Citation Nr: 21039841 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 15-36 305 DATE: July 1, 2021 ORDER 1. Entitlement to a rating in excess of 10 percent for left knee meniscal tear with degenerative changes (left knee disability) is denied. 2. Entitlement to a rating in excess of 10 percent for residuals of right wrist fracture (right wrist disability) is denied. FINDINGS OF FACT 1. For the entire rating period, the Veteran's left knee disability has been manifested by pain and limitation of motion resulting in disability equivalent to no worse than limitation of flexion to 45 degrees, without other compensable associated disability of the knee. 2. The Veteran's left knee disability has not been manifested by semilunar cartilage dislocation with frequent episodes of locking, pain, and effusion into the joint. 3. For the entire rating period, the Veteran's right wrist disability has been manifested by some limitation of motion and pain and pain with use as well as some limitation of functioning during flare-up and with repeated use over time, which taken together are equivalent to palmar flexion limited in line with the forearm. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for the left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5258, 5260. 2. The criteria for a rating in excess of 10 percent for the right wrist disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2010 to August 2012. The Department of Veterans Affairs is grateful for his service. The Veteran testified before the undersigned Veterans Law Judge of the Board of Veterans' Appeals (Board) at a video conference hearing in October 2018. A transcript of the hearing is of record. The Board remanded the appealed claims in March 2019, and they now return to the Board for further review. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects the Veteran's ability to function under the ordinary conditions of daily life, including employment, by comparing the Veteran's symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. § Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, if the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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 applies only when the limitation of motion is noncompensable under the applicable diagnostic code. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria." The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. In determining the weight to be assigned to evidence, credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self- interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511, 512 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996). Under Diagnostic Code 5260, a noncompensable evaluation is warranted when flexion is limited to 60 degrees, a 10 percent disability evaluation when flexion is limited to 45 degrees, a 20 percent disability evaluation when flexion is limited to 30 degrees, and a 30 percent disability rating when flexion is limited to 15 degrees. Normal range of motion for the knee is from 0 to 140 degrees. The rating criteria pertaining to some knee Diagnostic Codes were revised effective February 7, 2021. However, as those Codes are not applicable in this matter, the February 7, 2021 effective revisions do not require further discussion. As an initial matter, the Board notes that the Veteran has already been granted a total disability rating for compensation based on individual unemployability (TDIU) effective September 1, 2012 on the basis of multiple disabilities. However, the evidentiary record does not support unemployability due solely to one or both of the disabilities the subject of this appeal, as addressed in part below. 1. Entitlement to a rating in excess of 10 percent for the left knee disability The Veteran contends, in effect, that his left knee disability warrants a higher rating than the 10 percent assigned based on limitation of functioning with pain, locking, and instability. At his hearing in October 2018, the Veteran testified that since 2012 he had experienced worsening of his left knee disability, including locking up, instability, and giving way. He reported having fallen in the shower so that now he used a shower chair. The Veteran wore a left knee brace to the hearing. He also testified to having undergone physical therapy and going to recreational therapy for the knee. At a January 2014 VA examination for compensation purposes, records were not reviewed but the examiner noted the Veteran's reported history of a left knee meniscal tear status post arthroscopic meniscectomy, with no treatment since the Veteran's last VA examination. The Veteran did not report flare-ups of the knee condition. Upon examination, range of motion was to greater than 140 degrees flexion without objective evidence of painful motion, and no limitation of extension with no objective evidence of painful motion on extension. Testing after repetitive use produced no changes from these findings. The examiner found no functional loss or additional limitation of motion of the knee after repetitive use testing, and found no tenderness or pain to palpation of the knee. Strength in the knee was normal at 5/5 in both flexion and extension. Stability in the knee was also normal, and there was no evidence or history of recurrent patellar subluxation/dislocation. There was also no history of additional conditions including shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. A history of meniscal tear and arthroscopic meniscectomy in 2012 was noted. The Veteran reported having pain and locking-up as a residual of the meniscal tear. Reviewed x-rays did not show traumatic arthritis of the knee or patellar subluxation. The examiner found no functional impact of the Veteran's left knee disability on his ability to work. At a December 2019 VA knee examination, the Veteran reported limitations including with walking more than 30 minutes, standing in one position more than 30 minutes, sitting in one position (required for driving) more than 20 minutes, walking up stairs and down stairs, and squatting. The Veteran also reported that he could not run. The Veteran reported a baseline level of pain and added that an increased pain in his knee due to activity stopped after ceasing activity, and pain usually returned to baseline two hours after activity. He reported using a left knee brace constantly, which helped to some degree in taking pressure off the knee. The Veteran reported that he currently did not work, and that he last worked as a laborer in 2014. The Veteran denied flare-ups of his left knee. The Board notes that the Veteran's report at the December 2019 examination of a symptomatic left knee after walking for 30 minutes is inconsistent with his report upon March 2020 left foot and left ankle examinations of having excruciating pain in the left foot and left ankle after walking 100 feet. Excruciating pain after walking 100 feet would preclude walking for 30 minutes. The Veteran's statement at the ankle examination that he lost from zero to one week of work in the past year due to his left ankle is also inconsistent with his report at the knee examination that he last worked as a laborer in 2014. The Board accordingly finds the Veteran's report of symptoms associated with the left knee not credible, as inconsistent with his other statements of record. Caluza, 7 Vet. App. at 511, 512. The Board also observes that these inconsistent statements and associated non-credibility are consistent with the Veteran's past non-credible reporting upon examinations for compensation purposes. In a report of an October 2014 VA examination addressing claimed posttraumatic stress disorder (PTSD), the examiner noted that the Veteran's responses upon psychiatric examination were consistent with malingering, and feigned symptoms and/or exaggeration were also implicated, such that the examiner could not arrive at a valid conclusion as to the nature of any psychiatric disability the Veteran may or may not have had. At the December 2019 examination, range of motion of the left knee was from zero to 135 degrees flexion and 135 to zero degrees extension, with pain noted upon demonstrated motion. The examiner assessed that pain in the left knee resulted in functional loss upon flexion and extension, with pain also present on weightbearing. However, there was no localized tenderness or pain on palpation of the left knee and no objective evidence of crepitus. Repetitive use testing of the left knee also did not produce additional functional loss or loss of range of motion. The examiner assessed that limitation with repetitive use of the left knee over time, while not tested, was consistent with the Veteran's self-report of such limitations. The examiner found that the Veteran's left knee was limited by pain but did not find other limiting factors to be present of weakness, fatigability, or incoordination. The examiner expressed the Veteran's limitation of motion of the knee and pain with motion as equivalent to limitation of flexion to from zero to 130 degrees and limitation of extension from 130 to zero degrees (no limitation of extension). At the December 2019 examination range of motion of the right knee (the contralateral joint) was entirely normal, with motion from zero to 140 degrees flexion, 140 to zero degrees extension, no pain noted on examination, no evidence of pain with weight bearing, no objective evidence of localized tenderness or pain on palpation of the joint, and no objective evidence of crepitus. Repetitive use testing of the right knee also did not produce additional functional loss or loss of range of motion. The December 2019 examiner found normal strength (5/5) in both knees in both flexion and extension. The examiner also found no instability in either knee and no ankylosis. A meniscal condition of the left knee was shown on MRI in January 2012 as "nondisplaced small inferiorly surface tear of the posterior horn medial meniscus." A history of left knee meniscectomy in March 2012 was noted, with the Veteran currently having residual chronic left knee pain. The examiner found no other pertinent physical findings, complications, conditions, signs, or symptoms. In agreement with the Veteran's self-report at the examination, the examiner assessed that the Veteran's limitations associated with the left knee resulted in limitation to walking for 30 minutes, standing in one position for 30 minutes, sitting in one position for 20 minutes, and limitations in walking upstairs, down stairs, and squatting, and inability to run. The Board notes that for these assessments, the December 2019 examiner substantially relied on the Veteran's self-report of limitations of functioning, which the Board has noted are not credible based on inconsistent statements. However, the Board concludes that the December 2019 examiner's assessment is sufficiently based on objective findings to warrant its acceptance for purposes of the Board's adjudication in this case. The Board also notes that findings upon the December 2019 examination were substantially consistent with those from the January 2014 VA examination, reflecting no substantial change in the nature and severity of the left knee disability. Regarding the Veteran's testimony about the knee locking up, instability, giving way, and resulting falls, the Board notes that these are not supported by findings of locking or instability in treatment records, by documentation of associated falls, or by objective findings of ankylosis or locking or instability upon VA examinations in January 2014 and December 2019. While the Veteran reported pain and locking up of the knee at the January 2014 VA examination, objective findings to support locking up were not found by either examiner other than the history of meniscal tear with meniscectomy. The 10 percent rating currently assigned contemplates pain. Also relevant and weighing against the credibility of the Veteran's contentions of locking, instability, and giving way, the Board notes the Veteran's failure to report instability, locking, and giving way at the December 2019 VA examination, where reporting of such symptoms would be expected. Rather, at that examination the Veteran reported only pain in the left knee and above-noted limitations of functioning associated with pain in the knee. The January 2014 and December 2019 VA examiners also observed a surgical scar on the knee, but the scar was not painful, unstable, or of a total area of more than six square inches, and it did not otherwise impact functioning. Hence, a separate rating based on scar is not indicated. 38 C.F.R. § 4.118. The Board finds the balance of the evidence of record to be generally consistent with and supportive of the findings of the January 2014 and December 2019 examiners with regard to the Veteran's left knee disability and its impact on functioning. The Board finds credible and supported by more objective findings the presence of some pain and limitation of motion of the knee as addressed by the December 2019 examiner. The Board does not find credible the Veteran's assertions of locking, instability, and giving way, as these were not found on examination and are not otherwise supported by objective evidence other than the history of meniscal tear with meniscectomy, and the Board finds the very limited credibility of the Veteran's uncorroborated contentions of these symptoms of the knee disability to be outweighed by the Veteran's failure to report them at his December 2019 examination and the absence of corroboration or supportive objective findings upon examination in both January 2014 and December 2019, when examiners performed multiple forms of stability testing and found no instability. With due consideration of impact of pain on functioning and the December 2019 VA examiner's assessment of reduced functioning due to pain and its equivalence to limitation of range of motion, the Board finds that all disability associated with the knee as reflected by competent and credible evidence of record is equivalent to limitation of flexion to 45 degrees, with the preponderance of the evidence against disability equivalent to limitation of flexion to 30 degrees. Throughout the appeal, the Veteran was documented to have full muscle strength in his knee with both flexion and extension, which is evidence against more than mild weakness to warrant a higher rating. Hence, the Board finds the preponderance of the evidence against the Veteran's left knee disability warranting a higher disability rating than the 10 percent assigned based on this level of disability under the applicable diagnostic code for limitation of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board has considered staged ratings but does not find competent and credible evidence of record to support a greater level of impairment so as to warrant a higher rating under that or a higher or additional rating under any other code during any interval during the claim period. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Because the Veteran has reported locking and has a history of meniscal tear status post meniscectomy, the Board must consider whether a rating for the knee under Diagnostic Code 5258 is warranted. Under that Code, semilunar cartilage dislocation with frequent episodes of locking, pain, and effusion into the joint warrants a separate 20 percent rating. However, in this case the Board concludes that the Veteran's reports of locking are not credible, and effusion has also not been shown upon knee examinations. Thus, the preponderance of the evidence is against frequent episodes of locking, pain, and effusion into the joint. Hence, the Board finds that a 20 percent rating under Diagnostic Code 5258 is not warranted. The Board finds the preponderance of the evidence against other factors such as flare-ups or limitation of functioning with repeated use over time or less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, or pain on movement resulting in greater or additional disability than that reflected by the rating assigned based on pain with motion, as discussed. 2. Entitlement to a rating in excess of 10 percent for a right wrist disability The Veteran contends, in effect, that his right wrist disability resulting from a scaphoid fracture and repair in service is more disabling than is reflected by the 10 percent rating assigned. The record reflects that the Veteran is right hand dominant. Wrist limitation of motion is appropriately rated under Diagnostic Code 5215. Under that code, a 10 percent rating is assigned for limitation of palmar flexion in line with the forearm or dorsiflexion limited to less than 15 degrees, with 10 percent as the highest rating under that code. 38 C.F.R. § 4.71a, Diagnostic Code 5215. The Veteran suffered right wrist fracture in service and underwent open reduction internal fixation (ORIF) for repair of the scaphoid bone in November 2011. At a January 2014 VA examination for compensation purposes, records were not reviewed but the examiner noted the Veteran's reported history of wrist fracture status-post surgical repair by ORIF in 2011 resulting in initial improvement. The Veteran complained of decreased movement and aching/hurting of the wrist in cold weather. He also reported at times experiencing tingling of the ring finger and pinky, and having difficulty lifting weight of approximately 30 pounds. He stated that he wore a wrist brace all the time in winter and not at all in summer, and at times he experienced stiffness and throbbing with writing and typing. The January 2014 examiner noted the Veteran's reports of flare-ups, consisting of the wrist at times swelling with resulting limited range of motion. Objectively at the examination, range of motion was to 40 degrees palmar flexion with no objective evidence of painful motion, and to 30 degrees dorsiflexion also with no objective evidence of painful motion. Following three repetitions, palmar flexion increased to 45 degrees and dorsiflexion increased to 35 degrees; the examiner found no additional limitation in range of motion following repetitive use testing. However, the examiner did identify functional loss and/or impairment of the wrist, consisting of less movement than normal. No tenderness or pain on palpation was found for either wrist, and strength testing was normal at 5/5 for both flexion and extension bilaterally. There was no ankylosis of either wrist. Residuals of the Veteran's right wrist surgery consisted of reported pain and decreased motion. X rays were reviewed but these were found not to document any degenerative or traumatic arthritis. Post-surgical changes to the scaphoid bone were observed of "two small orthopedic screws transfixing a healed fracture site." The remainder of the wrist was "unremarkable" on x-ray with joint spaces "well-preserved." The examiner found that the Veteran's wrist condition did not impact his ability to work. At a September 2014 VA plastic surgery consultation, the Veteran reported that he had trouble with push-ups and exercise and failed to pass physical examinations for work due to his right wrist. He additionally reported that motion was limited and painful, so that "even flipping burgers is painful." He then complained of some feelings of numbness in the small and ring fingers of the right hand. The consulting physician reviewed August 2014 x-rays showing the bone healed, no loose screws, no soft tissue swelling or erosion, and mild degenerative changes in the radioscaphoid and scapholunate joint spaces. Motion of the wrist was to 20 degrees dorsiflexion with pain, and to 30 degrees flexion. The wrist was tender at the snuff bow, but vascularity and sensation were intact. There was mild Tinel's sign at the right cubital tunnel (at the elbow). The examiner assessed that current difficulties were due to arthritis in the wrist, concluding that the Veteran was having "a very difficult time with wrist pain and mobility." However, the other nerve complaints were noted to be associated with cubital tunnel irritation and unrelated to the wrist. March 2015 VA x-rays of the right wrist revealed the scaphoid fracture to be completely healed with no evidence of hardware failure. At his October 2018 hearing the Veteran testified to having undergone surgery for his right wrist in 2015 but that his wrist had not improved after the surgery. He testified to having aching pain in the wrist, problems gripping with the right hand, and having pain if he writes for too long. He testified that his hand would lock up if he held his phone for too long, and he contended that effectively he had lost use of his right hand. He added that he also underwent physical therapy and was prescribed a home hot wax machine to use for the wrist. He also reported having recreational therapy for the wrist. He wore a wrist brace to the hearing. He also then reported that he was having nerve problems with his fingers but did not know if this was due to his wrist. Upon VA wrist examination in December 2019, the examiner reviewed the Veteran's history of wrist fracture in 2011 with ORIF surgery in November 2011, and of reported gradual worsening of the wrist since that time. A history of an additional surgery in August 2015 for removal of a screw in the wrist was also noted. The Veteran reported pain improvement for three to four months after each surgery, but then with pain gradually recurring. The Veteran reported that pain in his wrist was at 6-8 out of 10, constant, and aching, with progression of symptoms for the past three years. The examiner observed that the Veteran had not received injections to the wrist for pain control, but that the Veteran reported that wrist pain resulted in limitations in lifting more than 15 pounds, pulling, pushing, and holding objects tightly for more than three minutes. The Veteran reported that after he ceased activities that caused increased pain, pain level would return to baseline after two hours. The Veteran also reported using a wrist brace constantly which helped. He reported not having worked since 2014, with his past work as a laborer. He denied flare-ups of his wrist disability. Objectively at the December 2019 examination, range of motion of the right wrist was zero to 40 degrees palmar flexion, zero to 60 degrees dorsiflexion, zero to 40 degrees ulnar deviation, and zero to 15 degrees radial deviation. Pain was noted on examination with all these directional ranges of motion. There was also evidence of pain with weight bearing. In contrast, no limitation of motion or limitation of functioning was found in the left wrist. Repetitive use testing of the right wrist did not produce additional limitation of functioning. The examiner assessed that the Veteran's self-report of limitations of functioning with repetitive use over time associated with the right wrist disability was consistent with objective findings. Expressing the Veteran's limitation of functioning in terms of range of motion limitation, the examiner assessed limitation of palmar flexion to 35 degrees, dorsiflexion to 55 degrees, ulnar deviation to 35 degrees, and radial deviation to 10 degrees. The examiner did not objectively find reduced strength or ankylosis in either wrist, and he observed no muscle atrophy. The examiner also found no additional factors contributing to disability for either wrist. The examiner concluded that the Veteran had residual chronic pain in the right wrist following his wrist surgeries, and that the Veteran's constant use of a wrist brace helped "to some degree taking pressure off the right wrist." The December 2019 VA examiner also observed a surgical scar on the wrist, but this was not painful, unstable, or having a total area of more than six square inches, and it did not otherwise impact functioning. The same scar observations had been made by the January 2014 examiner. Hence, a separate rating based on scar is not indicated. 38 C.F.R. § 4.118. The Board concludes that the weight of competent and credible evidence of record is reasonably consistent with and supportive of the findings and conclusions of the January 2014 and December 2019 examiners as reflecting the nature of the Veteran's right wrist disability during the entire claim period. While some changes were observed between the examinations in limitations of motion and observed pain with motion, the limitations of motion of the right wrist as recorded by the January 2014 and December 2019 examiners do not meet the criteria for a 10 percent rating based on either limitation of palmar or dorsiflexion under Diagnostic Code 5215. With due consideration of pain with motion, limitation of use over time, and reported flare-up limited prolonged functioning, the Board finds that the Veteran's wrist disability throughout the claim period has been equivalent to limitation of palmar flexion to the line with the forearm including based on actual limited motion and based on pain and pain with motion and functional limitation including with repeated use and due to flare-ups, thus warranting a 10 percent rating under Diagnostic Code 5215, which is the maximum schedular rating under that code. The Board finds the weight of the evidence against other disability of the wrist warranting a higher rating under a different code, such as based on limitation of use of the hand, or on an extraschedular basis. An extraschedular rating is not indicated by competent and credible evidence of record. While the Veteran and his representative attempted to make arguments at the October 2018 hearing to the effect that impairment due to the wrist disability was functionally equivalent to loss of use of the hand, that is not supported by the record including the Veteran's self-report in testimony and demonstrated motion and reported use at examinations and treatments with no atrophy documented in the September 2019 VA examination report. The Veteran has reported that prolonged writing caused excess pain, which demonstrates that the Veteran is capable of writing with/using the hand. He has also reported limitations with lifting 15 or 30 pounds, which demonstrates some lifting and carrying capacity. Hence, by his own statements loss of use is not present. The Veteran's endorsement at the hearing of his representative's argument of loss of use of the hand thus serves to reinforce impaired credibility, based on contradiction of that assertion by the Veteran's own statements and by other evidence of record. As reflected above in the Board's discussion of the left knee disability, contradictory assertions concerning impairment of ambulation due to a foot disability versus a knee disability undermine the Veteran's credibility for reporting of symptoms and history in furtherance of his appealed claims. With respect to the right wrist, the Board accepts as supported by objective evidence the presence of wrist disability with some limitation of motion and pain impairing some functioning. Loss of strength in the wrist was not found on examination. In the absence of corroboration including by objective findings, the Board does not find credible the Veteran's assertions of additional hand impairment associated with his wrist disability, such as his testimony that his hand locks up when using the telephone. The Board does not find that the wrist disability results over the claim period in more severe disability than that warranting the assigned 10 percent rating including based on pain-associated wrist limitation of motion and functioning, limitations associated with repeated use over time, and flare-ups with associated pain and limitation of functioning. Hence, the preponderance of the evidence is against a higher rating for the wrist disability. The Veteran at his hearing informed that he last work as a laborer in 2014, and in effect contends that right wrist disability plays a role in his no longer being capable of working. However, while the Veteran has already been granted a TDIU rating, the Board does not find that his right wrist disability results in impairment of work functioning beyond that reflected by the 10 percent rating assigned. Treatment records reflect some psychiatric issues and sleep impairment potentially playing a role in the Veteran not working, as well as marijuana and alcohol abuse and the Veteran's family care responsibilities, but treatment records do not, on balance, reflect that the Veteran's wrist plays a significant role in the Veteran not working. Examination records also do not inform of the Veteran being rendered incapable or obtaining or retaining work due to his wrist disability. Based on the above-noted contradictory and factually unsupported statements, the Board does not find credible the Veteran's testimony in this regard. The Board finds the preponderance of the evidence against other factors such as flare-ups or limitation of functioning with repeated use over time or less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, or pain on movement resulting in greater or additional disability than that reflected by the rating assigned, as discussed. The Board has reviewed the entire record and finds that the 10 percent rating assigned for the Veteran's right wrist disability reflects the most disabling this disability has been during the rating period in question. Thus, the Board concludes that staged ratings for this disability are not warranted. See Hart v. Mansfield, 21 Vet. App. 505 (2007). VA treatment records reflect that the Veteran underwent surgery to the right elbow in 2017 for ulnar nerve entrapment. The Veteran's medical symptoms associated with the ulnar nerve entrapment at the elbow (cubital tunnel) included numbness and tingling of the fingers of the right hand. The Board notes that the Veteran is separately service connected for right ulnar nerve entrapment with a 30 percent rating assigned from September 2012 based specifically on neuropathy in the fingers of the right hand under 38 C.F.R. § 4.124a, Diagnostic Code 8516. Thus, the Veteran is already separately rated based on his neuropathy of fingers of the right hand. While the Veteran raised an issue of entitlement to a higher or additional rating for his wrist based on these finger neuropathy symptoms, because he is already receiving compensation for these symptoms based on ulnar neuropathy, to additionally rate his wrist disability based on the same symptoms would amount to impermissible pyramiding, or assigning multiple ratings for the same disability. 38 C.F.R. § 4.14. Benefit of Doubt The Board has considered application of the benefit of doubt doctrine. However, because the preponderance of the evidence is against the appealed claims, the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b); 3§ 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.