May 1993. During his period of service, he earned the Army Commendation Medal, Army Achievement Medal (2nd Oak Leaf Cluster), Good Conduct Medal (6th Award), National Defense Service Medal (2nd Award), Noncommissioned Officer Professional Development Ribbon with Numeral 3, Army Service Ribbon, Overseas Service Ribbon with Numeral 4, and Sharpshooter Marksmanship Badge (Rifle M-16). This case was previously before the Board in January 2019, at which time the issues currently on appeal were remanded for additional development. All necessary development has been accomplished, and therefore appellate review of the claim may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Increased Ratings Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable DCs. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when assigning disability ratings. See generally 38 C.F.R. § 4.1. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. Although pain may cause a functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,' in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). With specific respect to knee disabilities, normal range of motion for the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. 1. Entitlement to higher ratings for right knee disabilities Currently, the Veteran is in receipt of a 10 percent evaluation for right knee DJD under DC 5260 prior to November 13, 2018, and a 30 percent evaluation for right knee TKR under DC 5055 from January 1, 2020. He has been awarded a temporary total rating for his disability from November 13, 2018 to December 31, 2019, based on surgical treatment required convalescence. As the Veteran is in receipt of the maximum disability rating, the period of convalescence will not be discussed herein. A. Prior to November 13, 2018 The Veteran's right knee DJD is evaluated under DC 5260, applicable to limitation of flexion. Under this DC, a 20 percent rating is warranted with evidence of flexion limited to 30 degrees. A separate, 10 percent rating may also be available for limitation of extension to 45 degrees. The Veteran appeared for a VA knee and lower leg examination in July 2012. The Veteran reported experiencing flare-ups, during which he was unable to stand or walk for prolonged periods. Right knee range of motion showed flexion ended at 100 degrees, with objective evidence of painful motion beginning at 100 degrees. Extension ended at 0 degrees, with objective evidence of painful motion beginning at 0 degrees. The Veteran was able to perform repetitive-use testing with three repetitions. Post-test right knee range of motion showed flexion ended at 100 degrees. Post-test extension ended at 0 degrees. Functional loss and/or functional impairment was noted. Contributing factors of disability included less movement than normal; pain on movement; and interference with sitting, standing, and/or weight-bearing. Tenderness or pain to palpation was also noted. The Veteran reported the occasional use of a cane for ambulation. The Veteran appeared for a VA knee and lower leg conditions examination in March 2016. The Veteran reported constant and dull knee pain. He reported pain with the severity level of 7 on a scale of ten. He reported experiencing flare-ups described as shooting and dull pain which caused difficulty sleeping. The Veteran reported experiencing functional loss or impairment, described prolonged standing limited to no more than 15 minutes, and walking limited to no more than a half mile. He also indicated that he had walking difficulties and sleep difficulty. Right knee range of motion showed flexion from 0 to 140 degrees, with objective evidence of painful motion beginning at 100 degrees. Extension was from 140 to 0 degrees, with objective evidence of painful motion beginning at 0 degrees. Pain that caused functional loss was noted on flexion and extension. There was also objective evidence of crepitus and pain with weight-bearing. The Veteran was able to perform repetitive-use testing with three repetitions. There was no evidence of additional loss of function or range of motion after three repetitions. The examiner indicated the examination was conducted immediately after repetitive use over time and during a flare-up. The examiner noted that the Veteran's functional ability was significantly limited by pain and lack of endurance. The examiner described the functional loss in range of motion as flexion of 0 to 140 degrees and extension from 140 to 0 degrees. Additional factors that contributed to disability included deformity, disturbance of locomotion, and interference with standing. The Veteran reported the occasional use of a knee brace and constant use of a cane for ambulation. The Veteran also appeared for a VA knee and lower leg conditions examination in April 2016. The Veteran reported constant daily pain, which was worsened by weight-bearing or ascending and descending stairs. He experienced intermittent giving way and stiffness. He also reported the occasional use of a knee brace and constant use of a cane for ambulation. The Veteran reported experiencing flare-ups, as well as functional loss or impairment described as limitations with walking; inability to kneel, squat, or run; inability to perform yardwork; difficulty ascending and descending stairs; requiring breaks with prolonged housework or driving long distances; and pain that wakes him up at night. Right knee range of motion showed flexion from 0 to 105 degrees. The Veteran's abnormal range of motion did not contribute to functional loss. Pain that resulted in or caused functional loss was noted on flexion. There was objective evidence of localized tenderness at the joint line. There was also evidence of pain with weight-bearing and objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with three repetitions. There was no evidence of additional loss of function or range of motion after three repetitions. The examiner indicated the examination was not conducted immediately after repetitive use over time or during a flare-up. The examiner explained that she was unable to determine if pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups, as it was not possible to estimate either loss of range of motion nor describe loss of function without resorting to mere speculation. The examiner indicated there was no conceptual or empirical basis for making such a determination without directly observing function under those conditions. Per the Veteran's testimony, additional factors that contributed to disability included less movement than normal due to ankylosis, adhesions, etc., deformity, disturbance of locomotion, and interference with standing. However, the examiner explicitly denied ankylosis in the Veteran upon his examination. The remaining evidence, to include treatment records and lay testimony, does not deviate from the above findings to any notable degree. Rather, this evidence speaks to the Veteran's history of right knee pain productive of mild limitation of motion. The Board has carefully reviewed the record and finds that the preponderance of the evidence is against an evaluation greater than 10 percent for limitation of motion. This evaluation is consistent with painful motion. 38 C.F.R. § 4.59. This is also consistent with the medical evidence of record, which fails to show that the Veteran's flexion was limited to 30 degrees or extension was limited to 15 degrees to warrant an increased or separate rating based on limitation of motion, at any time during the period on appeal. The Veteran's right knee limitation of motion has been noncompensable throughout the period on appeal prior to November 13, 2018. Despite this, he has been assigned a 10 percent evaluation for his reports of painful motion. See Mitchell, supra. Although the Board finds the Veteran's assertions as to the severity of his symptoms to be credible, these reports alone do not warrant the assignment of an increased disability rating. Without objective evidence of greater limitation of motion, the Board cannot grant an increased disability rating. There is also no indication that the Veteran's right disability warrants an increased rating under any other DC relating to the knees for the period on appeal prior to November 13, 2018. The claims folder contains no medical evidence indicating that the Veteran's right disability was manifested by ankylosis; dislocated semilunar cartilage; symptomatic removal of semilunar cartilage; impairment of the tibia and fibula; genu recurvatum; or symptoms other than those discussed above. As such, an increased rating cannot be assigned under DCs 5256, 5258, 5259, 5262, or 5263. 38 C.F.R. § 4.71a, DCs 5256, 5258, 5259, 5262, and 5263. In offering this finding, the Board acknowledges the Veteran's reports of ankylosis during April 2016 examination. However, the examiner denied objective evidence of ankylosis upon review of the Veteran, and there is no such evidence throughout the remainder of the claims file. Thus, the appeal cannot be granted on this basis alone, as the Veteran is a non-expert lay person without the training or expertise to competently identify the nature of his symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Thus, the Board concludes that an evaluation in excess of 10 percent for the period on appeal prior to November 13, 2018 is denied. B. From January 1, 2020 The Veteran's right knee TKR is evaluated under DC 5055, applicable to knee resurfacing or replacement (prosthesis). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select DCs "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. However, the criteria for a 60 percent rating under DC 5055 were unchanged by the February 2021 amendments. Thus, whether applying the old or new regulations, a 60 percent rating is warranted for prosthetic replacement of a knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity; or, with intermediate degrees of residual weakness, pain or limitation of motion is rated by analogy to DCs 5256, 5261, or 5262. 38 C.F.R. § 4.71a, DC 5055. The Veteran most recently appeared for a VA knee and lower leg conditions examination in October 2019. He reported daily achy and dull pain. He also reported that he could not sit, stand, walk, or squat for prolonged periods of time. The Veteran reported experiencing flare-ups, described as moderate stiffness occurring two to three times per week and lasting for 30 minutes to an hour. He reported experiencing functional loss or impairment described as an inability to sit, stand, walk, or squat for prolonged periods. He also reported sleep disturbances due to pain. Right knee range of motion showed flexion from 0 to 130 degrees. The Veteran's abnormal range of motion contributed to functional loss described as pain with sitting, standing, running, or squatting. Pain that resulted in or caused functional loss was noted on flexion and extension. There was also evidence of pain with weight-bearing. The Veteran was able to perform repetitive-use testing with three repetitions. There was additional loss of function or range of motion after three repetitions. Post-test right knee range of motion showed flexion from 0 to 120 degrees. Post-test extension was from 125 to 0 degrees. Pain and lack of endurance caused functional loss. The examiner indicated the examination was not conducted immediately after repetitive use over time nor during a flare-up. The examiner determined that pain significantly limited functional ability with repeated use over a period of time and during flare-ups. She was unable to describe the functional loss in terms of range of motion. The examiner was unable to describe any additional functional loss in terms of range of motion, and noted that there was no basis to offer additional loss of function or motion with repeated use over time or during flare-ups based on a review of the Veteran's records, current examination, reported history, subjective complaints, relevant evidence of record, and the examiner's own medical knowledge and expertise. The examiner noted that the Veteran had intermediate degrees of residual weakness, pain or limitation of motion following his November 2018 total knee joint replacement. The Veteran reported the constant use of a cane for ambulation. The remaining evidence, including treatment records and lay statements, reflect a similar disability picture as that assessed above. Notably, this evidence establishes the Veteran's history of chronic right knee pain following a TKR. Considering the foregoing, the evidence of record does not establish that this disability warrants more than a 30 percent disability rating under DC 5055. The medical evidence does not demonstrate severe painful motion or weakness. Further, rating the Veteran's limitation of motion by analogy to DCs 5260 and 5261, a rating in excess of 30 percent disabling is not warranted. Reference is made to the October 2019 VA examination that noted the Veteran's extension was to 0 degrees, which is not rated as disabling. See DC 5261. Additionally, his flexion was limited to, at worse, 125 degrees, which is also not rated as disabling. See DC 5260. There is no indication that pain due to the Veteran's service-connected right knee disability has caused functional loss greater than that contemplated by the 30 percent rating assigned. The degree of limitation of motion is contemplated in the current rating. Therefore, the Board finds that the holding in DeLuca and the provisions of 38 C.F.R. §§ 4.40 and 4.45 do not provide a basis for a higher rating. The Board has also considered whether a separate, compensable disability is warranted under the remaining DCs pertaining to the knee. As the relevant disorders are not shown in the record during the period on appeal (whether under the old or new regulations), DCs 5256, 5258, 5259, 5262, and 5263 do not provide an avenue upon which to grant this appeal. In sum, the preponderance of the evidence is against the award of a rating in excess of 30 percent for the Veteran's right total knee replacement for the period on appeal from January 1, 2020. For all of the foregoing reasons, the Board finds that the above ratings are appropriate for the right knee disability. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims of entitlement to increased ratings, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). 2. Entitlement to a higher rating for left knee painful motion The Veteran's left knee painful motion is currently evaluated as 10 percent disabling under DC 5260, applicable to limitation of flexion. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, this DC was unchanged. Thus, whether applying to new or old regulations, a 20 percent rating is warranted with evidence of flexion limited to 30 degrees. The Veteran first appeared for a VA knee and lower leg conditions examination in July 2012. The Veteran reported experiencing flare-ups, during which he was unable to stand or walk for prolonged periods. Left knee range of motion showed flexion ended at 100 degrees, with objective evidence of painful motion beginning at 100 degrees. Extension ended at 0 degrees, with objective evidence of painful motion beginning at 0 degrees. The Veteran was able to perform repetitive-use testing with three repetitions. Post-test left knee range of motion showed flexion ended at 100 degrees. Post-test extension ended at 0 degrees. Functional loss and/or functional impairment was noted. Contributing factors of disability included less movement than normal; pain on movement; and interference with sitting, standing, and/or weight-bearing. Tenderness or pain to palpation was also noted. The Veteran reported the occasional use of a cane for ambulation. The Veteran appeared for a VA knee and lower leg conditions examination in March 2016. The Veteran reported constant and dull knee pain. He reported pain with the severity level of 7 on a scale of ten. He reported experiencing flare-ups described as shooting and dull pain which caused difficulty sleeping. The Veteran reported experiencing functional loss or impairment, described prolonged standing limited to no more than 15 minutes, and walking limited to no more than a half mile. He also indicated that he had walking difficulties and also experienced sleep difficulty. Left knee range of motion showed flexion from 0 to 140 degrees, with objective evidence of painful motion beginning at 100 degrees. Extension was from 140 to 0 degrees, with objective evidence of painful motion beginning at 0 degrees. Pain that caused functional loss was noted on flexion and extension. There was also objective evidence of crepitus and pain with weight-bearing. The Veteran was able to perform repetitive-use testing with three repetitions. There was no evidence of additional loss of function or range of motion after three repetitions. The examiner indicated the examination was conducted immediately after repetitive use over time and during a flare-up. The examiner noted that the Veteran's functional ability was significantly limited by pain and lack of endurance. The examiner described the functional loss in range of motion as flexion of 0 to 140 degrees and extension from 140 to 0 degrees. Additional factors that contributed to disability included deformity, disturbance of locomotion, and interference with standing. The Veteran reported the occasional use of a knee brace and constant use of a cane for ambulation. The Veteran also appeared for a VA knee and lower leg conditions examination in April 2016. The Veteran reported constant daily pain, which was worsened by weight-bearing or ascending and descending stairs. He experienced intermittent giving way and stiffness. He also reported the occasional use of a knee brace and constant use of a cane for ambulation. The Veteran reported flare-ups, as well as functional loss or impairment described as limitations with walking; inability to kneel, squat, or run; inability to perform yardwork; difficulty ascending and descending stairs; requiring breaks with prolonged housework or driving long distances; and pain that wakes him at night. Left knee range of motion showed flexion from 0 to 105 degrees. The Veteran's abnormal range of motion did not contribute to functional loss. Pain that resulted in or caused functional loss was noted on flexion. There was objective evidence of localized tenderness at the joint line. There was also evidence of pain with weight-bearing and objective evidence of crepitus. The Veteran was able to perform repetitive-use testing with three repetitions. There was no evidence of additional loss of function or range of motion after three repetitions. The examiner indicated the examination was not conducted immediately after repetitive use over time nor during a flare-up. The examiner explained that she was unable to determine if pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time or during flare-ups, as it was not possible to estimate either loss of range of motion nor describe loss of function without resorting to mere speculation. The examiner indicated there was no conceptual or empirical basis for making such a determination without directly observing function under those conditions. Additional factors that contributed to disability included less movement than normal due to ankylosis, adhesions, etc., deformity, disturbance of locomotion, and interference with standing. However, the examiner denied ankylosis on contemporaneous examination of the Veteran. The Veteran most recently appeared for a VA knee and lower leg conditions examination in October 2019. The Veteran reported daily achy and dull pain. He also reported that he could not sit, stand, walk, or squat for prolonged periods of time. The Veteran reported experiencing flare-ups, described as moderate stiffness occurring two to three times per week and lasting for 30 minutes to an hour. He reported experiencing functional loss or impairment described as an inability to sit, stand, walk, or squat for prolonged periods. He also reported sleep disturbances due to pain. The Veteran reported the constant use of a cane for ambulation. Left knee range of motion showed flexion from 0 to 130 degrees. The Veteran's abnormal range of motion contributed to functional loss described as pain with sitting, standing, running, or squatting. Pain that resulted in or caused functional loss was noted on flexion and extension. There was also evidence of pain with weight-bearing. The Veteran was able to perform repetitive-use testing with three repetitions. There was additional loss of function or range of motion after three repetitions. Post-test left knee range of motion showed flexion from 0 to 120 degrees. Post-test extension was from 125 to 0 degrees. Pain and lack of endurance caused functional loss. The examiner indicated the examination was not conducted immediately after repetitive use over time nor during a flare-up. The examiner determined that pain significantly limited functional ability with repeated use over a period of time and during flare-ups. She was unable to describe the functional loss in terms of range of motion. The examiner was unable to describe any additional functional loss in terms of range of motion, and noted that there was no basis to offer additional loss of function or motion with repeated use over time or during flare-ups based on a review of the Veteran's records, current examination, reported history, subjective complaints, relevant evidence of record, and the examiner's own medical knowledge and expertise. The Board has carefully reviewed the record and finds that the preponderance of the evidence is against an evaluation greater than 10 percent under DC 5260. This evaluation is consistent with painful motion. 38 C.F.R. § 4.59. This is also consistent with the medical evidence of record, which fails to show that the Veteran's flexion was limited to 30 degrees at any time during the period on appeal. The Veteran's left knee limitation of motion has been noncompensable throughout the entire period on appeal. Despite this, he has been assigned a 10 percent evaluation for his reports of painful motion. See Mitchell, supra. Although the Board finds the Veteran's assertions as to the nature and severity of his symptoms to be credible, these reports alone do not warrant the assignment of an increased disability rating. Without objective evidence of greater limitation of motion, the Board cannot grant an increased disability rating. The Board has also considered whether a separate, compensable service-connected disability is warranted under the remaining DCs for knee disabilities. A positive finding is not offered in this instance, as the claims folder contains no medical evidence indicating that the Veteran's right disability was manifested by ankylosis; dislocated semilunar cartilage; symptomatic removal of semilunar cartilage; compensable limitation of extension; impairment of the tibia and fibula; genu recurvatum; or symptoms which are not otherwise contemplated in the applicable DCs (whether applying the old or revised criteria). As such, separate awards of service connection are not warranted under DCs 5256, 5258, 5259, 5261, 5262, or 5263. Again, the Board acknowledges that the Veteran reported ankylosis during his April 2016 examination. However, the examiner denied evidence of ankylosis upon review of the Veteran, and there is no such evidence throughout the remainder of the claims file. Thus, the appeal cannot be granted on this basis alone, as the Veteran is a non-expert lay person without the training or expertise to competently identify the nature of his symptoms. See Jandreau, 492 F.3d at 1376-77. Thus, an evaluation in excess of 10 percent for the entire period on appeal is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased rating, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). 3. Entitlement to a higher rating for right knee instability 4. Entitlement to a higher rating for left knee instability The Veteran is also in receipt of separate, noncompensable disability ratings for right and left knee instability under DC 5257. The right knee rating is in effect from July 16, 2012, to November 13, 2018, when the Veteran was awarded a temporary total evaluation for his knee replacement. The left knee rating is in effect from July 16, 2012, to the present. The periods on appeal have been applied accordingly. Again, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. The criteria more favorable to the Veteran will be applied. Prior to the regulatory change, DC 5257 rated recurrent subluxation or lateral instability of the knee. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. The criteria do not define what constitutes "slight" recurrent subluxation or lateral instability. Under the amended regulations, a 10 percent rating is warranted for 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 now also applies to patellar instability, and establishes 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. Of note, the amended regulations only apply to the left knee appeal, as the Veteran's right knee rating under DC 5257 was terminated prior to the February 2021 amendments. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Turning to the evidence, compensable ratings are not warranted for the Veteran's bilateral knee instabilities under the old version of DC 5257. Notably, the evidence does not show that the Veteran's right and left knees were manifested by slight recurrent subluxation or lateral instability as to warrant higher ratings. Indeed, no examiner has characterized the Veteran as experiencing even slight instability of the joints; rather, VA examiners in July 2012, March 2016, April 2016, and October 2019 all concluded that there was no history of recurrent subluxation or lateral instability. Joint stability testing was also performed in July 2012, April 2016, and October 2019. The examiners indicated that joint instability was not observed. The Veteran's treatment records are also silent for such a history, whether as reported by the Veteran or a medical examiner. Further, a compensable rating is not warranted for the Veteran's left knee instability under the amended regulations. As stated above, the record is silent for a history of recurrent subluxation or lateral instability, to include that caused by a sprain or ligament tear. Although the Veteran has reported the use of assistive devices for ambulation, to include a brace and cane, the record fails to show that these devices are due to a sprain or ligament tear, particularly that which causes "persistent" instability. Absent competent reporting of instability, a compensable rating is not warranted on this basis. Similarly, the record does not establish a history of patellar instability, with or without a history of surgical repair. Simply stated, the Board has contemplated the Veteran's use of assistive devices but finds no evidence that they are required to assist with recurrent subluxation, lateral instability, or patellar instability. As such, application of the amended regulations fails to yield a compensable rating in this case. In offering these findings, the Board has considered the Veteran's competent lay testimony and contemporaneous treatment records, as well. Collectively, this evidence does not speak to such a history of bilateral instability as to grant these appeals. Thus, the preponderance of the evidence is against the award of a compensable rating for the Veteran's left knee instability for the entire period on appeal, and for right knee instability prior to November 13, 2018. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims of entitlement to increased ratings, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Of final note, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). Kate E. Kovarovic Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tracy O. Joseph, 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.