Citation Nr: 22017478 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 13-33 216 DATE: March 25, 2022 ORDER Entitlement to an initial increased rating of 20 percent, but no higher, for right knee disability is granted. Entitlement to a separate 20 percent rating, but no higher, for right knee, limitation of flexion, from October 25, 2019, is granted. Entitlement to an initial rating in excess of 10 percent for a left knee disability is denied. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's right knee disability is manifest with frequent episodes of locking, pain, and effusion of the joint, 2. From October 25, 2019, the Veteran's right knee disability is manifest with limitation of motion limited to 25 degrees. 3. Throughout the appeal period, the Veteran's left knee disability is manifest by painful motion. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial increased rating of 20 percent, but no higher for right knee disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 2. The criteria for entitlement to a separate 20 percent rating, but no higher, for right knee, limitation of flexion from October 25, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 3. The criteria for entitlement to an initial rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the Navy from June 1980 to June 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's right and left knee disabilities claims have been remanded by the Board several times for further development. Most recently, the claims were remanded by the Board in June 2021 for an updated VA examination. An examination was scheduled and completed in July 2021. Thus, the Board finds that the RO has substantially complied with the June 2021 Board remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to an initial increased rating of 20 percent, but no higher for right knee disability 2. Entitlement to a separate 20 percent rating, but no higher, for right knee, limitation of flexion 3. Entitlement to an initial rating in excess of 10 percent for a left knee disability The Veteran contends that he is entitled to a higher rating for his right and left knee disabilities. Disability ratings are determined by the application of the facts presented to VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claim for increased rating remains in controversy when less than the maximum available benefit is awarded AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 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 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 38 C.F.R. § 4.71a; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran's right knee disability is evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259, and 5260. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Veteran's left knee disability is evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes 5260-5010. The Board notes that hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. The hyphenated disability will be rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27. Additionally, the assigned Diagnostic Code 5260-5010 suggests that the left knee disability is rated based on compensable limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that the left knee disability has manifested as osteoarthritis and been rated based on painful noncompensable limitation of motion, and that the left knee disability has not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the relevant rating period. Therefore, the Diagnostic Code assigned should have been Diagnostic Code 5003, to show that the left knee disability with osteoarthritis is being rated based on noncompensable limitation of motion that is painful. For this reason, the Board is changing the Diagnostic Code for the left knee disability to Diagnostic Code 5003 to reflect the actual rating already assigned. 38 C.F.R. § 4.71a. The Board acknowledges that 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). However, Diagnostic Codes 5258 and 5259 were unchanged. Diagnostic Code 5003 was changed "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. But the change was minimal, and only reflects a more accurate title description. The evaluating criteria remained unchanged. Under Diagnostic Code 5003 for degenerative arthritis, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: 10 percent with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups; or 20 percent with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) indicates that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. The evidence relevant to the severity of the Veteran's right and left knee disabilities include VA examinations, VA treatment records, private treatment records, and lay statements. The Veteran's private treatment records reveal complaints of right knee swelling and normal range of motion beginning in February 2011. Statements provided by the Veteran's co-workers and spouse in February 2011 indicated that they witnessed the Veteran suffering with knee pain, swelling, and stiffness. They observed him limping around as his knees would give out and lock up on him after minimal activity. He was also observed with a brace to walk around as his job duties required him to walk and stand for several hours per day. In March 2011, the Veteran stated that he has experienced chronic right knee pain and swelling after his ACL surgery, and his knee locks up from the smallest movement. He stated that he wears a knee brace on both knees to support them when walking. He also experienced chronic left knee pain that prevents him from sitting and walking for long periods of time. VA treatment records include bilateral knee x-rays completed in March 2011. His right knee x-ray revealed degenerative changes with narrowing medial joint compartment and small posterior spurs at the patella and evidence of prior ACL repair. There was no effusion documented. The left knee x-ray revealed small posterior spurring at patella margins compatible with early degenerative change of the patellofemoral joint space. The Veteran was first afforded a VA examination in March 2011. He reported that his pain was a 10/10. He uses a cane and a brace occasionally with minimal help. He stated that he can walk up to 30 minutes or 1/4 mile, and has flare-ups from excessive standing, walking, or physical activity. He is employed as a police officer, and his knees do affect his ability to do his job. He denied mechanical, locking, or instability sensations. As for the left knee, the Veteran reported anterior pain and denied mechanical instability or locking. He stated his knee seems to be worse with going down hills or stairs, and his pain is 8/10. He uses a cane or brace which moderately helps. He can walk up to 30 minutes or 1/4 mile and has flare-ups with physical activity. Upon examination, left knee pain and crepitus were noted. There was no evidence of instability or effusion. His left range of motion was normal at 0 to 140 degrees. His right knee examination revealed range of motion of 140 degrees of flexion and lacking the last 5 degrees of extension. Crepitus was noted, but there was no evidence of instability or effusion. His right knee x-ray revealed patellar tendonitis as well as some chondromalacia. His left knee x-ray did not reveal any abnormalities. A June 2011 VA examination revealed both right and left knee range of motion from 0 to 115 degrees with pain. The examiner opined that repetition does not change the range of motion pr pain on either knee. The examiner also opined that it is conceivable that excessive physical activity, particularly involving heavy activity, gripping, pinching, or twisting items, could exacerbate the Veteran's pain, but it is not conceivable to discuss this in terms of limitation of motion. In the March 2012 VA Form 9, the Veteran reported that he has pain in his right knee, and it locks and swells. During a March 2012 VA examination of the right knee only, the Veteran reported pain rated as an 8/10, and other symptoms including swelling, instability, and decreased range of motion. He stated that he takes Advil and uses a brace for pain. He also reported flare-ups occurring a couple of times a week without warning and lasting up to 3 weeks. He stated that they are improved with rest and extending the knee. Upon range of motion testing, his right knee range from 0 to 120 degrees with pain upon motion. After repetitive use testing, there was no additional loss of motion, but the examiner opined that that he did experience functional loss or impairment as he has less movement than normal and pain on movement. Joint stability testing was normal and there was no evidence of patellar subluxation or dislocation. The examiner observed guarding during range of motion testing that was secondary to pain. The examiner checked that the Veteran uses a knee brace regularly and an x-ray revealed degenerative arthritis. The examiner opined that the right knee disability impacts the Veteran's ability to complete occupational tasks as his knee pain worsens with prolonged standing or walking, when getting out of squatting position, or when running. In a September 2013 letter to his congressional representative, the Veteran contended that his right knee ACL surgery has resulted in severe pain and swelling. He further stated that he is unable to stand, walk, or exercise for long periods of time, and is required to wear a knee support to complete daily work-related tasks. He also suffers from severe arthritis in both knees, which causes stiffness and pain in the joints making it difficult to walk and stand. In a November 2013 VA Form 9, the Veteran stated that he is still experiencing pain in the right knee, and due to the pain, he is unable to participate in sports activities and other things causing a major change in lifestyle. The Veteran further stated that as a result of right knee pain, he is favoring his left knee, which has caused a problem. VA treatment records include a right knee x-ray completed in April 2014 revealing stable severe patellofemoral knee joint space narrowing with small posterior patellar osteophytes and stable small knee joint effusion. During a June 2014 orthopedics consultation, the Veteran reported right knee pain at a 10/10 level with locking and giving way. A physical examination of the right knee revealed normal gait, no swelling or effusion, crepitus, and range of motion from 0 to 100 degrees. There was no locking noted. A right knee brace was ordered, and the Veteran was given a right knee steroid injection. A June 2014 prosthetics consultation noted the right knee brace given for osteoarthritis and to help with medial and lateral instability. A February 2015 orthopedic surgery note indicated that the Veteran's pain level remained at 10/10. He denied locking or buckling of the knees. An examination revealed normal gait, crepitus, no swelling or effusion, and range of motion from 0 to 100. In August 2015, the Veteran received a steroid injection during an orthopedic surgery appointment. He described his pain level as 10/10 and he denied locking and buckling. He had crepitus with a normal gait, and no swelling, effusion, or locking. His range of motion was from 0 to 100 degrees. In February 2016, he received steroid injections on both knees during an orthopedic surgery appointment. The physician's assistant noted a history of right ACL with partial medial meniscectomy of the right knee in 1990 with degenerative joint disease and chondromalacia currently present. The Veteran complained of his right knee giving way. Upon physical examination, his gait was normal and there was no swelling or effusion present. Crepitus was noted with range of motion from 0 to 100. In February 2017, the Veteran received steroid injections in both knees. The Veteran's findings were the same as described during the February 2016 appointment. He also received x-rays in February 2017. The x-rays noted that the Veteran's right and left knees were stable from the previous April 2014 x-ray. The right knee x-ray revealed persistently moderate patellofemoral knee joint space narrowing with small posterior patella osteophytes. There was no knee joint effusion. The left knee x-ray revealed stable, mild patellofemoral joint space narrowing with small posterior patella osteophytes and no joint effusion. In February 2018, the Veteran reported constant, sharp pain in both knees, with the right worse than the left during a VA examination. He rated his pain as 9/10. His right knee also gives out on him, and reported that going up stairs, running, walking up hills, squatting, bending, and prolonged standing/sitting aggravates his pain. His current treatment includes steroid injections and a knee brace. He denied flare-ups, but reported functional loss and impairment as he is not able to run or exercise, he is not able to sit for long periods, and he has pain mowing his lawn because his yard is on a hill. Range of motion testing revealed right knee range from 0 to 70 degrees, with decreased range of motion due to pain and pain causing functional loss. His left knee range of motion was from 0 to 105 degrees, with decreased range of motion due to pain and pain causing functional loss. The examiner noted that the Veteran was unable to completely perform range of motion testing. The Veteran was able to perform repetitive use testing without additional loss of function or range of motion. After repeated use over time, the examiner unable to say without speculation whether pain, weakness, fatigability, or incoordination would significantly limit functional ability. There was no objective evidence of atrophy, ankylosis, or joint instability. The examiner noted a right-side meniscal tear, with frequent episodes of joint locking and pain and a right knee meniscectomy in 1989 with residual signs and symptoms of joint pain, decreased range of motion, and weakness. The examiner also noted that the Veteran uses a knee brace for stability. The examiner opined that the Veteran's knee disabilities impact his functional abilities as he is unable to stand, walk, or sit for prolonged periods, and he is unable to squat, bend, or walk up the stairs. During an October 2019 VA examination, the Veteran reported constant pain rate as a 10/10. He stated that prolonged standing, walking, and daily activities will aggravate his pain. He also reported being unable to squat anymore, and that overcompensation has extended pain to the left knee rated as 8/10. He has constant sharp pain like being hit with a baseball bat. His pain depends on the activity he is doing, and he occasionally has swelling in the right knee. He uses a knee brace and heat/cold applications. He reported experiencing flare-ups when walking up and down hills and stairs. His flare-ups result in stiffness, walking more crooked to compensate, and pain beyond a 10/10. His flare-ups occur more in the right knee than the left knee, and occur after simple activities like walking, climbing stairs. He further stated that his flare-ups occur daily and are rated as moderate to severe, lasting a few hours. The Veteran also reported functional loss due to his knee disabilities as he is unable to run, climb stairs, or do any activity that requires prolonged standing, sitting, or walking. Range of motion testing of the right knee revealed flexion ending at 25 degrees with pain noted and not causing functional loss. Left knee flexion was limited to 45 degrees with pain noted and not causing functional loss. He was able to perform observed repetitive use without additional loss of function or range of motion. The examiner noted that the Veteran was examined immediately after repeated use. During flare-ups, the examiner opined that pain, weakness, fatigability, or incoordination do not significantly limit functional ability. The examiner found no signs or symptoms of atrophy, ankylosis, or joint instability. The examiner noted that right knee meniscal tear with frequent episodes of joint pain, as well as the previous right knee meniscectomy. The Veteran's constant use of a brace for his right knee was noted. The examiner opined that the Veteran's knee disabilities impact his ability to perform occupational tasks as prolonged standing, walking, and sitting aggravate the knee. In October 2020, the Veteran was afforded a VA examination where he reported his knee pain as 8/10 bilaterally. He described the pain as constant and feeling like a sharp aching pain. He also stated that only his right knee swells up. He is unable to squat, bend, or run. Factors that worsen his right knee pain and function include prolonged walking, standing, sitting, and ascending/descending from steep places. He stated that his right knee has worse function compared to his left and he denied flare-ups. Range of motion testing revealed right knee flexion limited to 50 degrees with pain noted on examination that causes functional loss. He was able to perform observed repetitive use without additional loss of function or range of motion. After repeated use over time, the examiner opined that pain significantly limits functional ability and estimated that his flexion would be reduced to 45 degrees. Left knee range of motion testing revealed flexion limited to 70 degrees with pain noted on the examination causing functional loss. He was able to perform repetitive use testing without additional loss of function or range of motion. The examiner opined that pain significantly limits functional ability after repeated use over time with flexion decreased to 60 degrees. The examiner found no objective evidence of atrophy, ankylosis, or joint instability. A right meniscal condition with frequent episodes of joint pain and effusion was noted, as well as the Veteran's right knee meniscectomy. The examiner noted that the Veteran uses a knee brace on a regular basis for his right knee. The Veteran's knee disabilities impact his ability to engage in occupational tasks due to limitations with standing, sitting, walking for prolonged periods of time, bending, ascending, descending, squatting, and running. The examiner concluded the examination by noting the Veteran's antalgic gait and that he avoids placing excessive weight on his right knee. VA treatment records from January 2021 include a physical therapy consultation. His left knee extension was limited to 5 degrees and his flexion was normal at 140 degrees. His right knee extension was normal and his flexion was limited to 115 degrees. Crepitus was noted with flexion. His left knee had poor stability and his right knee had decreased range of motion. During a January 2021 prosthetics consultation, he was provided with bilateral hinged knee brace due to pain and support with ambulation. Most recently, in July 2021, the Veteran was afforded another VA examination. He denied flare-ups, functional loss or impairment, or a history of instability, recurrent subluxation, or recurrent effusion. Range of motion testing revealed both right and left knee flexion limited to 135 degrees with no evidence of pain. He was able to complete observed repetitive use testing without additional loss of function. After repeated use over time, the examiner opined that pain significantly limits functional ability over time, and estimated flexion reduced to 125 degrees. There was no objective evidence of atrophy, ankylosis, or other knee conditions. The examiner noted that the Veteran uses a cane occasionally for right knee pain. The examiner opined that the Veteran's knee disabilities would impact his functional ability as he is unable to sit, stand, or walk for long periods of time, and is unable to jump, hike, climb, run, sprint, bend, squat, hop, dance, kneel, or crawl. Right knee disability After carefully considering the evidence of record and the evaluation criteria under Diagnostic Codes 5258 and 5259, the Board finds that the Veteran's symptoms are more nearly approximate to a rating of 20 percent under Diagnostic Code 5258 throughout the appeal period. The evidence shows that the Veteran had a right knee meniscectomy during his active service and has had resulting symptoms of the meniscectomy since service. The Veteran's private treatment records note swelling in the right knee as early as February 2011 and the Veteran reported right knee swelling, pain, and locking in his March 2011 statement in support of claim. The Board finds that the Veteran is competent to report his right knee symptoms including, pain, swelling, and locking, and finds that the lay statements are credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In further support of a 20 percent rating throughout the appeal under Diagnostic Code 5258, the Board cites to the April 2014 x-ray included in the Veteran's VA treatment records which noted joint effusion. Additionally, the February 2018, October 2019, and October 2020 VA examiners all determined that the Veteran suffered from a right knee meniscal condition resulting in frequent episodes of joint pain, effusion, and locking. Additionally, the Board finds it significant to note that the Veteran has used a brace and was prescribed a knee brace in June 2014, as documented by his VA treatment records for his complaints of right knee pain, swelling, locking, and giving way. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). After carefully considering the evidence of record, the Board finds that the evidence supports a 20 percent rating under Diagnostic Code 5260 for limitation of flexion from October 25, 2019, the date of the VA examination finding reduced range of motion. The October 2019 VA examiner determined that the Veteran's right knee flexion was limited to 25 degrees, which warrants a 20 percent rating under Diagnostic Code 5260. However, prior to the October 2019 VA examination, the Veteran's flexion was limited to no less than 70 degrees, as noted by the February 2018 VA examination, which does not warrant a compensable rating under Diagnostic Code 5260. Other Diagnostic Codes considered include Diagnostic Code 5257, other impairment of the knee. Prior to February 7, 2021, under Diagnostic Code 5257, a 10 percent rating was warranted for slight recurrent subluxation or lateral instability, a 20 percent rating was warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating was warranted for severe recurrent subluxation or lateral instability. After February 7, 2021, Diagnostic Code 5257 requires evidence of either a sprain, incomplete ligament tear, or complete ligament tear causing persistent instability or a diagnosed condition involving the patellofemoral complex to warrant a compensable rating. The Board finds that the evidence does not support a rating under Diagnostic Code 5257 either prior to February 7, 2021 or thereafter. Prior to February 7, 2021, the objective medical evidence of record did not reveal any instability of the joints. Joint stability testing completed in March 2011, June 2011, March 2012, February 2019, October 2019, and October 2020 did not reveal any evidence of right knee instability. After February 7, 2021, the Board notes that the evidence does support a finding that the Veteran was prescribed a knee brace for ambulation; however, neither the BVA treatment records nor the July 2021 VA examination indicate that the Veteran is diagnosed with a sprain or tear that causing persistent instability or a patellofemoral complex condition. Thus, a separate compensable rating under Diagnostic Code 5257 after February 7, 2021 is also not warranted. The Board has considered the Veteran's statements regarding instability including that his knees "give out," and as previously noted, finds his statements credible. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). However, the Board affords more probative value to the objective medical evidence of record, which has found no evidence of right knee instability throughout the appeal period. Furthermore, the Board considered the Veteran's statements pertaining to "locking" and "giving out" as well as the use of the knee brace when awarding a 20 percent rating under Diagnostic Code 5258. In conclusion, the Board finds that the evidence of record persuasively favors a rating of 20 percent under Diagnostic Code 5258 throughout the appeal period; and a rating of 20 percent under Diagnostic Code 5260 from October 25, 2019. Left knee disability The Board finds that the evidence of record persuasively weighs against a rating in excess of 10 percent under Diagnostic Code 5003 for the left knee. The evidence of record indicates that the Veteran had a diagnosis of left knee degenerative arthritis as documented by the March 2011 x-ray. The Veteran has also complained of left knee pain, less severe than the right knee, throughout the appeal period. Additionally, throughout the appeal period, the Veteran's left knee range of motion has not been limited to less than 45 degrees flexion. The Board notes that under Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to 45 degrees. However, here, the Veteran is already in receipt of a 10 percent rating for his degenerative arthritis with painful motion and limitation of motion, and a separate compensable rating under Diagnostic Code 5260 would violate the rule against pyramiding. 38 C.F.R. § 4.14; see also Esteban, 6 Vet. App. at 261-62. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain and decreased movement. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he experiences daily left knee flare-ups of moderate to severe severity would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The Veteran's VA treatment records indicate that the Veteran's knee complaints were limited primarily to his right knee until February 2016 when he received steroid injections in both the right and left knees. Additionally, his range of motion was close to normal with the exception of the October 2019 and October 2020 VA examinations, but as previously noted, his flexion was not so limited to warrant a rating in excess of 10 percent. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg, specifically Diagnostic Code 5257 as the Veteran was prescribed a left knee brace in January 2021. However, similar to the findings for the right knee, the objective medical evidence of record does not suggest that the Veteran has joint instability of the left knee as every VA examination throughout the appeal has not documented joint stability after testing. Consequently, the Board finds that the evidence is persuasively against awarding a separate compensable rating for instability under Diagnostic Code 5257, In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 10 percent for his left knee disability. As the evidence of record persuasively weighs against a rating in excess of 10 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Hartford, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.