Citation Nr: 1334224 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 09-18 760A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for irritable bowel syndrome with gastroesophogeal reflux disease. 2. Entitlement to an initial compensable rating for left foot plantar fasciitis. 3. Entitlement to an initial compensable rating for right foot plantar fasciitis. 4. Entitlement to an initial compensable rating for left knee patellofemoral pain syndrome. 5. Entitlement to an initial compensable rating for right knee patellofemoral pain syndrome. 6. Entitlement to service connection for a sinus disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Turner, Counsel INTRODUCTION The Veteran served on active duty from December 1986 to June 2007. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from a September 2007 rating decision issued by the Regional Office (RO) in Salt Lake City, Utah. The case comes to the Board from the RO in Atlanta, Georgia. FINDINGS OF FACT 1. The Veteran's irritable bowel syndrome with gastroesophogeal reflux disease (GERD) is not shown to be characterized by severe irritable bowel syndrome with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress or by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health. 2. The symptoms of the Veteran's plantar fasciitis of the left foot most closely approximates a moderate foot injury. 3. The symptoms of the Veteran's plantar fasciitis of the right foot most closely approximates a moderate foot injury. 4. The symptoms of the Veteran's patellofemoral pain syndrome of the left knee most closely approximates slight recurrent subluxation or lateral instability. 5. The Veteran's patellofemoral pain syndrome of the right knee was not shown to result in limited or painful motion or any recurrent subluxation or lateral instability. 6. A sinus disorder was not shown to have been caused or made worse by service. The Veteran was not shown to have a current sinus disorder at any time relevant to this appeal. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for irritable bowel syndrome with GERD were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, 4.113, 4.114, Diagnostic Codes 7319, 7346 (2012). 2. The criteria for a rating of 10 percent, but no higher, were met for left foot plantar fasciitis. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5284 (2012). 3. The criteria for a rating of 10 percent, but no higher, were met for right foot plantar fasciitis. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5284 (2012). 4. The criteria for a rating of 10 percent, but no higher, were met for left knee patellofemoral pain syndrome. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5257 (2012). 5. The criteria for a compensable rating for right knee patellofemoral pain syndrome were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5257, 5260, 5261 (2012). 6. A sinus disorder was not incurred in, or aggravated by, service. . 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims 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. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper VCAA notice must inform the claimant of any information and 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. The Board notes that 38 C.F.R. § 3.159 was revised in part, effective May 30, 2008. See 73 Fed. Reg. 23,353-23,356. The third sentence of 38 C.F.R. § 3.159(b)(1), which stated that "VA will also request that the claimant provide any evidence in the claimant's possession that pertains to the claim," was removed. This amendment applies to all applications pending on, or filed after, the regulation's effective date. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g. Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sum nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was not provided with the aforementioned notices prior to the adjudication of her claim. However, she was sent a statement of the case (SOC) in April 2012 that provided the required information. The SOC discussed VA assistance to Veterans with developing claims, provided the specific criteria that were used in rating the Veteran's disabilities, and explained that service connection may be granted for a disability that began in military service or was caused by some event or experience in service. Additionally, the Veteran was sent VCAA notices in connection with other claims that she filed while this appeal was pending. These letters also contained information about VA's duty to assist, the criteria necessary to establish service connection for a claimed disability, and how VA assigns ratings and effective dates; for example, a letter dated in October 2009 provided this information. The information provided in the SOC and the October 2009 letter were sufficient to enable a reasonable person to know what the evidence needed to show in order to support her claims. The Veteran had ample opportunity after receiving these correspondences to submit additional evidence and argument prior to the most recent readjudication of her claim in a May 2012 SOC. VA also must make reasonable efforts to assist the claimant with obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record evidence including service treatment records, VA treatment records, post-service treatment records from other providers, and the written contentions of the Veteran. The Veteran was provided with a medical examination in connection with her claim in February 2007, prior to her discharge. The Veteran was scheduled for another VA examination in February 2012 to assess the current severity of her disabilities. However, the Veteran was a no show for the examination. Neither the Veteran nor her representative indicated any reason why the Veteran did not appear for her examination nor did they ask that it be rescheduled. In an original claim for disability compensation, if a Veteran fails to appear for her examination, the claim must be rated on the evidence of record. 38 C.F.R. § 3.655. To the extent that additional examination would have provided helpful information, such information is unavailable due to the Veteran's failure to attend the scheduled examination. The Board finds that sufficient efforts have been made to obtain information in support of the Veteran's claim, and there is no indication that other evidence exists which has not been obtained. Initial Rating The Veteran contends that she should receive higher ratings for her irritable bowel syndrome with GERD, bilateral plantar fasciitis, and bilateral patellofemoral syndrome. The Veteran's irritable bowel syndrome with GERD is presently rated 10 percent disabling. Her plantar fasciitis and patellofemoral syndrome are rated noncompensably disabling. Disability ratings are determined by applying criteria that are set forth in the VA's Schedule for Rating Disabilities (38 C.F.R. Part 4). Ratings are based on average impairments of earning capacity resulting from particular diseases and injuries and the residuals thereof in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities are described utilizing diagnostic codes set forth in 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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In cases, such as this one, in which a claim for a higher evaluation arises out of the initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the claim and appellate process. See generally Fenderson v. West, 12 Vet. App. 119 (1999). See also Hart v. Mansfield, 21 Vet. App. 505 (2007). A. Irritable bowel syndrome with GERD The Veteran's irritable bowel syndrome with GERD is presently rated 10 percent disabling, pursuant to 38 C.F.R. § 4.114, diagnostic code 7319. The Veteran's irritable bowel syndrome with GERD may be rated pursuant to either 38 C.F.R. § 4.114 diagnostic code 7319 (pertaining to irritable colon syndrome) or 38 C.F.R. § 4.7346 (hiatal hernia, considered analogous to GERD, which is not specifically mentioned in the rating schedule). The Board notes that the Veteran contended in this appeal that these two conditions should each be separately rated. However, certain coexisting diseases of the digestive system, including irritable bowel syndrome and hiatal hernia, do not lend themselves to distinct and separate disability evaluations without violating the rule against pyramiding. 38 C.F.R. §§ 4.113, 4.114. Thus, ratings under diagnostic codes 7319 and 7436 will not be combined with each other. Rather, a single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Pursuant to diagnostic code 7319, a 10 percent rating is assigned for moderate disability, with frequent episodes of bowel disturbance with abdominal distress. A 30 percent rating applies when there is severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 30 percent is the highest scheduler rating available for this disability. Pursuant to diagnostic code 7346, a 10 percent rating applies when there are two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating applies for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating applies when there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. 60 percent is the highest scheduler rating for this disability. The Veteran's service treatment records show various complaints of abdominal discomfort, constipation, and diarrhea. Complaints of acid reflux were also documented. At her examination in February 2007, the Veteran reported she had heartburn symptoms for 20 years, for which she was currently prescribed aciphex. This got worse while she was stationed in Korea as a result of eating the local food and she had breakthrough symptoms about twice a week. She used zantac as needed to help with this. An EGD in December 2006 showed minimal changes due to reflux esophagitis but was otherwise normal. She reported that she was diagnosed with irritable bowel syndrome 10 years ago and had recurring symptoms of sour stomach and alternating constipation and diarrhea. She took Colace, Mylanta, and milk of magnesia as needed. Symptoms were worse since she started eating local food in Korea; at this time flare ups occurred weekly. A colonoscopy showed 3 rectal polyps but was otherwise normal. The Veteran was able to work during flare ups but she had frequent discomfort. Post service treatment records continued to show problems with abdominal discomfort. Sometimes she complained of bloating and diarrhea or constipation. She had dark stools at times but no blood was visible. In September 2008 she noted decreased appetite but had actually gained weight over the past few months. Later records reflected complaints of frequent heartburn and nausea as well as abdominal pain. Symptoms were worse with dairy products. She was eventually diagnosed with lactose intolerance and advised to eliminate as much fat from her diet as possible. The Veteran was scheduled for an updated VA examination in February 2012 but she failed to appear for her examination; therefore, information that might have been gleaned from this examination about the current severity of the Veteran's digestive system disabilities is unavailable and her claim must be rated on the evidence of record. The evidence indicates that the predominant disability in this case is irritable bowel syndrome. While the Veteran also experiences GERD, her symptoms appear primarily limited to periodic heartburn. There was no dysphagia, regurgitation, or substernal pain. However, the Veteran's treatment records show frequent complaints related to her irritable bowel syndrome, inclusive of nausea, abdominal pain, constipation, and diarrhea. The evidence does not show that the Veteran meets the criteria for a rating higher than 10 percent for her irritable bowel syndrome. A 10 percent rating contemplates moderate symptoms including frequent episodes of bowel disturbance with abdominal distress as is shown here by the Veteran's fairly frequent medical visits related to her gastrointestinal complaints. A higher 30 percent rating applies when there is evidence of severe disability with diarrhea, or alternating diarrhea and constipation, and more or less constant abdominal distress. While the Veteran clearly experiences discomfort due to her irritable bowel syndrome, this was not shown to be more than moderate. She was able to maintain her weight despite her symptoms, her symptoms did not appear to significantly limit her activities, and she was able to reduce symptoms somewhat by eliminating fatty foods and dairy products from her diet. While she periodically reported complaints of abdominal pain, this was not shown to be constant or near constant. The Board has considered whether the additional symptoms related to the Veteran's GERD causes her overall disability to approximate the next higher level, but does not find this to be the case. Rather, her symptoms are contemplated by currently assigned 10 percent rating. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). Symptoms such as abdominal distress, diarrhea, and constipation are specifically contemplated by the rating schedule. 2. Plantar fasciitis of the bilateral feet Plantar fasciitis is not specifically listed in the rating schedule. Therefore, it must be rated pursuant to a diagnostic code reflecting a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptoms are closely analogous. 38 C.F.R. § 4.20. In this case, the Veteran's plantar fasciitis was rated by the RO pursuant to 38 C.F.R. § 4.71a, diagnostic code 5284, other foot injuries. Pursuant to that diagnostic code, a 0 percent rating applies for symptoms which are less than moderate. 38 C.F.R. §4.31. A 10 percent rating applies for moderate foot injuries. A 20 percent rating applies for moderately severe foot injuries. A 30 percent rating applies for severe foot injuries. Alternatively, plantar fasciitis may be analogized to pes planus and rated under diagnostic code 5276. Pursuant to that diagnostic code, mild symptoms relieved by a built up shoe or arch supports is 0 percent disabling. Moderate symptoms including weight bearing line over the medial to great toe, inward bowing of the tendo Achilles, pain on manipulation and use of the feet, bilateral or unilateral, is 10 percent disabling. Severe pes planus with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, is 20 percent disabling when the condition is unilateral and 30 percent disabling when it is bilateral. Pronounced flatfoot with marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, which is not improved by orthopedic shoes or appliances, is 30 percent disabling when it is unilateral and 50 percent disabling when it is bilateral. 50 percent is the highest available rating under this diagnostic code. Service treatment records show numerous complaints of foot pain and the Veteran was put on a permanent profile for foot pain. At her examination in February 2007, the Veteran reported she had symptoms of foot pain for five years which had gotten better after she was placed on a permanent profile. She complained of arch pain first thing in the morning and after walking more than one hour. She denied swelling, numbness, or weakness of the feet. She used inserts and stretching exercises, but limiting use of the feet was the most helpful in reducing her symptoms. Examination of the feet showed no pes cavus, pes planus, calluses, or oncymycosis. Range of motion of the feet were within normal limits. Treatment records from January 2008 showed severe tenderness to palpation over the plantar heels but her feet were otherwise normal. They were normal in appearance and there was normal motion of the feet without pain on motion. In her July 2009 notice of disagreement, the Veteran contended her feet pain was worse and usually occurred with driving, standing, and walking. Subsequent treatment notes showed continued problems with tender plantar surfaces of the feet with reduced arches bilaterally for which the Veteran repeatedly sought treatment. The Veteran saw a podiatrist and was prescribed orthotics. However, she was noted to use poor judgment in care of her feet by wearing high heeled shoes despite her foot pain. X-rays showed mild degenerative changes at the first metarsophalangeal joint of both feet. The Veteran was scheduled for a VA examination in February 2012 to assess the current severity of her plantar fasciitis. However, she failed to appear for her examination. Therefore, her claim must be evaluated on the evidence of record. Giving the benefit of the doubt to the Veteran, her symptoms most closely approximate a moderate foot injury. Her frequent visits to medical care providers for foot pain in service and after service as well as her need to limit her activities at times due to her foot pain (as shown by her profile in service), when considered most favorably to the Veteran, constitute moderate symptoms. However, more than moderate symptoms are not shown. The Veteran's symptoms primarily consist of subjective foot pain. Despite her foot pain, she was still able to wear high heeled shoes at times although this was not advised by her podiatrist. She was issued orthotics which did provide some relief when she wore them. While the Veteran was placed on a profile in service as a result of foot pain and tried to limit certain activities to minimize her foot pain, there is no evidence that her activities were limited to such an extent that would be consistent with a moderately severe or severe foot injury and there are no objective symptoms indicative of a foot injury that is more than moderate in nature. The Board has considered whether a higher rating is available pursuant to the rating criteria applicable to the analogous condition of pes planus. However, applying the diagnostic code for other foot injuries is more favorable to the Veteran because it allows a separate 10 percent rating for each foot. Under diagnostic code for pes planus, moderate symptoms of pes planus, including pain on manipulation and use of the feet, allow only a single 10 percent rating for the bilateral condition. Here, there is no evidence of a condition akin to severe pes planus which would permit the assignment of a 30 percent rating for the bilateral condition. While there is some evidence of reduced arches, there is no evidence here of symptoms such as marked deformity, swelling, notably abnormal weight bearing, or callosities. A 10 percent rating for left foot plantar fasciitis and a 10 percent rating for right foot plantar fasciitis is granted. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). The rating schedule contemplates the symptom of foot pain, and the Veteran has not shown any unusual symptoms or limitations which are outside the scope of the rating schedule. C. Bilateral patellofemoral pain syndrome Patellofemoral pain syndrome is not specifically addressed in the rating schedule and must also be rated by analogy. The RO analogized the Veteran's patellofemoral syndrome to tenosynovitis, 38 C.F.R. § 4.71a, diagnostic code 5024, which is rated on limitation of motion of the affected parts as degenerative arthritis (diagnostic code 5003). Pursuant to diagnostic code 5003, a 10 percent rating may also be assigned when there is a non-compensable limitation of motion with pain or when certain x-ray findings are present. Disabilities of the knees are rated pursuant to diagnostic codes 5256-5262. Diagnostic code 5256 involved ankylosis of the knee. A rating of 30 percent applies when there is ankylosis that is at a favorable ankle in full extension, or in slight flexion between 0 and 10 degrees. A 40 percent rating applies when there is ankylosis of the knee in flexion between 10 and 20 degrees. A 50 percent rating applies when there is ankylosis of the knee in flexion between 20 and 45 degrees. A 60 percent rating applies when there is extremely unfavorable ankylosis, in flexion at an angle of 45 degrees of more. Diagnostic code 5257 refers to other impairments of the knee. An evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability, and evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Diagnostic code 5258 applies to dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. A 20 percent rating applies for disability. Diagnostic code 5259 applies to removal of symptomatic semilunar cartilage. A 10 percent rating applies for this disability. Diagnostic Code 5260 pertains to limited flexion of the knee. A 10 percent rating is applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees. A 30 percent rating applies when flexion is limited to 15 degrees. Diagnostic Code 5261 pertains to limitation of extension of the knee. A 10 percent evaluation is assigned for extension that is limited to 10 degrees. A 20 percent evaluation is assigned for extension that is limited to 15 degrees. A 30 percent evaluation is assigned for extension that is limited to 20 degrees. A 40 percent evaluation is assigned for extension that is limited to30 degrees. A 50 percent evaluation is assigned for extension that is limited to 45 degrees or greater. Diagnostic Code 5262 applies to impairment of the tibia and fibula. A 10 percent rating is applied when there is malunion with a slight knee or ankle disability. A 20 percent rating is applies when there is malunion with a moderate knee or ankle disability. A 30 percent rating applies where there is malunion with marked knee or ankle disability. A 40 percent rating applies when there is nonunion of the tibia and fibula with loose motion requiring a brace. Diagnostic Code 5263 applies to genu recurvatum; a 10 percent rating applies for this disability. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. DeLuca v. Brown , 8 Vet. App. 202, 205-206 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. The VA General Counsel held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257, provided that a separate rating must be based upon additional disability. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9- 98, 63 Fed. Reg. 56,704 (1998). Also, separate rating may be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same knee, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). At her February 2007 examination, the Veteran reported pain around her knee caps without swelling after walking more than one and a half miles. Previously, symptoms onset with walking. She denied morning stiffness, locking, and giving way, but did endorse stiffness after activity which improved with over the counter medication. She had tried physical therapy, but activity modification was the most helpful in controlling her symptoms and she had not run for several years. She was able to work during flare ups. Examination of the knees showed normal range of motion. There was no effect on range of motion due to pain, weakness, fatigue, or incoordination during repetitive use or during flare ups. There was no crepitus or patellar grind. There was no swelling, effusion, tenderness, muscle spasm, joint laxity, muscle atrophy, or bony residual of a fracture. After service, the Veteran had additional physical therapy for her knees from January 2008 to March 2008. An initial evaluation showed full range of motion of the knees, with full strength on the right and 4/5 strength on the left. At that time, the Veteran reported that her left knee symptoms were worsening and her left knee was constantly painful and frequently gave way. Her left knee was tender to palpation, and her left knee was hypermobile with left patellar medial/lateral motion. Later notes reflect left knee pain that got worse with squatting, bending, or using stairs. She continued to complain that her left knee gave way and had a hypermobile knee. Range of motion continued to be normal bilaterally. However, she only attended three sessions of physical therapy. Medical notes from around the same time noted tenderness to palpation that was worse with stretching of the tendons with a normal exam except for mild retropatellar crepitus/quad apprehension although this did not reproduce her symptoms. Appearance of the knees was normal, there was no anterior or posterior drawer sign, and a McMurray test was negative. January 2008 x-rays of the left knee showed normal joint spaces, bony cortical margins, and trabecular patterns. Surrounding soft tissues were normal with swelling, joint effusion, or periarticular calcification. It was a negative study. In her January 2009 notice of disagreement, the Veteran contended that her knee pain was worse in the past year. She had constant pain that was made worse by squatting, bending, and using stairs. She contended that her knees frequently gave way during the day with no particular activity. The Veteran was scheduled for a new VA examination of her knees in February 2012, but she failed to appear for her examination. Therefore, evidence that might have been gleaned from that examination is unavailable and the Veteran's claim must be evaluated based on the evidence of record. Giving the benefit of the doubt to the Veteran, the criteria for a 10 percent rating for patellofemoral pain syndrome, left knee, were met, pursuant to diagnostic code 5257, for slight recurrent subluxation and lateral instability. Treatment records document complaints of the left knee giving way, and there were objective indications of hypermobility and decreased strength. However, the Veteran's symptoms were not shown to be more than slight by the evidence of record. The Veteran failed to appear for a VA examination to objectively assess whether her symptoms were more than slight in severity. A separate rating for limitation of flexion or extension, or for painful limited motion with arthritis, is not warranted, because there was no indication of any limitation of motion or painful motion of the left knee. While the Veteran complained of left knee pain, this was not shown to be associated with range of motion. Other diagnostic codes pertaining to the knee are not applicable to the Veteran's symptoms. However, the criteria for a compensable rating for right knee patellofemoral pain syndrome were not met. VA examination and treatment records document full range of motion of the right knee; there is no evidence of any limitation of motion or painful motion to warrant a 10 percent rating under diagnostic code 5003 or for limitation of flexion or extension. In contrast to the left knee, the only indication of any impairment of the right knee, other than subjective complaints of pain, was the Veteran's January 2009 statement that both of her knees gave way at times. This statement alone is insufficient to warrant a compensable rating for the right knee disability, absent any documentation in the medical records of instability or giving way or any other objective indications of right knee instability. The Veteran was afforded the opportunity to attend a VA examination to determine if any greater disability of the right knee was present, but she did not attend that examination. The Board finds that the Veteran's symptoms do not present such an exceptional disability picture as to render the schedular rating inadequate. 38 C.F.R. § 3.321(b). See also Thun v. Peake, 22 Vet. App. 111, 115 (2008) (the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). Her symptoms, consisting of bilateral knee pain that is not associated with range of motion, and some evidence of instability of the left knee, is contemplated by the rating schedule. The Veteran has not shown any unusual symptoms or limitations referable to either of her knees that are not contemplated by the rating schedule. A 10 percent rating for patellofemoral syndrome of the left knee is granted. A compensable rating for patellofemoral syndrome of the right knee is denied. Service connection The Veteran contends that she has a sinus condition that is related to her military service. The Board notes that the Veteran also had a claim for service connection for allergies which was also denied. However, the Veteran did not appeal that decision and only appealed the denial of service connection for a sinus disorder. Service connection may be granted for a disability resulting from disease or injury that was incurred in, or aggravated by, service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for some chronic diseases which are listed in 38 C.F.R. § 3.309, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge if all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirement that a current disability exist is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In most cases, establishing a nexus to service requires medical evidence. However, in the case of the chronic diseases set forth in 38 C.F.R. § 3.309, the requisite nexus may also be provided by evidence of continuity of symptoms. Walker v. Shinseki, 708 F.3d 1331 (2013). The Veteran's service treatment records show complaints of allergy symptoms and symptoms which the Veteran referred to as sinus problems. Although she was diagnosed with seasonal allergies and viral syndromes, no sinus disorder was shown to have been diagnosed and in the case of this Veteran a current sinus disability is not shown. While sinus headaches are documented, the Board notes that the Veteran is already service connected for her headaches. The Veteran was afforded a general medical examination in February 2007 at which time she reported seasonal allergy symptoms, but stated that she had never been prescribed antibiotics for a sinus infection. Examination of the sinuses were normal and there was no sinus tenderness. The examiner noted that although the Veteran had recurrent sinus headaches, she did not have any documented previous history of any other sinus condition and did not give a history consistent with chronic or recurrent bacterial sinusitis. Post service treatment records indicate a 2009 diagnosis of allegeric sinusitis with CT scan to follow, however a CT scan of the Veteran's sinuses in June 2009 was normal and weighs against the Vetean's claim that she has sinusitis. There is no other evidence of a current diagnosis of sinusitis or a sinus disorder. In sum, the evidence does not indicate the existence of a current sinus disorder. The only indication of a sinus disorder other than headaches is the assessment of allergic sinusitis in her post-service treatment records which resulted in the order for a sinus CT in June 2009 which turned out to be negative. The VA examiner specifically noted that the history given by the Veteran was not consistent with bacterial sinusitis. While the Veteran may believe that her symptoms relate to a sinus disorder, her opinion is outweighed by the objective evidence which shows that the Veteran has seasonal allergy symptoms that do not result in recurrent bacterial sinusitis. As previously noted, the Veteran did not appeal the denial of service connection for her seasonal allergies. The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine is inapplicable in the instant case because the preponderance of the evidence is against the Veteran's claim. See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Accordingly, service connection for a sinus disorder is denied. ORDER An initial rating in excess of 10 percent for GERD is denied. An initial rating of 10 percent for left foot plantar fasciitis is granted. An initial rating of 10 percent for right foot plantar fasciitis is granted. An initial rating of 10 percent for left knee patellofemoral pain syndrome is granted. An initial compensable rating for right knee patellofemoral pain syndrome is denied. Service connection for a sinus disorder is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs