Citation Nr: 1327262 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 07-20 395 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a rating in excess of 40 percent for urinary tract infection, cystitis, and urethral syndrome . 2. Entitlement to a rating in excess of 20 percent for residuals of ectopic pregnancy and adhesions surgeries (with scars). 3. Entitlement to a rating in excess of 10 percent for postoperative right patellofemoral syndrome. 4. Entitlement to a rating in excess of 10 percent for left patellofemoral syndrome. 5. Entitlement to a rating in excess of 10 percent for anemia. 6. Entitlement to a compensable rating for status post salpingectomy, with uterine fibroids. 7. Entitlement to a temporary total rating based on a need for convalescence from August to October 2009. 8. Entitlement to an effective date earlier than August 13, 2010 for the grant of service connection for rectovaginal fistula. 9. Entitlement to an effective date earlier than August 13, 2010 for the grant of service connection for urinary tract infection, cystitis, and urethral syndrome. 10. Entitlement to an effective date earlier than August 13, 2010 for the grant of service connection for residual of ectopic pregnancy and adhesions surgeries (with scars). 11. Entitlement to an effective date earlier than August 13, 2010 for the grant of service connection for status post salpingectomy, with uterine fibroids. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is a Veteran who served on active military duty from May 1986 to January 1998. These matters are before the Board of Veterans' Appeals (Board) on appeal from September 2006, January 2010, and November 2012 rating decisions by the Roanoke, Virginia Department of Veterans Affairs (VA) Regional Office (RO). The September 2006 rating decision, in pertinent part, continued a 10 percent rating for the right knee disability. [An earlier (May 2005) rating decision had adjudicated a prior claim for increase. The Veteran did not file a notice of disagreement with that determination. Nor did she file a notice of disagreement with the interim rating decision which assigned a temporary total (convalescence) rating from April 1 to June 1, 2005. While she submitted additional evidence and information in the year following, it pertained to the status of the right knee after the May 2005 rating decision, and was not new and material as to the period considered in the May 2005 rating decision. Therefore, the May 2005 rating decision, and an interim rating decision that assigned a temporary total rating from April to June 2005 are final; the period for consideration herein begins June 1, 2005.] The January 2010 rating decision, in pertinent part, denied service connection for a psychiatric disorder, continued a 10 percent rating for a left knee disability, and denied a temporary total rating based on a need for convalescence for a period from August to October 2009. In August 2011, a Travel Board hearing was held before the undersigned; a transcript of the hearing is associated with the claims file. In November 2011, the matters were remanded for development. An October 2012 rating decision granted service connection for major depressive disorder with panic disorder with agoraphobia and general anxiety disorder, rated 70 percent, effective September 29, 2008, and the matter of service connection for a psychiatric disability is no longer before the Board. The November 2012 rating decision granted service connection for rectovaginal fistula rated 100 percent, effective August 13, 2010; urinary tract infection, cystitis and urethral syndrome, rated 40 percent, effective August 13, 2010; residuals of an ectopic pregnancy and adhesions surgeries (with scars), rated 20 percent, effective August 13, 2010; and status post salpingectomy, with uterine fibroids, rated 0 percent effective August 13, 2010; and awarded a 10 percent rating for anemia, effective August 13, 2010. In December 2012 the Veteran filed a timely notice of disagreement initiating an appeal as to the effective date of the awards and/or the respective ratings assigned for the disabilities. The issues of entitlement to: A rating in excess of 40 percent for urinary tract infection, cystitis, and urethral syndrome; a rating in excess of 20 percent for residuals of ectopic pregnancy and adhesions surgeries (with scars); a rating in excess of 10 percent for anemia; a compensable rating for status post salpingectomy with uterine fibroids; an effective date earlier than August 13, 2010 for the grant of service connection for rectovaginal fistula; an effective date earlier than August 13, 2010 for the grant of service connection for urinary tract infection, cystitis, and urethral syndrome; an effective date earlier than August 13, 2010 for the grant of service connection for residuals of ectopic pregnancy and adhesions surgeries (with scars); and an effective date earlier than August 13, 2010 for the grant of service connection for status post salpingectomy with uterine fibroids are being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action on her part is required. FINDINGS OF FACT 1. Throughout, the Veteran's postoperative right patellofemoral syndrome has been manifested by X-ray evidence of arthritis, and pain on use; compensable limitations of extension or flexion (other than limitation of flexion to 45 degrees on July 2006 examination), instability/subluxation, and ankylosis are not shown. 2. Throughout, the Veteran's left patellofemoral syndrome disability has been manifested by X-ray evidence of arthritis and pain on use; compensable limitations of extension or flexion, instability/subluxation, and ankylosis are not shown. 3. The Veteran's treatment for gastrointestinal problems in August 2009 did not involve surgery or immobilization of a major joint. CONCLUSIONS OF LAW 1. A rating in excess of 10 percent for right patellofemoral syndrome is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.71a, Diagnostic Codes (Code(s)) 5003, 5257, 5260, 5261, (2012). 2. A rating in excess of 10 percent for left patellofemoral syndrome is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.71a, Codes 5003, 5257, 5260, 5261, (2012). 3. The criteria for a temporary total rating under 38 C.F.R. § 4.30 (based on a need for convalescence) are not met for the period from August to October 2009. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.30 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase (such as those addressed herein) the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely evidence demonstrating a worsening or increase in severity of the disability and the effect the worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. See Vazquez-Flores v. Shinseki, 580 F. 3d 1270 (Fed. Cir. 2009). The Veteran received such notice in January and July 2005, February 2006, and November 2011 letters. While she did not receive full notice (and in particular of what was needed to substantiate the convalescent rating claim) prior to the initial adjudication of the claim(s), she is not prejudiced by the notice timing defect, as the claims were readjudicated (by supplemental statement of the case (SSOC)) after she received the notice, and had opportunity to respond. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Notably, she has not alleged prejudice from a notice defect. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran's pertinent treatment records have been secured. She was afforded a hearing before the undersigned. At the hearing, she was advised of what was still needed to substantiate her claims; her testimony reflects that she is aware of what is necessary. The RO arranged for VA examinations for the knee disabilities in February 2005, July 2006, August 2009, and March 2012 (November 2012 addendum). A review of the examination reports found them (cumulatively) adequate for rating purposes. The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Factual Background Initially, the Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and in Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. An October 2004 private treatment report (from Dr. Romash) notes that the Veteran fell, twisting her right knee. The knee became swollen and tender and she was unable to extend it. No previous knee injury was reported. She stated that she had previously been involved in athletics (including coaching and playing basketball). On physical examination the Veteran had an antalgic gait. The right knee had non-tense effusion and terminal extension was painful; it was stable to anterior and posterior varus and valgus stress; McMurray's test was painful. X-rays of the knee showed a well-maintained joint without any evidence of fracture, dislocation or subluxation. The assessment was probable tear of the medial meniscus. She was placed in a knee immobilizer. In a November 2004 follow-up report, Dr. Romash noted that MRI [magnetic resonance imaging] of the right knee found a very small area of injury to the medial meniscus, posteriorly, and the Veteran seemed to be "getting better." The swelling in the knee had gone down and range of motion had increased. A December 2004 treatment note showed the swelling had diminished. A January 2005 treatment note revealed the Veteran had some discomfort with full flexion of the right knee; however, it generally was improving. On February 2005 VA examination on behalf of VA, the Veteran reported that her bilateral knee discomfort had its onset in 1995 and was exacerbated by running, or standing and sitting for long periods of time. She reported recent diagnoses of patellofemoral syndrome and meniscal tear of the right knee, and had surgery for continued symptoms for which she took hydrocodone, naproxen, and Tylenol. She denied any recent trauma. She reported she had lost time from due to her bilateral knee symptoms and associated functional impairment. On physical examination there were no atrophic findings or abnormal weight-bearing signs of the lower extremities. She did not use an assistive device to ambulate. Her gait was within normal limits; there was no appreciable leg length discrepancy. Her right knee showed edematous and erythematous changes with associative warmth (in comparison with the left knee that appeared normal). Range of motion studies of the knees revealed flexion to 95 degrees on the right and approximately 100 degrees on the left, with pain. Extension of each knee was to 0 degrees, without pain. The Drawer's test was normal, bilaterally; McMurray's test was slightly positive on the right. There was appreciable (mild) joint effusion and crepitus during right knee range of motion studies without recurrent subluxation or locking pain. The left knee was without recurrent subluxation, locking pain, joint effusion, and crepitus. No further limitation by fatigue, weakness, lack of endurance, or incoordination was shown; but there was further limitation with repetitive range of motion studies. X-rays of the knees were negative. The diagnosis was bilateral patellofemoral syndrome. The examiner noted that there was evidence of symptom worsening with inclusion of right meniscal tear and upcoming surgical intervention. In April 2005, the Veteran underwent a right knee arthroscopy (debridement of delaminated articular cartilage of the medial femoral condyle) for chronic medial pain and tear of the medial meniscus. Operative findings revealed minimal changes in the right patellofemoral joint. There was a slight area of irritation and chondromalacia on the medial patellar facet and the very medial corner of the trochlea. There was significant arthritic change on the weight-bearing surface of the right medial femoral condyle. The medial meniscus looked intact and was intact to probing. The anterior cruciate ligament was intact and the lateral compartment was pristine. There were no complications. A May 2005 rating decision increased the ratings for right and left knee patellofemoral syndrome to 10 percent, each, under Code 5261 (for limitation of extension). In June 2005 the Veteran filed a claim for a temporary total rating for surgery on her service-connected right knee (arthroscopy in April 2005); a temporary total (convalescent) rating was assigned from April 1, 2005 until June 1, 2005 (when the 10 percent rating was restored). A June 2005 private treatment report shows the Veteran's range of motion was returning and her right knee was less painful. It was recommended that she return for a follow-up evaluation in three to four months. During the August 2005 follow-up the Veteran noted that she had some problems with standing on her right leg for a long period of time. On physical examination, there was slight effusion of the right knee; range of motion was from 0 to 120 and the knee was stable. The physician recommended placing limitations on the amount of time for standing. In a November 2005 statement the Veteran noted that she was still having problems with swelling, pain, and instability, and she had a "popping" sound from the knee. She stated that the cause of her knee problems was a medial femoral condyle lesion "(which is like a pothole behind the knee)." She further stated that her doctor recommended, and she was considering having, a mosaicplasty. She noted that based on her need for additional surgery, a higher rating was warranted. The April 2006 rating decision continued a 10 percent rating for right patellofemoral syndrome under Code 5261. On July 2006 VA examination on behalf of VA, it was noted that the Veteran had right patellofemoral syndrome with status post arthroscopy. She denied weakness, stiffness, swelling, heat, redness, giving away, lack of endurance, locking, fatigability or dislocation. She reported that she has right patella pain which is localized, aching in nature, and is constant. She described her pain as 8/(on a scale if) 10, and that it was elicited by physical activity and relieved by rest. The right knee disability did not cause incapacitation, or functional impairment. On physical examination there were no signs of abnormal weight-bearing; posture and gait were within normal limits. There was no edema, effusion, weakness, tenderness, redness, heat, abnormal movement or guarding of movement of the right or left knee. Right knee crepitus was noted. Right knee flexion was to 45 degrees, and extension was to 0 degrees. Left knee flexion was to 140 degrees, and extension was to 0 degrees. It was noted that right knee joint function was additionally limited by pain with repetitive use, and that pain had the major functional impact. Right knee joint function was not additionally limited by fatigue, weakness, lack of endurance or incoordination after repetitive use. Left knee joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The anterior and posterior cruciate ligaments stability test, the medial and lateral collateral ligaments stability test, and the medial and lateral meniscus test, of both knees, were within normal limits. X-rays of the right knee were within normal limits. The examiner noted that for the right knee the diagnosis was: "status post arthroscopy of the right knee with scars.". The examiner commented that the effect of the Veteran's right knee disability on her daily activity was mild; there was no functional impairment resulting from the right knee disability. There was a level scar present at the right anterior knee, and there were three identical scars measuring about 1 cm by 0.2 cm. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, inflammation, edema, deltoid formation, hypopigmentation, hyperpigmentation or abnormal texture. A September 2006 rating decision continued a 10 percent rating for right patellofemoral syndrome, status post arthroscopy (under Code 5261), and granted service connection for right knee scars. In her September 2006 notice of disagreement, the Veteran stated that the July 2006 VA examiner had hesitated to touch or examine her right knee because the pain was unbearable. The swelling was too much to measure, and she could not bend or extend the right leg. After the examiner removed the brace she could bend the right knee approximately 45 degrees with pain. She stated that due to right leg pain she was putting too much pressure on the left leg and foot; to relieve right knee heat and pain she slept with an ice pack. She wore a brace and used crutches to stabilize the right knee (from excessive popping, pain, swelling and weakness). On August 2009 examination on behalf of VA, the Veteran reported symptoms of weakness, stiffness, swelling, heat, redness, giving way, lack of endurance, locking, fatigability, effusion, pain and dislocation of the knees. There was no deformity, tenderness, drainage or subluxation of the knees. She experienced constant flare-ups. She described the level of the severity of her pain as 8/10. Flare-ups were precipitated by physical activity and resting in a certain position; they were alleviated by rest and medication. During flare-ups she was unable to exercise, walk or sit for long periods of time. She experienced pain on bending, and had difficulty with standing and walking. She was unable to walk or stand for more than five minutes without knee pain. She reported having muscle spasms in her legs. She described the residuals of right knee surgery as throbbing, swelling, giving way easily and popping. She stated that her condition had not resulted in any incapacitation. On physical examination the Veteran's posture was normal, and she walked with a normal gait. She had no difficulty with weight-bearing, balance or ambulation. She did not require any assistive device for ambulation. The right knee showed effusion. There were no signs of edema, instability, abnormal movement, weakness, tenderness, redness, heat, deformity, guarding of movement, malalignment and drainage, or subluxation. There was no locking pain, genu recurvatum or crepitus of the right knee. The left knee revealed crepitus. There were no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement. There was no genu recurvatum and locking pain. Flexion on the right was to 140 degrees, and extension was to 0 degree. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test and the medial/lateral meniscus ligaments stability test were all within normal limits for the right knee. Flexion on the left was to 120 degrees, and extension was to 5 degrees. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. The Veteran was unable to perform the stability tests for the left knee because she complained of severe pain on any attempt to examine the knee. X-rays of the left knee showed no evidence of fracture or other significant bone, joint, or soft tissue abnormality. The impression was negative left knee. X-rays of the right knee showed no evidence for fracture or other significant bone, joint, or soft tissue abnormality. The impression was negative right knee. There was no change in the diagnosis of patellofemoral syndrome for either knee. The examiner noted that the Veteran's condition was active. The subjective factors were complaints of pain on any use of the knees, especially the left. The objective factors were severe pain on the left on attempt to examine the knee and crepitation and scars on the right from surgery. The examiner noted that the major functional impairment from the knee disabilities would be in work requiring standing or walking; the veteran had been working for the past six years as a substance abuse counselor and should be able to maintain that type of work. There was no impairment as to sedentary employment. There was no impact from the knee disabilities on the Veteran's usual occupation, as standing or walking were not required in her job as a counselor. The impact of the knee disabilities on daily activities was tiredness and difficulty walking or standing. An August 2009 Obici Hospital report notes that the Veteran was seen for complaints of chest pain, nausea, vomiting, diarrhea and fever. She felt dizzy and weak, and had shortness of breath. She had not eaten much in the past four days. She noted chest pain, and overall was feeling weak. She was instructed to return for worsening symptoms or further concerns, otherwise she was to follow-up with her primary care physician in two to three days. In an August 2009 follow-up appointment (at Bennett's Creek Family Medicine) to the emergency room visit (for gastrointestinal problems(nausea, vomiting, diarrhea, headaches and body ache), it was noted that the Veteran was seen in the emergency department twice for watery diarrhea with abdominal pain, fever and fatigue. She was given IV fluids due to dehydration. The assessment was acute gastroenteritis, likely viral. Medication was prescribed. September 2009 treatment records from Bennett's Creek Family Medicine show the Veteran was seen with complaints of watery diarrhea (with some improvement) and right knee pain and swelling with difficulty ambulating, left elbow pain, with no prior episodes. The pain was localized, moderate to severe, and there was no history of trauma. The assessment was diarrhea with joint pain and swelling of the right knee and left elbow. Also noted as possible diagnoses were reactive arthritis, inflammatory bowel disease, salmonella, gout, and rheumatoid and septic arthritis. Additional September 2009 treatment records (Bennett's Creek), show the Veteran had complaints of bilateral knee pain. X-rays of the right knee revealed small suprapatellar joint effusion without evidence of fracture. There was mild tibial spine pointing and patellar spurring suggesting minimal degenerative change. X-rays of the left knee revealed moderate joint effusion without evidence of fractures or dislocations. In a September 2009 statement, the Veteran sought a temporary total (convalescence) rating for the month she was unable to work due to a bowel infection that was precipitated by a rectal examination by an examiner on behalf of VA. She related that the examiner was rough when examining her knees, back and neck and the examination was very painful. He was also very rough when he performed the rectal examination (he pushed on her bladder and intestine causing excruciating abdominal pain), which caused her to have to go to the emergency room and while there she was treated with an "IV" for dehydration and a "high temperature," with severe migraine headaches. She was released from the emergency room with a gastrointestinal infection and was placed on bedrest. She stated that she was subsequently seen at Obici Hospital for nausea, vomiting, diarrhea, dehydration and chest pain. In connection with this, her doctor extended her bedrest (August 27, 2009 to October 12, 2009). She stated that the joints in her knees, left elbow, neck and low back had been affected by the bowel infection, and had "aggravated all service connected conditions." In an October 2009 statement the Veteran's daughter noted that the Veteran complained of knee pain that had progressed in severity. She noted that the Veteran's knee "swells up like a coconut." She stated that she has had to take care of the Veteran (carry her around the house, dress her and cook for her). In an October 2009 statement, a co-worker noted that she witnessed the Veteran's health deteriorate from August 2009 to September 2009. She noted that the Veteran had swollen knees and other symptoms of bilateral patellofemoral syndrome, low back pain and irritable bowel syndrome that limited her to the point that her children had to do almost everything for her. In an October 2009 statement, the Veteran's private physician, Dr. Mapanao, noted "Please avoid anymore rectal exams for her IBS. Her recent rectal exam has rendered her discomfort and flare up of her gastrointestinal condition. She needs crutches/walker for ambulation since 9/1/09 to indefinite period." A "Certificate to Return to Work or School" dated in September 2009 and signed by Dr. Mapanao, notes that the Veteran had been under her care from September 18, 2009 and would be able to return to work on October 19, 2009. In an April 2010 statement, in support of her claim for a temporary total rating based on convalescence from August to October 2009, the Veteran noted that she was excused from work and placed on bedrest from September 3, 2009 to October 19, 2009 for acute gastroenteritis, right and left knee swelling and severe pain, left elbow swelling and pain (with difficulty ambulating), flare-ups of irritable bowel syndrome, and migraine headaches. In a February 2011 statement, Dr. Mapanao noted that the Veteran had been under her care from August 31, 2009 to October 19, 2009. She had seen her for diarrhea, that had persisted and became chronic, and was associated with debilitating generalized joint pains and muscle weakness that compromised her mobility. The Veteran required crutches, then a walker and then a cane. She was incapacitated due to severe pain and weakness that required ADL [activities of daily living] assistance from family and friends. She was referred to a rheumatologist and a gastroenterologist for irritable bowel syndrome flare up and ankylosing spondylitis. She was unable to go to work during that time due to the severity of her symptoms. The Veteran saw Dr. Mapanao at a follow-up visit in July 2011 and was diagnosed with "[history] of Fall -- Bilateral knee pain". At the August 2011 Travel Board hearing the Veteran testified that she had received constant treatment for her knee disabilities since 2006. She stated that sometimes she cannot move because of her knees. She stated that her knees have been swelling quite often and lasts from two or three days to one week. She stated that she works full-time but is often absent as a result of her bilateral knee disability. She used braces for her knees, especially when she is on the job, and also used a cane or crutches. She stated that due to her knee disabilities, she had limitations at work in lifting, walking, standing or sitting for long periods. She stated that her physician and rheumatologist found knee instability, and that she was seen by a doctor during a flare-up of knee symptoms. She explained that her convalescence was due to the loss of bowel function, which caused joint swelling that lasted for about two months. In an August 2011 statement the Veteran's long-time friend noted that she had witnessed a steady decline in the Veteran's physical abilities. She stated that the Veteran is unable to walk short distances without becoming fatigued, overheated and exhausted. She no longer took shopping trips to the mall because of her physical disabilities. In another statement LRJ (whom the Veteran supervised while employed at a community center) related that there were times when the Veteran was unable to make it through a complete work-day without having to leave early due to severe headaches and being mentally drained. She stated that usually the Veteran was in her office with the lights out and complaining of head, back, neck and knee pain. On March 2012 VA examination of the knees and lower legs, the diagnosis was contusion and impairment of both knees, and degenerative joint disease of the left knee. She had constant pain of both knees for which she took Motrin and Percocet. The pain level was 7/10. She reported that flare-ups (such as weather, prolong walking or standing) impacted the function of her knees and or lower leg. Right and left knee flexion was to 90 degrees, each; objective evidence of painful motion began at 85 degree; extension of each knee was to 5 degrees. On repetitive-use testing with three repetitions, right and left knee flexion was to 90 degrees and extension was to 5 degrees. There was no additional limitation in ranges of knee motion following repetitive-use testing. The Veteran had functional impairment of the knee and lower leg manifested by less movement than normal, pain on movement, disturbance on locomotion, and interference with sitting, standing and weight-bearing. There was tenderness or pain to palpation for joint line or soft tissues of both knees. Muscle strength was 4/5. Lachman's and Drawer's tests were normal bilaterally. Medial-lateral instabilitytesting was normal bilaterally. There was no recurrent patellar subluxation/dislocation. There were no shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and or fibular impairment. The Veteran had a right meniscal tear. She had not had a meniscectomy. Constant use of a cane was noted. The examiner viewed X-ray findings from May 1998, which revealed no significant knee findings. No definite defect or definite arthritic disease at either knee was shown. Compartments were normal and there were no effusions. X-rays of the left knee, taken in January 2004, were also viewed and showed slight joint effusion and mild degenerative change and medial and patellofemoral articulation. March 2012 X-rays of both knees showed normal alignment without evidence of a fracture deformity. There was no evidence of effusion. Mild degenerative changes were seen on both sides, and there was probably minimal narrowing of the right medial compartment. It was noted that her knee disabilities impacted on her ability to work to the extent that she had many absences due to her knee and back disabilities. The examiner noted that 1998 knee X-rays were normal and 2004 X-rays revealed mild degenerative joint disease of the knees. In a November 2012 addendum (to the March 2012 VA examination report) the examiner opined that the Veteran's bilateral knee degenerative joint disease is less likely as not related to her knee contusion. His rationale was that the evidence, such as the report from the Bennett Clinic that notes the Veteran had a history of a fall and knee pain, and the note from her friend that noted that she was having problems dating back to 2004 (which was 6 years after separation) favors that she most likely had an acute knee problem that started in 2004. The examiner concluded that a review of the record does not favor that the Veteran's knee problem is linked to her service knee contusion in a car accident. Legal Criteria and Analysis In general, disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity caused by a given disability. Separate diagnostic codes identify the various disabilities which are rated according to the specific criteria therein. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Right and Left Patellofemoral Syndrome The Veteran's service-connected right and left knee disabilities have been rated (apparently by analogy, as limitation of extension to 10 degrees has not been reported) under 38 C.F.R. § 4.71a, Code 5261 (for limitation of extension). Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Code 5261. The Board has considered other diagnostic codes for rating knee disability. Under Code 5260 (for rating based on flexion limitation) flexion of the leg limited to 60 degrees warrants a 0 percent rating, flexion limited to 45 degrees warrants a 10 percent rating, flexion limited to 30 degrees warrants a 20 percent rating, and flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, Code 5260. [Flexion of the knee to 140 degrees is considered full, and extension of a knee to 0 degrees is considered full. See 38 C.F.R. § 4.71a, Plate II.] A precedent opinion by VA's General Counsel (OGC) holds that separate ratings for limitations of knee flexion and extension may be assigned where a service-connected knee disability is manifested by both limitation of flexion under Code 5260 and limitation of extension under Code 5261, provided that the degree of disability is compensable under both criteria. VAOPGCPREC 09-04; 69 Fed. Reg. 59990 (2004). OGC has also held that a claimant who has arthritis and instability of a knee may be rated separately under Codes 5003 and 5257, while cautioning that any such separate rating must be based on additional disabling symptomatology. VAOPGCPREC 23-97 (July 1997). Other diagnostic codes for rating knee disability include Code 5256 (for ankylosis), Code 5257 (for other impairment, including recurrent subluxation or lateral instability), Code 5258 (dislocated semilunar cartilage), and Code 5259 (for symptomatic removal of semilunar cartilage. Significantly, ankylosis, removal of semilunar cartilage, and dislocated semilunar cartilage have not been reported. Code 5257 provides for a 10 percent rating for slight recurrent subluxation or lateral instability of a knee, a 20 percent rating for moderate recurrent subluxation or lateral instability, and a 30 percent rating for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995) (evaluation of musculoskeletal disorders rated on the basis of limitation of motion requires consideration of functional losses due to pain). Degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When the limitation of motion is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint affected by limitation of motion, to be combined, not added under Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Codes 5003. The Board has reviewed the Veteran's complete treatment records, including private medical reports, beyond those discussed above. They include references to the Veteran's right and left knee disabilities and symptom complaints at various times. The information presented in these reports is less detailed and presents generally limited findings pertinent to proper application of the rating criteria to the findings presented in the thorough VA examination reports discussed above (which were prepared for rating purposes). The Board notes that private treatment records do not present any information pertinently expanding the shown facts in these matters, and do not provide a separate basis for the assignment of increased ratings. Throughout the evaluation period, the Veteran's right and left knee disabilities have been rated 10 percent each under Code 5261 (as was noted above, apparently by analogy, as limitation of extension to 10 degrees has not been reported). Her treatment and examination reports do not show limitation of extension of either knee limited to 15 degrees (so as to warrant a 20 percent rating for either knee under that Code 5261), even with consideration of factors such as pain on use/repetitive motion) Nor do they show that at any time under consideration there was a compensable limitation of both extension and flexion of a knee; on the one occasion when right knee flexion was shown to be limited to a compensable degree (to 45 degrees in July 2006, with further limitation on repetition due to pain, although not noted to be to 30 degrees), extension was full (to 0 degrees). Significantly, ratings under Code 5003 may not be combined with ratings based on limitation of motion (and 10 percent is the maximum rating for a single joint under that Code). See Note 1 following Code 5003. Therefore, consideration of ratings under Code 5003 would be of no benefit to the Veteran. The Board has also considered the possibility of separate ratings for limitation of motion and for subluxation/instability (which may be awarded where there is both (X-ray evidenced) arthritis with limitation of and instability of a knee. See VAOPGCPREC 23-97 (1997). However, despite the Veteran's allegations of knee instability (in a November 2005 statement, by her alleged use of a brace and crutches for right knee instability noted in September 2006, and in her August 2011 hearing testimony indicating her physician and rheumatologist found instability in her knees) no examination report or treatment record notes a finding of instability. All tests for ligamentous laxity have been negative. Without any objective evidence of such, the Veteran's accounts of instability are self-serving and lack probative value. Her account of what a physician/rheumatologist purportedly indicated is "too attenuated and inherently unreliable to constitute medical (and competent) evidence". See Robinette v. Brown, 8 Vet, App, 69, 77 (1995). Consequently, a separate compensable rating for instability would be inappropriate. Additional factors that could provide a basis for an increase have also been considered; however, it is not shown that the Veteran has any loss of knee function beyond that currently compensated. 38 C.F.R. §§ 4.40, 4.45. The current ratings specifically encompass limitation of motion due to pain shown. The Board has further considered the Veteran's lay statements and those of her family, friend and co-workers, describing the severity of her knee symptoms and related functional impairment. See Jandreau v. Nicholson, 492 F.3d, 1372 (Fed. Cir 2007). While these statements are competent, credible, and probative, they do not show that the criteria for a rating in excess of 10 percent are met or approximated. The evidence shows that the Veteran's doctor has recommended the surgery, and that she has not yet undergone any such procedure. The fact that a surgeon has recommended a surgical procedure is not a separate criterion for rating the knee disability. The symptoms leading to the recommendation are for consideration; here, all symptoms shown by the record have been considered in the ratings assigned.. In summary, the schedular criteria for the next higher, 20 percent, ratings for right and left knee are not met (or approximated) at any time during the appeal period, and such ratings are not warranted. The Board also has considered whether this claim warrants referral for consideration of an extraschedular rating. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If the schedular criteria are not inadequate, that is where the analysis ends. Comparing the manifestations of the Veteran's knee disabilities and the associated impairment with schedular criteria, the Board finds that the degree of disability and impairment shown throughout the entire period under consideration are wholly encompassed by the schedular criteria for the ratings assigned. Consequently, the schedular criteria are not inadequate, and referral for consideration of an extraschedular rating is not necessary. Finally, the record shows (including by her testimony at the August 2011 hearing) that the Veteran has been employed full-time. Therefore, the matter of entitlement to a total disability rating based on individual unemployability due to service connected disability (TDIU) is not raised in the context of these claims. Notably, during the pendency of these claims/appeals the Veteran filed a claim for TDIU that was denied by a January 2010 rating decision. She did not appeal that decision. Temporary Total (Convalescence) Rating A temporary total (convalescence) rating is warranted if treatment of a service-connected disability results in: (1) surgery necessitating at least one month of post-operative convalescence; (2) surgery with severe post-operative residuals such as incomplete healed surgical wounds, therapeutic immobilization of one major joint or more, application of a body cast, the necessity for house confinement, or the necessity for continued use of a wheelchair or crutches (regular weight-bearing prohibited); or, (3) immobilization by cast, without surgery, of one major joint or more. See 38 C.F.R. § 4.30(a). In September 2009, the Veteran filed a claim for a temporary total evaluation under 38 C.F.R. § 4.30 for convalescence following treatment in August 2009 for gastrointestinal problems, for which her private physician prescribed bedrest (from August 27, 2009 to October 12, 2009). The criteria for awarding a convalescence rating under 38 C.F.R. § 4.30 contain specific requirements, including either surgery or immobilization by casting. A review of the records of the treatment the Veteran received from August to October 2009 did not find that her treatment included either surgery or immobilization of a major joint. The Veteran does not allege otherwise. Consequently, the criteria for a total rating under 38 C.F.R. § 4.30 are not met. The Veteran seeks the benefit on the basis that bedrest was prescribed; that is not a criterion listed in Section 4.30 for establishing entitlement to a total rating under that Section. The Board observes that it has no authority to award benefits not authorized by Statute or regulation. See 38 U.S.C.A. §§ 501, 7104. Accordingly, this claim must be denied as lacking legal merit. ORDER A rating in excess of 10 percent for right patellofemoral syndrome is denied. A rating in excess of 10 percent for left patellofemoral syndrome is denied. A temporary total rating based on a need for convalescence from August to October 2009 is denied. REMAND A November 2012 rating decision granted service connection for rectovaginal rated 100 percent, effective August 13, 2010; urinary tract infection, cystitis and urethral syndrome, rated 40 percent, effective August 13, 2010; residuals of ectopic pregnancy and adhesions surgeries (with scars), rated 20 percent, effective August 13, 2010; and status post salpingectomy with uterine fibroids rated 0 percent, effective August 13, 2010; and awarded a 10 percent rating for anemia, effective August 13, 2010. The Veteran disagreed with the effective date of the award and/or the rating assigned for the respective disabilities. The RO has not issued a statement of the case (SOC) addressing these issues. Under Manlincon, 12 Vet. App. at 240 when this occurs, the Board must remand the case and instruct the RO that the issues remain pending in appellate status (see 38 C.F.R. § 3.160(c)) and require further action. See 38 U.S.C.A. § 7105; 38 C.F.R. § 19.26. Accordingly, the case is REMANDED for the following action: Issue an appropriate SOC on the matters of entitlement to: A rating in excess of 40 percent for urinary tract infection, cystitis, and urethral syndrome; a rating in excess of 20 percent for residuals of ectopic pregnancy and adhesions surgeries (with scars); a rating in excess of 10 percent for anemia; a compensable rating for status post salpingectomy, with uterine fibroids; an effective date earlier than August 13, 2010 for the grant of service connection for rectovaginal fistula; an effective date earlier than August 13, 2010 for the grant of service connection for urinary tract infection, cystitis, and urethral syndrome; an effective date earlier than August 13, 2010 for the grant of service connection for residuals of ectopic pregnancy and adhesions surgeries with scars; and an effective date earlier than August 13, 2010 for the grant of service connection for status post salpingectomy with uterine fibroids. The appellant must be advised of the time limit for filing a substantive appeal, and that, in order for the Board to have jurisdiction in any of these matters, a timely substantive appeal must be filed. If that occurs, the matters should be returned to the Board for appellate consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs