Citation Nr: 1329906 Decision Date: 09/18/13 Archive Date: 09/25/13 DOCKET NO. 07-20 301 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for migraine headaches, to include as secondary to a service-connected disability. 2. Entitlement to a compensable evaluation for residuals of cervical cancer. 3. Entitlement to an initial disability rating in excess of 10 percent for right knee patellofemoral syndrome. 4. Entitlement to an initial disability rating in excess of 10 percent for left knee patellofemoral syndrome. 5. Entitlement to an initial disability rating in excess of 20 percent for a lumbar spine disability (residuals of post-epidural anesthesia back strain). 6. Entitlement to total rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from October 1998 to October 2002. These matters come before the Board of Veterans' Appeals (Board) from January 2006 and February 2006 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in Winston-Salem, North Carolina. These matters were previously before the Board in February 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. The Veteran's request for an increased rating for residuals of cervical cancer was denied by the RO in a January 2006 rating decision. The RO issued an SOC in March 2007. In June 2007, the Veteran submitted a VA Form 9 on other issues contained in the March 2007 rating decision, but did not appeal the issue of an increased rating for residuals of cervical cancer. Nevertheless, the RO certified the issue to the Board. In a January 2011 written brief representation, the Veteran's accredited representative stated the issue as "evaluation of cervical cancer residuals, currently 20 percent disabling." The Board finds that this was an error by the representative, as the Veteran's cervical cancer residuals have always been evaluated as noncompensable. Based on the actions of VA, the Board will waive any objections to timeliness and adequacy of a substantive appeal. See Percy v. Shinseki, 23 Vet. App. 37 (2009). During the pendency of the appeal, in a March 2007 SOC, the RO granted a compensable evaluation of 10 percent for the Veteran's left knee patellofemoral syndrome disability, effective from December 17, 2004. The issues of entitlement to service connection for migraine headaches, to include as secondary to a service-connected disability, entitlement to an initial disability rating in excess of 20 percent for a lumbar spine disability (residuals of post-epidural anesthesia back strain) and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's cervical cancer residuals have been manifested by complaints of painful intercourse, pain, and urinary urgency and frequency; objectively, the Veteran's reported symptoms have been clinically disassociated from her cervical cancer residuals and she has been clinically found to have no residuals of her service-connected cervical disability. 2. From September 4, 2009 to June 21, 2011, the Veteran's right knee patellofemoral disability has been manifested by complaints of swelling, pain, limitation of motion, and instability; but objectively the Veteran has flexion which is not limited to worse than 30 degrees and extension which is not limited to 10 degrees or worse. 3. From June 21, 2011, the Veteran's right knee patellofemoral disability has been manifested by complaints of swelling, pain, limitation of motion, and instability; but objectively the Veteran has flexion which is not limited to 60 degrees or worse and extension which is not limited to 10 degrees or worse. 4. The Veteran's right knee instability is separately evaluated from her patellofemoral disability and has been evaluated as 30 percent disabling, the highest possible schedular rating. 5. Throughout the rating period on appeal, the Veteran's left knee disability has been manifested by complaints of swelling, pain, limitation of motion, locking, and instability; objectively the Veteran has flexion which is not limited to 60 degrees or worse, and extension which is not limited to 5 degrees or worse. 6. The Veteran has no more than slight laxity of the knee which is already assigned a separate rating from her patellofemoral syndrome of the left knee. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for residuals of cancer of the cervix have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.117, Diagnostic Codes 7627-7612 (2012). 2. The criteria for an initial disability rating of 20 percent for right knee patellofemoral syndrome from September 4, 2009 to June 21, 2011, and no higher have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260-5019 (2012). 3. The criteria for an initial disability rating in excess of 10 percent for right knee patellofemoral syndrome from June 21, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260-5019 (2012). 4. The criteria for an initial disability rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R.§§ 3.321, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5019 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in March 2005 and May 2008. VA has a duty to assist the appellant in the development of the claims. The claim file includes service treatment records (STRs), a written article, VA medical records (both paper and electronic), and the statements of the Veteran in support of the claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. VA examinations/opinions were obtained in 2005, 2009, and 2011. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that, taken as a whole, the Veteran has been afforded adequate VA examinations/opinions. The reports include clinical examinations, diagnostic testing, and the Veteran's reported symptoms. The reports provide findings relevant to the criteria for rating the disabilities at issue. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008), Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating musculoskeletal disabilities Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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 and 4.45 (2012), see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59 (2012). The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. Id. § 4.45. Pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss. Pain may cause a functional loss but itself does not constitute functional loss; rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011). Flexion and Limitation of the Lower extremity DC 5260 provides a noncompensable rating when flexion is limited to 60 degrees or more. A 10 percent rating is warranted for leg flexion limited to 45 degrees. A 20 percent evaluation is for leg flexion limited to 30 degrees. A 30 percent evaluation is for leg flexion limited to 15 degrees. DC 5261 provides a noncompensable rating when extension is limited to 5 degrees or less. A 10 percent rating is warranted for leg extension limited to 10 degrees. A 20 percent evaluation is for leg extension limited to 15 degrees. A 30 percent evaluation is for leg extension limited to 20 degrees. A 40 percent evaluation is for leg extension limited to 30 degrees. A 50 percent evaluation is for leg extension limited to 45 degrees. In VAOPGCPREC 9 - 2004 (Sept. 17, 2004), it was held that a claimant who had both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. As such, if the evidence of record reflects compensable loss of both flexion and extension of either leg, the Veteran would be entitled to the combined evaluation under Diagnostic Codes 5260 and 5261, per the combined ratings table in 38 C.F.R. § 4.25. Instability of the knee Instability of the knee and limitation of motion of the knee are two separate disabilities. As such, it is permissible to award separate ratings under both a range of motion code and an instability code (DC 5257), without violating the prohibition on pyramiding. See VAOPGCPREC 23-97. DC 5257 is predicated on instability, rather than limitation of motion, therefore, an analysis under DeLuca does not apply. See Johnson v. Brown, 9 Vet. App. 7 (1996). Rating disease of the cervix The General Rating Formula for Disease, Injury, of Adhesions of Female Reproductive Organs (to include the cervix) provides a noncompensable rating for symptoms that do not require continuous treatment, a 10 percent rating for symptoms that require continuous treatment, and a 30 percent rating for symptoms not controlled by continuous treatment. 38 C.F.R. § 4.116 Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Rating for residuals of cancer of the cervix Service connection for residuals of cervical cancer, evaluated as noncompensable, has been established since October 14, 2002. In 2005 correspondence, the Veteran indicated that she wished to file for an increased rating. A September 2005 examination report reflects that the Veteran complained of pelvic pain. The examiner stated that "[s]he just describes premenstrual discomfort." She also reported irregular periods, heavy bleeding, stress incontinence, urinary leakage if she sneezes or coughs, low sex desire, and painful intercourse. The examiner noted that on clinical examination, the Veteran appeared to have some uterine bleeding. The cervical opening had some blood. The examiner noted that there "is no sign of any active malignancy. As for residuals of the cervical cancer, I see no residuals on physical examination of this and the cytology report was negative." A December 2009 VA record reflects a stable small uterine fibroid, a tiny cervical cyst, and normal appearing ovaries. A July 2010 VA medical gynecological note reflects that the Veteran reported a history of pelvic pain and endometriosis. She reported pain across the lower abdomen, which was present constantly and which is significantly worsened by intercourse. She also complained of significant urinary urgency and frequency. Upon clinical examination, the assessment was "Chronic pelvic pain and dyspareunia-certainly can be due to endometriosis, but due to significant bladder tenderness, urgency, and frequency must also consider possible interstitial cystitis component." A November 2010 addendum reflects that a urine culture of August 2010 was positive for E. coli and the Veteran was treated with Septra, but her symptoms did not improve. December 2010 records reflect that the Veteran had bladder testing with potassium chloride due to "likely interstitial cystitis as evidenced by symptoms." A January 2011 VA record also notes likely interstitial cystitis. An August 2011 VA examination report reflects that that the Veteran had pap smears in 2007 and 2009 which showed no signs of malignancy. It was noted that the Veteran complained of pain with intercourse. It was further noted that her gynecologist thought that the dyspareunia might be related to the interstitial cystitis but the Veteran continued to complain of pain during intercourse following the [bladder instillation] treatment. The Veteran reported frequent pelvic pain, frequent abdominal pain, post-coital bleeding, constipation, occasionally bleeding between periods, and frequent voiding. She denied vaginal fecal leakage and vaginal urine leakage. A urinary tract disease of cystitis was noted to have been in December 2010. Upon clinical examination, there was no tenderness, no mass, no prolapse of uterus, no uterine displacement, no cervical abnormality, no vaginal abnormality, and no fistula. The report reflects that the examination of the cervix was negative for cervical motion tenderness, atrophic in appearance, and exhibited contact bleeding. Bimanual examination revealed no palpable uterine or ovarian mass, but generalized pelvic discomfort. A May 2012 VA addendum states that it is less likely than not that the Veteran's uterine enlargement/leiomyoma are related to cervical dysplasia residuals. The examiner opined, pertinent part, as follows: Uterine fibroids (leiomyoma) are not related to cervical cancer or a history of abnormal pap smears. Leiomyoma in 99 plus percent of cases are benign growths of smooth muscle uterine tissue that can occur on various areas of the uterus. They are slow growing non cancerous benign tumors that can cause pelvic pain or pressure and thus can be a source of dyspareunia/painful intercourse, but they are not related to cervical dysplasia. . . . It is less likely as not (50/50 probability [)] that the veteran's claimed painful intercourse is due to residuals of cervical dysplasia. . . The veteran had normal thin prep pap smears in 2007 and 2008. Pelvic exam provided no evidence of cervical motion tenderness or of a cervical lesion. There may be several reason[s] for her pelvic pain. Given past history of PID there may be associated pelvic scar tissue which could cause pain during intercourse, however, given the finding of of [sic] August 09, 2011 pelvic echogram which suggest uterine enlargement with the presence of fibroids in comparison to the pelvic ultrasound December 21, 2009 which related a smaller fibroid uterus. . . . It is at least as likely as not that the claimed residuals of cervical dysplasia, and dyspareunia are due to her enlarged fibroid uterus. . . . In sum, the Veteran's uterine fibroids were the most likely cause of her abdominal pain, dyspareunia (painful intercourse), and dysfunctional uterine bleeding. Such fibroids were less likely than not caused by the Veteran's service-connected residuals of cervical disability. A May 2013 VA examination is also of record. It reflects that the Veteran's hysterectomy in 2012 was less likely than not causally related to the Veteran's service-connected cervical disability. Based on the evidence of record, as noted above, the Board finds that the Veteran's service-connected cervix disability does not warrant a compensable rating. The competent credible evidence is against a finding that the Veteran has any residuals of cancer of the cervix. She does not have any symptoms which require continuous treatment such that a 10 percent rating would be warranted, or any symptoms that cannot be controlled with continuous treatment, such that a 30 percent rating would be warranted. The Veteran's various complaints, which she may attribute to residuals of cervical cancer, have been clinically disassociated from the cervical cancer. While the Veteran is competent to report her pain, urinary frequency and urgency, and painful intercourse, she has not been shown to have the necessary education, training, or experience to make a etiology finding as to such symptoms, especially in light of her numerous diagnoses associated with her gynecological system (i.e. interstitial cystitis, endometriosis, urine culture positive for E. Coli, cervical cyst, uterine fibroid) Moreover, the opinion of a clinician, who has medical education, training, and experience in gynecological matters is more probative than that of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011). See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2012), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Initial disability rating in excess of 10 percent for right knee patellofemoral syndrome. The Veteran's service-connected right knee patellofemoral syndrome is evaluated as 10 percent disabling from December 17, 2004 under DCs 5260-5019. The Veteran' service-connected right knee instability is separately evaluated as 30 percent disabling from December 17, 2004 under DC 5257. A November 2005 examination report reflects that the Veteran reported pain, giving out, and popping of the knees. She reported that the symptoms occur constantly. She reported a functional impairment of an inability to kneel, stoop, and bend. She reported no time lost from work. Upon clinical examination, she had right knee effusion, flexion to 120 degrees with pain at 120 degrees, and normal extension. She had pain on palpation of the medial joint line. Range of motion was additionally limited by weakness and pain after repetitive use, but was not additionally limited by fatigue, lack of endurance, or incoordination. There was severe instability of the right knee with McMurray's testing, and moderate instability with Drawer testing. The Veteran reported that she takes Ibuprofen for pain. In her VA Form 9, dated in June 2007, the Veteran stated that she has lateral instability and falls down to her knees. She also reported severe pain. A July 2009 VA record (correspondence) reflects MRI shows mild degeneration of the cartilage. The report states that "[o]verall the knee is healthy." A July 13, 2009 VA history and physical note reflects an impression of internal derangement of the right knee, with a plan for arthroscopy and shaving of the right knee. A July 16, 2009 record reflects that a post operative diagnosis was "plica med, synovium adherent to anterior horn, no tear." An August 2009 orthopedic surgery note reflects that the Veteran was doing "OK" after surgery. She had no effusion, flexion to 90 degrees, full extension, and a moderate limp with a cane. The assessment was slow improvement of the right knee. The Veteran underwent a QTC exam on September 4, 2009. At the time, she was approximately six and a half weeks post surgery. The report reflects that the Veteran reported weakness, stiffness, swelling, heat, giving way, locking, tenderness and pain. She indicated that she does not experience redness, lack of endurance, fatigability, deformity, drainage, effusion, subluxation and dislocation. The claimant reports experiencing flare-ups as often as 3-4 time(s) per day and each time lasts for 1 hour. From 1 to 10 (10 being the worst), the severity level was reported to be at a 9. During the flare-ups she experienced the following limitation of motion of the joint which is described as squatting, sitting too long or standing too long. She reported difficulty with standing/walking. The Veteran reported that she walked with a cane, had pain, had weakness, and that her knee gives out. It was noted that she had had surgery for a torn meniscus on July 16, 2009. The 2009 examiner found that the Veteran had a leg length discrepancy. Examination of the feet did not reveal any signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern. For ambulation, she required a cane. The examiner stated that the use of the cane was because of right knee instability and decreased weight bearing capacity. The right knee showed edema, effusion, tenderness and guarding of movement. There was no sign of instability, abnormal movement, weakness, redness, heat, deformity, malalignment and drainage. There was no subluxation. Range of motion was 115 degrees of flexion with pain beginning at 30 degrees. Repetitive use testing could not be performed due to pain. The examiner stated that the diagnosis of patellofemoral syndrome of the right knee with instability was changed to torn meniscus of the right knee, status post laparoscopic surgery. The examiner noted that this was a result of a progression of the previous diagnosis. The subjective factors were: right knee pain making standing and sitting difficult, uses cane. The objective factors were: edema, effusion, tenderness and guarding of movement found on exam, locking pain and crepitus on exam, decreased flexion range of motion and pain with range of motion A December 2009 VA orthopedic surgery note reflects that the leg was much improved after physical therapy, although still weak. She had a normal gait. The assessment was healing knee post surgery. The Veteran underwent a VA examination on June 21, 2011. The Veteran reported that she takes NSAIDs (Motrin) and Glucosamine for her treatment. She reported right knee giving way, instability, pain, stiffness, weakness, decreased speed of joint motion, and locking episodes daily or more often. She denied episodes of dislocation or subluxation, and effusion. She reported warmth, swelling, and tenderness. She reported flare-ups of moderate severity occurring weekly and lasting one to two days induration. Upon clinical examination, she had right knee flexion to 95 degrees and normal extension. There was objective evidence of pain with active motion. There was no additional limitation after three repetitions of range of motion. Notably, the Veteran reported that "she had to stand or walk around a lot to lessen the pain. Her job involved a lot of sitting." Thus, according to the Veteran, repetitive motion actually lessened the pain. The disability had a moderate effect on chores, shopping, exercise, an driving. It had a severe effect on exercise, recreation, and traveling. It had no effect on feeding, bathing, dressing, toileting, and grooming. A May 2011 MRI of the right knee reflects that there was no major internal derangement, no joint effusion or popliteal cyst, and no soft tissue or bone mass. The ACL and PCL were intact. The medial and lateral collateral ligaments were intact. The patellar and quadriceps tendons were unremarkable. There was minimal degeneration in the posterior horn of the medial meniscus. The patellofemoral cartilage was intact. There was no evidence of full-thickness defect in the articular hyaline femoral or tibial cartilage. June 2011 radiology views of the right knee revealed no significant degenerative changes. The joint spaces appeared normal. No joint effusion was identified. No bony abnormities were seen. The Board has considered the Veteran's subjective complaints and the objective findings on examination. As noted above, the Veteran is currently rated at 10 percent for her right knee disability under 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion)-5019 (bursitis). DC 5019 is rated on limitation of motion of affected parts, as arthritis, degenerative. Under DC 5260, the Veteran would be entitled to a 20 percent rating if she had flexion limited to 30 degrees. In sum, the Veteran had flexion to 120 degrees with pain beginning at 120 degrees in 2005. She had flexion to 90 degrees in August 2009, after surgery. A September 4, 2009 record reflects flexion to 115 degrees with pain beginning at 30 degrees and that the Veteran could not perform repetitive use testing due to pain. Three months later, the December 2009 record reflects that her leg was "much improved after physical therapy"; however, it does not provide a level of improvement in terms of degrees of flexion, and notes a "weak quad." The Veteran had flexion to 95 in June 2011 with no additional limitation after three repetitions of range of motion. The Board also notes that the Veteran has stated that she is able to walk 1/4 mile. In addition, she has stated that she has had to stand or walk around a lot to lessen the pain. Thus, repetitive use actually reduces her pain. In giving the benefit of the doubt to the Veteran, the Board finds that she is entitled to a 20 percent evaluation, and no higher, for flexion limited to 30 degrees under DC 5260 from September 4, 2009 to June 21, 2011, but no later. Under DC 5261, the Veteran would be entitled to a 10 percent rating if she had leg extension limited to 10 degrees. The evidence is against such a finding. The Veteran had full extension, or near full extension in 2005, 2009, and 2011. Thus, a compensable evaluation is not warranted. The evidence shows that the Veteran does not experience such functional loss to a degree that would warrant a higher, or compensable, rating. The Board has also considered whether an increased rating for the right knee disability is warranted under any alternate diagnostic code. However, as the evidence fails to establish ankylosis, DC 5256 is not for application. Similarly, as the evidence fails to demonstrate malunion of the tibia and fibula, DC 5262 is not applicable. DC 5263 is inapplicable because there is no showing of genu recurvatum. The Veteran has been granted a separate 30 percent rating under DC 5257 for right knee instability, which the Board finds is adequate and is the highest rating allowable under DC 5257. The Veteran is not entitled to a separate rating under DC 5259 because her symptomatic removal of semilunar cartilage, which would warrant a 10 percent rating, has already been considered in the assigned ratings of 10 percent under DC 5260 for symptoms including pain and limitation of motion. Moreover, her instability has already been separately rated as 30 percent disabling under DC5257. A separate rating under DC 5259 would not be appropriate because that would be pyramiding. Moreover, a separate rating under DC 5258 would not be warranted as that would also be pyramiding the "pain" for which she is already compensated. In a statement dated in July 2012, the Veteran asserted that a rating higher than 10 percent was warranted because she has locking of the knee. June 2011 radiology views of the right knee revealed no significant degenerative changes. The joint spaces appeared normal. No joint effusion was identified. No bony abnormities were seen. The May 2011 MRI of the right knee reflects no major internal derangement, no joint effusion or popliteal cyst, and no soft tissue or bone mass. The ACL and PCL were intact. The medial and lateral collateral ligaments were intact. The patellar and quadriceps tendons are unremarkable. There was minimal degeneration in the posterior horn of the medial meniscus. The patellofemoral cartilage is intact. There was no evidence of full-thickness defect in the articular hyaline femoral or tibial cartilage. Locking of the knee warrants a 20 percent rating if it is associated with dislocated semilunar cartilage, locking, pain, and effusion into the joint; however, the clinical evidence of record does not support a finding of effusion into the joint in the Veteran's case. Moreover, her internal derangement of the right knee has been adequately compensated under DC 5257 and DC 5260. In making this determination, the Board considered the benefit-of-the-doubt doctrine. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initial disability rating in excess of 10 percent for left knee patellofemoral syndrome The Veteran's service-connected left knee patellofemoral syndrome is evaluated as 10 percent disabling from December 17, 2004 under DC 5019. The Veteran's service-connected left knee instability is separately evaluated as 10 percent disabling from December 17, 2004 under DC 5257. A November 2005 examination report reflects that the Veteran reported pain, giving out, and popping of the knees. She reported that the symptoms occur constantly. She reported a functional impairment of an inability to kneel, stoop, and bend. She reported no time lost from work. Upon clinical examination, she had left knee slight effusion, flexion to 130 degrees with pain at 130 degrees, and normal extension. Range of motion was additionally limited by weakness and pain after repetitive use, but was not additionally limited by fatigue, lack of endurance, or incoordination. There was slight instability of the left knee. (Positive drawer and McMurray tests.) The Veteran reported that she takes Ibuprofen for pain. In her VA Form 9, dated in June 2007, the Veteran stated that she has lateral instability and falls down to her knees. She also reported severe pain. The Veteran underwent a QTC exam on September 4, 2009 for the right knee. The examiner also noted findings with regard to the left knee. On the left there was tenderness. The left showed no signs of edema, instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding of movement, malalignment and drainage. There was no subluxation. Examination of the left knee revealed locking pain and crepitus. There was no genu recurvatum. Upon examination of the knee, there was no ankylosis. Range of motion was full extension with no loss of degrees due to pain or on repetitive use. The Veteran had flexion to 115 with pain beginning at 115 and no additional loss of range of motion with repetitive use. (The examiner found that the left knee joint was limited by pain, fatigue, weakness, lack of endurance, and incoordination after repetitive use, with pain having the major functional impact, but found no additional range of motion after repetitive use in terms of degrees.) She had full extension with no limitation due to pain prior to, or after repetition. The Veteran underwent a VA examination in June 2011. The Veteran reported that she takes NSAIDs (Motrin) and Glucosamine for her treatment. She reported left knee giving way, instability, pain, stiffness, weakness, decrease speed of joint motion, locking episodes several times a year, swelling, tenderness, and mild flare-ups every one to two months lasting 1 to 2 days in duration. She denied incoordination and effusion. Upon clinical examination, she had left knee flexion to 110 degrees and normal extension. There was objective evidence of pain with active motion. There was no additional limitation after three repetitions of range of motion. Notably, the Veteran reported that "she had to stand or walk around a lot to lessen the pain. Her job involved a lot of sitting." Thus, indicating that repetitive motion lessened the pain. The disability had a moderate effect on chores, shopping, exercise, and driving. It had a severe effect on exercise, recreation, and traveling. It had no effect on feeding, bathing, dressing, toileting, and grooming. June 2011 radiology views of the left knee revealed no significant degenerative changes. The joint spaces appeared normal. No joint effusion was identified. No bony abnormities were seen. The Board has considered the Veteran's subjective complaints and the objective findings on examination. As noted above, the Veteran is currently rated at 10 percent for her left knee disability under 38 C.F.R. § 4.71a, Diagnostic Code 5019 (bursitis). DC 5019 is rated on limitation of motion of affected parts, as arthritis, degenerative. Degenerative arthritis established by x-ray findings is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by the limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, of satisfactory evidence of painful motion. Under DC 5260, the Veteran would be entitled to a 20 percent rating if she had flexion limited to 30 degrees. The evidence is against such a finding. In sum, the Veteran had flexion to 130 degrees with pain beginning at 130 degrees in 2005. She had flexion to 115 degrees in 2009, with pain beginning at 115. She had flexion to 110 degrees in 2011, with no additional limitation after three repetitions of range of motion. Under DC 5261, the Veteran would be entitled to a 10 percent rating if she had leg extension limited to 10 degrees. The evidence is against such a finding. The Veteran had full extension in 2005, 2009, and 2011. Thus, a compensable evaluation is not warranted. The evidence shows that the Veteran does not experience such functional loss to a degree that would warrant a higher, or compensable, rating. The Board has also considered whether an increased rating for the left knee disability is warranted under any alternate diagnostic code. However, as the evidence fails to establish ankylosis, DC 5256 is not for application. Similarly, as the evidence fails to demonstrate malunion of the tibia and fibula, DC 5262 is not applicable. DC 5263 is inapplicable because there is no showing of genu recurvatum. The Veteran has been granted a separate 10 percent rating under DC 5257 for left knee instability, which the Board finds is adequate; a higher rating is not warranted for the Veteran's slight knee impairment. Words such as "mild", "slight", "moderate", " marked ", and " severe " are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The Board finds that the objective clinical findings are the most probative as to the severity of the Veteran's disability, and finds that the Veteran's left knee instability is no more than slight. The November 2005 examination report reflects "slight instability" of the left knee. The September 2009 examination report reflects that the stability tests (medial/lateral collateral, anterior/posterior cruciate, and medial/lateral meniscus) were all within normal limits for the left knee. While the Veteran may be competent to report what she feels to her to be instability, such reports are are subjective in nature. Joint instability can be objectively diagnosed upon clinical examination. The Veteran is not entitled to a separate rating under DC 5259 because the evidence is against a finding of removal of semilunar cartilage. In a statement dated in July 2012, the Veteran asserted that a rating higher than 10 percent was warranted because she has locking of the knee. June 2011 radiology views of the left knee revealed no significant degenerative changes. The joint spaces appeared normal. No joint effusion was identified. No bony abnormities were seen. Locking of the knee warrants a 20 percent rating if it is associated with dislocated semilunar cartilage and effusion into the joint; however, the clinical evidence of record does not support a finding of dislocated semilunar cartilage with effusion into the joint in the Veteran's case. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim. In making this determination, the Board considered the benefit-of-the-doubt doctrine but finds that it is inapplicable. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-schedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extra-schedular disability rating would be warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). The discussion above reflects that the rating criteria reasonably describe and contemplate the severity and symptomatology of the Veteran's service-connected cervix disability. In reaching this conclusion, the Board has considered the Veteran's contentions that she has numerous symptoms, to include pain, painful intercourse, and urinary problems; however, such symptoms have been clinically disassociated from the Veteran's service-connected disability. The competent clinical evidence of record reflects that she does not have symptoms or residuals of her service-connected cervical disability. The rating criteria is broad enough to allow for any related symptoms that require continuous treatment, or which are not controlled by continuous treatment; however, as the Veteran does not have symptoms, a compensable rating is not warranted. Referral for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). With regard to the Veteran's right and left knee disabilities, the discussion above reflects that the rating criteria reasonably describe and contemplate the severity and symptomatology of the Veteran's service-connected disabilities. The symptoms experienced by the Veteran generally correspond to the symptoms contemplated by the applicable Diagnostic Codes. The Diagnostic Codes allow for compensation for limitation of motion, to include as due to pain (both flexion and extension), and instability. They also allow for compensation for locking, provided that there is dislocated semilunar cartilage and effusion into the joint; however, the Veteran does not have such severity of disability. The Board is of the opinion that the compensable ratings for pain on motion and instability are ultimately sufficient for the purpose of compensating the Veteran for the type of impairment which she experiences. Therefore, referral for consideration of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to a compensable evaluation for residuals of cervical cancer is denied. Entitlement to an initial disability rating of 20 percent, and no higher, for right knee patellofemoral syndrome, for the period from September 4, 2009 to June 21, 2011, is granted. Entitlement to an initial disability rating of in excess of 10 percent from June 21, 2011 for right knee patellofemoral syndrome is denied. Entitlement to an initial disability rating in excess of 10 percent for left knee patellofemoral syndrome is denied. REMAND Migraine headaches, to include as secondary to a service-connected disability The Veteran avers that she has a migraine disability as a result of active service, or due to a service connected disability. A VA opinion was provided in June 2011, with an addendum in June 2011. The examiner stated, in the June 2011 opinion, that the Veteran "was treated for headaches while in service but all of them were related to or associated with URI's, sinusitis, Viral illnesses and mononucleosis on dates ranging from 10/28/98 thru 1/3/2000. Nowhere did I find any records stating that she was ever diagnosed or treated for Migraine headaches while in military service." The examiner also stated that the "first entry I found in her VA Med Recs was on 9/14/2007 when she was seen and stated to the MD that her 'Migraines were getting worse'. I found no entries for the previous 5 years from her discharge in 2002 for diagnosis or treatment of Migraine headaches." In an addendum, the clinician stated that the Veteran has been diagnosed with migraine headaches from March 15, 2011 and has been treated for migraine headaches from that date to present. The Board finds, based on the above, that a supplemental opinion is warranted for the following reasons. First, an in-service April 2000 optometric examination report reflects that the Veteran reported daily headaches for 5 months; such record has not been considered by examiner. In addition, her report of medical history for separation purposes reflects that she was prescribed glasses for her headaches while in service. The Board acknowledges that the Veteran denied frequent or several headaches on her September 2002 report of medical history for separation purposes. Nonetheless, her earlier records do reflect a complaint which was not considered by the 2011 examiner. Second, the June 2011 VA examiner stated that the Veteran was diagnosed in 2011 and the first entry of her reporting migraines was in 2007. However, the 2005 VA examination shows a diagnosis of migraines based on the Veteran's reported history. Such a factor should be considered by the clinician in providing an opinion. Finally, the Board notes that the Veteran should be provided with the elements necessary to obtain service connection for a disability as secondary to a service-connected disability. Spine Rating Historically, in a February 2006 rating decision, the RO granted the Veteran service connection for residuals of post-epidural. The RO denied service connection for low back strain. In a March 2007 statement of the case (SOC), the RO resolved doubt in favor of the Veteran and granted service connection for "back strain which has been incorporated in with the evaluation of residuals, post-epidural anesthesia." In her VA Form 9, dated in June 2007, the Veteran asserted that she has a 'knot" in her back which is painful. In a January 2011 written brief, the Veteran's accredited representative requested another examination because the most recent examination of record was from 2005. The Veteran underwent a subsequent examination in June 2011. The June 2011 VA examination reflects that the Veteran reported lumbar back pain. Upon examination, she had spasm, flexion to 60 degrees, and extension to 20 degrees. The examiner stated that there was objective evidence of pain following repetitive motion; however, the examiner stated that she was unable to test whether there was additional limitation after three repetitions of range of motion. The examiner stated the reason for the inability to test was "Veteran developed a severe migraine [headache] and could not continue repeated testing." In a July 2013 appellate brief, the Veteran's accredited representative has requested another VA examination so that the examiner can fully test the Veteran, and report the findings. The Board finds that the Veteran should be afforded such an examination. TDIU The Veteran has several service-connected disabilities and numerous nonservice-connected disabilities. In a May 2013 rating decision, the RO denied TDIU. In a July 2013 appellate brief presentation, the Veteran's representative requested a VA examination with a medical opinion that specifically addresses unemployability. The Veteran has made various statements with regard to her unemployment. The November 2005 QTC report reflects that the Veteran reported that her knees and back did not result in any time lost from work. The June 2011 VA examination report reflects that the Veteran reported that she is not working primarily due to her migraines. The appellant's representative has asserted that the Veteran's bilateral knee disability prevents her from maintaining substantial gainful employment. Accordingly, the case is REMANDED for the following action: 1. Issue a VCAA notice letter for the issue of entitlement to service connection for migraines as secondary to a service-connected disability, in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) and any other applicable legal precedent. 2. Request the June 2011 clinician, or another appropriate clinician if he is unavailable, to provide a supplemental opinion as to whether it is as likely as not that the Veteran has a migraine disability causally related to, or aggravated by, active service or a service connected disability. Any such opinion should include consideration of the entire claims file to include: a.) the prior June 2011 opinion; b.) the in-service April 2000 optometric examination report which reflects that the Veteran reported daily headaches for 5 months; c.) the Veteran's report of medical history for separation purposes in which she stated that she was prescribed glasses for her headaches; d.) the 2005 VA examination report which reflects a diagnosis of migraines based on the Veteran's reported history; and e) the Veteran's physical disabilities, if pertinent, as they may relate to migraines. 3. Schedule the Veteran for a VA examination to determine the extent of her service-connected back disability (residuals post epidural anesthesia back strain). The examiner should perform all necessary diagnostic tests, and report all clinical manifestations in detail, to include functional use and limitation of range of motion after repetitive use. Associate a copy of the examination report with the claims file. 4. Thereafter, obtain a clinical opinion, based on the record as a whole, as to whether the Veteran's service-connected disabilities, considered in combination, (and only her service-connected disabilities) render the Veteran unemployable. The examiner should consider the entire claims file. The clinician is requested to furnish an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran's service-connected disabilities are so severe that it is impossible for the her to sustain substantially gainful employment. The clinician is requested to provide a complete rationale for his or her opinion, as a matter of medical probability, based on his or her clinical experience, medical expertise, and established medical principles. If an adequate opinion cannot be rendered without an examination of the Veteran, she should be scheduled for such an examination. 5. After undertaking any other development deemed appropriate, the RO should readjudicate the issues on appeal. If a benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and her representative with an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration as warranted. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims 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). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs