Citation Nr: 0813466 Decision Date: 04/24/08 Archive Date: 05/01/08 DOCKET NO. 05-11 812 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for right retropatellar pain syndrome. 2. Entitlement to an initial rating in excess of 10 percent for left retropatellar pain syndrome. 3. Entitlement to an initial rating in excess of 10 percent for right sacroiliac joint pain syndrome (back disability). 4. Entitlement to an initial compensable rating for chronic allergic rhinitis. 5. Entitlement to service connection for gastroesophageal reflux disease (GERD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Helena M. Walker, Associate Counsel INTRODUCTION The veteran served on active duty from February 2000 to January 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which granted the veteran's claim of service connection for right and left knee retropatellar pain syndrome, rated 10 percent each knee; back pain, rated 10 percent; and chronic allergic rhinitis, rated as noncompensable. The RO denied service connection for GERD. The Board notes that the veteran's file was subsequently transferred to the Oakland, California RO. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. The veteran experiences 120 degrees of flexion in the right knee with slight subluxation and lateral laxity. 3. The veteran experiences 125 degrees of flexion in the left knee with slight subluxation and lateral laxity. 4. The veteran experiences 85 degrees of lumbar spine flexion and a combined range of motion of the thoracolumbar spine of 235 degrees without evidence of muscle spasm or guarding causing an abnormal gait or abnormal spinal contour. 5. As of December 5, 2006, the veteran's experiences obstruction of one side of her nasal passage, without evidence of nasal polyps, due to her service-connected chronic allergic rhinitis. 6. The veteran's GERD is attributable to her period of active service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a right knee disability based on limitation of motion have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1- 4.16, 4.71a, Diagnostic Codes 5024, 5260 (2007). 2. The criteria for a rating of 10 percent for subluxation and lateral laxity of the right knee have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.71a, Diagnostic Code 5257 (2007). 3. The criteria for a rating in excess of 10 percent for a left knee disability based on limited range of motion have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.71a, Diagnostic Codes 5024, 5260 (2007). 4. The criteria for a rating of 10 percent for subluxation and lateral laxity of the left knee have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.71a, Diagnostic Code 5257 (2007). 5. The criteria for a rating in excess of 10 percent for a back disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.71a, Diagnostic Code 5237 (2007). 6. The criteria for a compensable rating for chronic allergic rhinitis, prior to December 5, 2006, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.16, 4.97, Diagnostic Code 6522 (2007). 7. The criteria for a 10 percent rating for chronic allergic rhinitis have been met as of December 5, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.16, 4.97, Diagnostic Code 6522 (2007). 8. The criteria for service connection for GERD have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2007) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a veteran of the evidence necessary to substantiate her claim for benefits and that VA shall make reasonable efforts to assist a veteran in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters dated in October 2003 and May 2004, VA notified the veteran of the information and evidence needed to substantiate and complete her claims for service connection, and for increased ratings, respectively, including what part of that evidence she was to provide and what part VA would attempt to obtain for her. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letters also generally advised the veteran to submit any additional information in support of her claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service- connection claim, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), was provided in March 2006. As such, the Board finds that VA met its duty to notify the veteran of her rights and responsibilities under the VCAA. With respect to the timing of the notice, the Board points out that the United States Court of Appeals for Veterans Claims (Court) held in Pelegrini that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. In this case, the initial VCAA notice was given prior to the appealed AOJ decision, dated in February 2004. The notice in compliance with Dingess, however, was given following the appealed AOJ decision. The Court specifically stated in Pelegrini, however, that it was not requiring the voiding or nullification of any AOJ action or decision if adequate notice was not given prior to the appealed decision, only finding that appellants are entitled to VCAA-content- complying notice. Thus, the timing of the notice in this matter does not nullify the rating action upon which this appeal is based. Because proper notice was provided in March 2006 and a Supplemental Statement of the Case was issued subsequent to that notice in September 2007, the Board finds that notice is pre-decisional as per Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board notes that the veteran was provided inadequate VCAA notice for her appeal regarding her initial ratings for her right and left knee disability, back pain and chronic allergic rhinitis, and was not advised of the specific rating criteria used to determine the rating percentage for her service-connected disabilities. In Dingess, the Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the veteran is challenging the initial evaluations assigned following the grant of service connection. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service- connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was found to be legally sufficient, VA's duty to notify in this case has been satisfied and the purpose of the notice has been fulfilled. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the veteran in obtaining evidence, affording her physical examinations, obtaining medical opinions as to the etiology and severity of her disabilities, and by affording her the opportunity to give testimony before an RO hearing officer and/or the Board, even though she declined to do so. It appears that all known and available records relevant to the issue here on appeal have been obtained and are associated with the veteran's claims file. Thus, the Board finds that VA has done everything reasonably possible to notify and assist the veteran and that no further action is necessary to meet the requirements of the VCAA. Increased ratings Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Where entitlement to compensation has been established and a higher initial disability rating is at issue, as in this case, the level of disability at the time entitlement arose is of primary concern. See Fenderson v. West, 12 Vet. App. 119 (1999). Recently, in Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged" ratings are appropriate for an increased rating claim in such a case, when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The Board notes that the evaluation of the same disability under various diagnoses is to be avoided. That is to say that the evaluation of the same manifestation under different diagnoses, a practice known as "pyramiding," is to be avoided. See 38 C.F.R. § 4.14. The critical inquiry in making such a determination is whether any of the symptomatology is duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259 (1994). The Board notes at this juncture that VA will handle cases affected by change in medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and regulations governing disability compensation and pension. See 38 C.F.R. § 3.344(a). It is important to note that it is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Right and left retropatellar pain syndrome The veteran contends that her service-connected right and left retropatellar pain syndrome should be rated in excess of 10 percent per knee. The veteran's right and left knee disabilities are rated based on painful motion under 38 C.F.R. § 4.71a, Diagnostic Code 5024. The Board notes that when an unlisted condition is encountered, it is permissible to rate that condition under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology, are closely analogous. See 38 C.F.R. § 4.20. Diagnostic Code 5024 requires that tenosynovitis be rated as degenerative arthritis based on limitation of motion of the affected part. As such, the veteran was rated under Diagnostic Code 5260 for limitation of flexion of the leg, which provides that limitation of flexion of the knee to 60 degrees warrants a zero percent evaluation. Limitation of flexion of the knee to 45 degrees warrants a 10 percent evaluation. A 20 percent evaluation requires that flexion be limited to 30 degrees, and a 30 percent evaluation requires that flexion be limited to 15 degrees. The Board notes that, as interpreted by the Court, 38 C.F.R. §§ 4.40 and 4.45 require the Board to consider a veteran's pain, swelling, weakness and excess fatigability when determining the appropriate evaluation for a disability using the limitation of motion Diagnostic Codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court in DeLuca v. Brown, 8 Vet. App. 202 (1995), held that all complaints of pain, fatigability, etc., shall be considered when put forth by a veteran. It appears that the veteran was given a 10 percent rating for each knee based upon the DeLuca factors. The veteran may be rated separately under codes that address limitation of motion (like Diagnostic Codes 5003, 5260, and 5261) and Diagnostic Code 5257 because the latter code does not take limitation of motion into account. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994); VAOPGCPREC 9-98. In deciding this claim, the Board also looks to 38 C.F.R. § 4.71a, Diagnostic Code 5257, which allows for the assignment of ratings based on knee impairment with evidence of recurrent subluxation or lateral instability. Specifically, a 10 percent evaluation is assigned when the impairment due to subluxation or instability is deemed to be slight, a 20 percent evaluation is assigned when the impairment is moderate, and a 30 percent evaluation is assigned when the impairment is deemed to be severe due to recurrent subluxation or lateral instability. In a pre-discharge VA examination in November 2003, the veteran's knees were evaluated and she complained of daily knee pain-greater on the right than the left. She reported the location of her pain was within the knees and above the kneecaps and was aggravated by prolonged sitting, descending stairs or repetitive knee extension. Objectively, the veteran's right knee revealed 140 degrees of flexion and 0 degrees of extension. The left knee revealed left knee flexion of 140 degrees and an extension of 0 degrees. The examiner noted that upon repetitive motion, there is pain from the right knee flexion, but no decrease in range of motion or increase in weakness, fatigue or incoordination. The examiner found bilateral crepitus present. Additionally, the veteran was found to have a full range of motion in both knees. The examiner diagnosed the veteran as having chronic retropatellar pain syndrome, with no decreased range of motion, but pain upon prolonged sitting and descending stairs. There was no discussion of whether the veteran had subluxation or lateral instability. In June 2004, the veteran underwent x-rays of her knees. The film revealed no osseous abnormalities. The joints were noted to be well maintained and there were no arthritic changes or abnormalities noted. In July 2005, the veteran underwent another VA examination. The veteran reported the same subjective complaints of knee pain as expressed in her previous VA examination. Upon physical examination of the knees, the veteran had full extension of the knees and the right knee flexion was 120 degrees and the left knee flexion was 125 degrees. The examiner noted that he found no laxity except in the patellar ligament and he could easily dislocate the patella towards the lateral side of the knees. Given the evidence as outlined above, the Board finds that the veteran does not meet the criteria under Diagnostic Code 5260 for a rating in excess of 10 percent for her bilateral knee disability. In her November 2003 examination, the veteran had 140 degrees of flexion in both knees and in July 2005, she had 120 degrees of flexion in the right knee and 125 degrees of flexion in the left knee. There is no evidence that the veteran has a limitation of flexion to 30 degrees to warrant a higher, 20 percent rating under Diagnostic Code 5260. The Board finds, however, that the veteran is entitled to separate 10 percent ratings for each knee under Diagnostic Code 5257 regarding subluxation and lateral laxity. The July 2005 examination revealed laxity of the patellar ligaments and the examiner noted that he could easily dislocate the patellas. There is no evidence that the prior VA examination included an examination of subluxation or lateral laxity of the knees. The veteran has consistently complained of bilateral knee pain and difficulty in descending stairs and running. Thus, in order to properly evaluate this veteran's disability, the Board finds that it would not be considered pyramiding to award an additionally 10 percent rating for each knee for slight subluxation and instability of the knees, effective January 14, 2004. Back pain The veteran contends that she is entitled to an initial rating in excess of 10 percent for her back pain. Criteria for rating spine disorders were amended in September 2003. As the veteran filed her claim in October 2003, she is entitled to evaluation under the current regulations. These regulations provide that all spine disorders (save, in some instances, intervertebral disc syndrome) are to be rated by applying the General Rating Formula for Rating Diseases and Injuries of the Spine. Using the General Rating Formula with respect to rating lumbosacral strain under Diagnostic Code 5237, a 50 percent evaluation is assigned when there is unfavorable ankylosis of the entire thoracolumbar spine; a 40 percent evaluation is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the thoracolumbar spine; a 20 percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or with muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; and, a 10 percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, or the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees, or with muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. Under these rating criteria, the "combined range of motion" refers to the sum of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. Upon her November 2003 VA examination, the veteran was diagnosed as having chronic mid-back pain and severe, chronic right sacroiliac (SI) joint pain. The veteran reported first experiencing pain in April 2000 while running during training. Since then, the veteran experienced right SI joint pain radiating down her right buttocks. She advised that she experiences pain with weightbearing activities and a decrease range of motion with pain. The constant, daily pain is aggravated by prolonged sitting, exercising and when attempting to turn her lower body. Upon physical examination of the lumbar spine, her flexion was noted to be 95 degrees and extension of 35 degrees. Right and left lateral flexions were both 40 degrees, and right and left rotation were 35 degrees. The examiner noted that the veteran had decreased range of motion on flexion, extension, right and left lateral flexion and right and left rotations. Pain was noted during repetitive motions. The examiner indicated that there is only a decreased range of motion vis-à-vis the left lateral flexion. There was no increase in fatigue, weakness or incoordination following repetitive motions. Palpation of the right SI joint revealed tenderness and the lower extremities were noted to be neurovascularly intact. The x- ray of the lumbar spine was within normal limits. During her thoracic spine examination, the veteran reported that 6 months following her right SI joint pain, she began to experience mid thoracic back pain. She recalled that her pain had worsened during her 2002 pregnancy. The veteran reported that the pain occurs daily to once or twice weekly, depending on her activities. She advised that the pain is aggravated by lying flat or during back extension. The physical examination revealed no tenderness of the thoracic spine upon palpation, and her lower extremities were neurovascularly intact. The veteran's thoracic spinal x-ray was negative. She was ultimately diagnosed as having chronic, mechanical thoracic back pain. The veteran underwent another VA examination in July 2005. She reported that she experienced pain when picking up her daughter and upon lying flat on her back. She further advised that upon driving for 15 minutes, she begins to stiffen and has to change positions. The examiner noted that the veteran's back was tender to palpation and there was pain, without muscle spasm, reported in the lumbar area. The lumbar spine flexion was 85 degrees and decreased to 65 degrees upon repetition. The veteran's extension was 10 degrees and she complained of pain. The veteran's right and left lateral flexion was 25 degrees and she complained of discomfort in the right iliosacral area during both lateral flexions. The examiner noted that rotation was full at 45 degrees bilaterally. The veteran's hips revealed full extension and abduction with flexion of 110 degrees on the right and 120 degrees on the left-noted was the veteran's discomfort in the right iliosacral area. The veteran was able to rotate externally to 60 degrees and internally to 40 degrees. The veteran was diagnosed as having right iliosacral arthritis. Upon review of the evidence of record, the Board finds that the veteran is not entitled to an initial rating in excess of 10 percent for her back disability. The veteran's combined range of motion of her thoracolumbar spine is 235 degrees, her forward flexion is 85 degrees-this does not meet the rating criteria for a rating in excess of 10 percent under the general rating formula for spinal disabilities. Moreover, there is no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis to warrant a 20 percent rating. The Board has further considered whether factors including functional impairment and pain as addressed under 38 C.F.R. §§ 4.40 and 4.45 would warrant higher ratings. See DeLuca. The Board finds, however, that an increased evaluation for the back disability is not warranted under DeLuca. In this case, the veteran's complaints of discomfort and pain have been considered and have been taken into account in the assignment of the 10 percent evaluation for her service- connected back disability. Although pain has been the primary problem experienced by the veteran, the available medical evidence does not suggest that loss of function due to pain, weakness, etc. equates to more than limitation of flexion to 65 degrees or limitation of extension to 10 degrees. Although the Board is required to consider the effect of pain when making a rating determination, which has been done in this case, it is important to emphasize that the rating schedule does not provide a separate rating for pain. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). The Board has also considered whether staged ratings are appropriate under these circumstances and has found no evidence to support staged ratings. Thus, an initial rating is excess of 10 percent for the veteran's service-connected back disability is denied. Chronic allergic rhinitis The veteran seeks an initial compensable rating for her service-connected chronic allergic rhinitis. Under the rating schedule, allergic rhinitis is rated as 30 percent disabling if there are polyps. Without polyps, it is rated as 10 percent disabling if there is greater than 50 percent obstruction of the nasal passages on both sides, or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6522. During the veteran's November 2003 VA examination, the veteran reported experiencing itchy and watery eyes and nose. She was noted to have nightly nosebleeds. Objectively, the examiner found the conjunctiva were without infection or discharge. Her nares patent revealed no discharge and the oral cavity/oropharynx was without erythema or exudate. The veteran was diagnosed as having chronic allergic rhinitis, currently controlled with medication. In her substantive appeal, the veteran indicated that her nose is constantly stuffed and has to awaken to clean it. She reported that it feels like she constantly has a cold and often experiences nosebleeds and itchiness of the face, nose and arms. She further noted that her eyes are red and she experiences strong headaches. In July 2005, the veteran underwent a VA examination. The veteran reported that she is stuffy all the time and her nose also runs all the time and itches. The veteran reported itchy eyes. She noted that her medications did not help her symptoms. The examiner noted that the veteran had crusting in her nose as well as traces of blood in the mucous. Upon physical examination, the veteran was frequently scratching her nose and the examiner noted the presence of excoriations. He found that her mucosa was puffy and there was clear discharge present, particularly on the right side. He noted crusting around the nares. Her eyes were not particularly erythmatous. The veteran's pharynx was pink and moist and it appeared normal without a postnasal drip. Her voice was normal. The veteran did not show any dyspnea during the examination and her respirations were a regular 12 to 13. In January 2006, the veteran sought treatment for her facial congestion. The physician noted that the veteran had significant nasal congestion and general facial congestion. Upon a June 2006 x-ray of the veteran's sinuses, she was noted to have a mildly deviated nasal septum with trace mucosal thickening. The x-ray also revealed no evidence of a retention cyst or polyps. She had complained of 5 years of chronic sinus congestion. She reported that she was unable to breathe through her nostrils and experiences occasional nosebleeds. The veteran advised that she experiences sinus headaches. The VA physician suspected that the veteran had chronic sinusitis and that her deviated septum may be causing a lot of her symptomatology. In December 2006, the veteran again sought VA treatment for her nasal condition. She advised that she is unable to breathe through her nostrils and has difficulties breathing at night and running. She reported being totally congested and the examiner noted that this was despite her right nasal cavity being wide open. The physician indicated that if the veteran had her septum repaired, it would not ameliorate her ability to breathe through her nose, rather it would just allow her breathe at the same level as on the left through both of her nostrils. Upon review of the evidence of record, the Board finds that the veteran is not entitled to a compensable rating for her chronic allergic rhinitis from January 14, 2004 to December 4, 2006. There was no evidence of nasal polyps, nor is there clinical evidence that the veteran's nasal passages were 50 percent obstructed or completely obstructed on one side. The veteran is entitled, however, to a 10 percent rating for her service-connected chronic allergic rhinitis, effective December 5, 2006. During the veteran's December 2006 VA treatment, the physician indicated that the veteran's right nostril was wide open, but she was totally congested. This is consistent with the veteran's reported symptomatology. As of December 5, 2006, the Board finds that the veteran meets the criteria under Diagnostic Code 6522 for a 10 percent rating because of a complete obstruction of one side of her nasal passages. Extraschedular considerations The veteran has not identified any specific factors related to her service-connected bilateral knee disability, back disability and chronic allergic rhinitis which may be considered to be exceptional or unusual in light of VA's schedule of ratings. The Board has been similarly unsuccessful in locating exceptional factors. Specifically, the veteran has not required frequent periods of hospitalization for treatment of her disabilities. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a) and 4.1. 38 C.F.R. § 4.1 specifically states, "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Therefore, because there is no evidence of the veteran requiring frequent periods of hospitalizations due to her service-connected disabilities, the Board finds that the evaluations currently assigned adequately reflect the clinically established impairment experienced by the veteran. In the absence of requisite factors, the criteria for submission for assignment of an extraschedular rating for this disability pursuant to 38 C.F.R. § 3.321(b)(1) are not satisfied. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Consequently, the Board will not refer this claim to the Director of Compensation and Pension for extraschedular review. Service connection Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). GERD The veteran seeks service connection for GERD attributable to service. The veteran's enlistment medical examination reveals no preexisting gastrointestinal disorder. The veteran's service medical records, however, reveal treatment for heartburn. In October 2003, the veteran was noted to have a 2 to 3 year history of heartburn. She advised that she used over-the- counter antacids to treat the symptoms. The veteran was diagnosed as having GERD and was prescribed Aciphex for treatment. The veteran was told to return if her symptoms worsened or were not controlled by her medication. Upon the veteran's November 2003 VA examination, she reported that in 2001 she began to experience pain at her xiphoid process and experienced acid reflux. The veteran advised that she self-treated with over-the-counter medications and noticed aggravation upon consumption of greasy foods and consuming acidic juices. Two weeks prior to the examination, she began taking Aciphex for her condition. The physical examination revealed positive bowel sounds and that she was mildly tender in the right lower quadrant without rebound or guarding. The veteran's diagnosis was listed as "GERD suspected." In a February 2005 VA treatment note, the veteran was noted to have GERD and was given medication for her symptoms. Upon a July 2005 VA examination for the veteran's service- connected disabilities, the veteran was diagnosed as having epigastric distress, which was somewhat controlled with medication. Given the evidence as outlined above, the Board finds the criteria of entitlement to service connection for GERD have been met. While in service, the veteran was diagnosed and treated for GERD and has since been treated for it. There is no indication that the veteran had symptomatology associated with GERD prior to enlistment. Thus, all reasonable doubt is found in favor of the veteran and service connection for GERD is granted. (CONTINUED ON NEXT PAGE) ORDER An initial rating in excess of 10 percent for a right knee disability is denied. A separate rating of 10 percent for a right knee disability based upon subluxation and instability is granted, effective January 14, 2004, subject to the laws and regulations governing the award of monetary benefits. An initial rating in excess of 10 percent for a left knee disability is denied. A separate rating of 10 percent for a left knee disability based upon subluxation and instability is granted, effective January 14, 2004, subject to the laws and regulations governing the award of monetary benefits. An initial compensable rating for chronic allergic rhinitis, from January 14, 2004 to December 4, 2006, is denied. A rating in excess of 10 percent for a back disability is denied. A rating of 10 percent for chronic allergic rhinitis is granted, effective December 5, 2006, subject to the laws and regulations governing the award of monetary benefits. Service connection for GERD is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs