Citation Nr: 1821030 Decision Date: 04/11/18 Archive Date: 04/19/18 DOCKET NO. 14-21 029A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a corneal scar of the right eye. 2. Entitlement to service connection for anemia. 3. Entitlement to service connection for keloid scars of the breast. 4. Entitlement to an initial disability rating in excess of zero percent prior to June 6, 2013; in excess of 10 percent as of June 6, 2013, and prior to September 17, 2015; and in excess of 40 percent as of September 17, 2015, for chronic urinary tract infections (UTIs), also claimed as yeast infections. 5. Entitlement to an initial disability rating in excess of zero percent prior to September 17, 2015, an in excess of 20 percent thereafter, for right shoulder impingement. 6. Entitlement to an initial disability rating in excess of 10 percent for a degenerative joint disease of the right knee. 7. Entitlement to an initial disability rating in excess of 10 percent for status post anterior cruciate ligament (ACL) repair of the left knee. 8. Entitlement to an initial disability rating in excess of zero percent prior to September 17, 2015, an in excess of 10 percent thereafter, for bilateral hallux valgus with pes planus and degenerative changes of the great toe (bilateral foot disability). 9. Entitlement to an initial compensable disability rating for gastroesophageal reflux disease (GERD) with gastritis. 10. Entitlement to an initial compensable disability rating for a scar of the right knee. 11. Entitlement to an initial compensable disability rating for scars of the left knee. 12. Entitlement to an initial disability rating in excess of 10 percent prior to September 17, 2015, for scars of the anterior trunk. 13. Entitlement to an initial compensable disability rating for status post breast reduction. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD J.A. Gelber, Associate Counsel INTRODUCTION The Veteran served on active duty from May 2002 to September 2010. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2011, July 2012, and May 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a Board hearing in her Form 9 substantive appeal. The RO scheduled a hearing in June 2017 and sent notice to the Veteran in May 2017; however, she did not appear for this Board hearing and the hearing request was effectively withdrawn. A May 2014 rating decision granted service connection for tender scars of the anterior trunk (left breast) and assigned a 10 percent rating effective September 14, 2010. An October 2016 rating decision assigned a 30 percent rating effective September 17, 2015, based on finding five or more painful scars. As scars of the trunk are part and parcel of the Veteran's claim for an increased initial rating for residuals of a breast reduction, the Board has jurisdiction over the rating assigned for scars of the anterior trunk; thus, it is among the issues currently before the Board. Chronic UTIs was initially evaluated as noncompensable; a May 2014 rating decision assigned a 10 percent rating effective June 6, 2013, and an October 2016 rating decision assigned a 40 percent rating effective September 17, 2015. The October 2016 rating decision also assigned increased ratings for the right shoulder (20 percent effective September 17, 2015), bilateral foot disability (10 percent effective September 17, 2015), and scars of the trunk (30 percent effective September 17, 2015). Although increased ratings were granted, the issues remained in appellate status, as the maximum schedular ratings had not been assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). In an April 2015 report of contact and December 2016 notice of disagreement (NOD) form, the Veteran expressed disagreement with the effective dates for the increased ratings for UTIs, right shoulder and bilateral foot disabilities, and scars of the trunk. The Board notes that the issues of the effective dates of the increased ratings are contemplated by the initial increased rating claims on appeal, and will be decided as part of those issues. The Veteran raised the claim of service connection for a neck disability in her June 2010 application for compensation. In a statement by the Veteran received by VA in July 2014 (see 07/28/2014 VA 21-4138), the following issues were raised: service connection for sleep apnea; reopen the claims of service connection for defective vision, hearing loss, tubal ligation, an acquired psychiatric disorder (to include anxiety, depression, and posttraumatic stress disorder), memory loss, headaches, and chronic dysuria; increased ratings for back pain, tinnitus, allergic rhinitis, and dermatitis of the neck. None of the identified issues have been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). FINDINGS OF FACT 1. The competent and probative evidence is at least in equipoise as to whether the Veteran's corneal scar of the right eye had its onset in or is otherwise related to her period of active service. 2. The weight of the competent and probative evidence is against finding anemia during the period on appeal. 3. The Veteran is service-connected for scars of the anterior trunk. 4. The competent and probative evidence is at least in equipoise as to whether chronic UTIs required long-term drug therapy prior to June 6, 2013. 5. The weight of the competent and probative evidence is against finding voiding dysfunction resulting in daytime voiding interval between one and two hours or awakening to void three to four times per night as of June 6, 2013, and prior to July 28, 2014. 6. The competent and probative evidence is at least in equipoise as to whether voiding dysfunction resulted in leakage and/or daytime voiding interval between one and two hours as of July 28, 2014, and prior to September 17, 2015. 7. The weight of the competent and probative evidence is against finding voiding dysfunction requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day as of September 17, 2015. 8. The competent and probative evidence is at least in equipoise as to whether the Veteran had painful motion of the right shoulder prior to September 17, 2015. 9. The weight of the competent and probative evidence is against finding limitation of motion of the right shoulder to midway between side and shoulder level at any time during the period on appeal. 10. The weight of the competent and probative evidence is against finding limitation of extension of the right knee to 15 degrees or less. 11. The weight of the competent and probative evidence is against finding limitation of extension of the left knee to 15 degrees or less. 12. The competent and probative evidence is at least in equipoise as to whether the Veteran had moderate pes planus, to include pain on use of the feet, prior to September 17, 2015. 13. The weight of the competent and probative evidence is against finding severe pes planus at any time during the period on appeal. 14. The competent and probative evidence is at least in equipoise as to whether GERD results in dysphagia, pyrosis, and regurgitation. 15. The weight of the competent and probative evidence is against finding a scar of the right knee that is painful, unstable, and/or at least 39 square centimeters in area. 16. The weight of the competent and probative evidence is against finding scars of the left knee that are painful, unstable, and/or at least 39 square centimeters in area. 17. The competent and probative evidence is at least in equipoise as to whether the Veteran had three or four painful scars of the anterior trunk prior to September 17, 2015. 18. Residuals of the breast reduction are compensated by the rating for service-connected scars of the anterior trunk. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for corneal scar of the right eye have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for entitlement to service connection for anemia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 3. The criteria for entitlement to service connection for keloid scars of the breast have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 4. The criteria for an initial disability rating of 10 percent, but no higher, for chronic UTIs prior to June 6, 2013, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, Diagnostic Code (DC) 7542 (2017). 5. The criteria for an initial disability rating in excess of 10 percent for chronic UTIs as of June 6, 2013, and prior to July 28, 2014, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, DC 7542. 6. The criteria for an initial disability rating of 20 percent, but no higher, for chronic UTIs as of July 28, 2014, and prior to September 17, 2015, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, DC 7542. 7. The criteria for an initial disability rating in excess of 40 percent for chronic UTIs as of September 17, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.115a, 4.115b, DC 7542. 8. The criteria for an initial disability rating of 20 percent, but no higher, for a right shoulder disability prior to September 17, 2015, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DC 5201 (2017). 9. The criteria for an initial disability rating in excess of 20 percent for a right shoulder disability as of September 17, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DC 5201. 10. The criteria for an initial disability rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DCs 5003, 5261. 11. The criteria for an initial disability rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DC 5261. 12. The criteria for an initial disability rating of 10 percent, but no higher, for a bilateral foot disability prior to September 17, 2015, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DCs 5276, 5280. 13. The criteria for an initial disability rating in excess of 10 percent for a bilateral foot disability as of September 17, 2015, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, DCs 5276, 5280. 14. The criteria for an initial disability rating of 10 percent, but no higher, for GERD with gastritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, DC 7346 (2017). 15. The criteria for an initial compensable rating for a scar of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7805 (2017). 16. The criteria for an initial compensable rating for scars of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7805. 17. The criteria for an initial disability rating of 20 percent, but no higher, for scars of the anterior trunk prior to September 17, 2015, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7804. 18. The criteria for an initial compensable rating for residuals of breast reduction surgery have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, DC 7802. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has considered the Veteran's claims and decided entitlement based on the evidence. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to the claims on appeal. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). I. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). As a general matter, establishing service connection requires competent evidence of (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. The current disability requirement is satisfied when a claimant "has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim," McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), or "when the record contains a recent diagnosis of disability prior to ... filing a claim for benefits based on that disability," Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). A veteran is presumed in sound condition except for defects, infirmities, or disorders noted at the time, or where evidence or medical judgment establishes that an injury or disease preexisted service. VA may rebut this presumption only if there is clear and unmistakable evidence that the disease or injury at issue existed prior to service and was not aggravated by service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b) (2017). The Veteran is competent to report symptoms and experiences observable by her senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) (2012) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). A. Right eye corneal scar After review of the record, the Board finds that the criteria for service connection for a corneal scar of the right eye have been met. The Veteran's entrance examination does not note the presence of a corneal scar; accordingly, she is presumed to be sound upon entry. 11/09/2010, STR-Medical. A corneal scar of the right eye was noted during service in April and May treatment records, including in the September 2010 separation examination. 06/11/2010, Medical-Government. A corneal scar of the right eye was indicated in a December 2010 VA examination; thus, the Board finds competent evidence of a current disability. 12/10/2010, VA Examination. Accordingly, the Board finds that the competent and probative evidence is at least in equipoise as to whether the corneal scar of the right eye had its onset during or is otherwise related to the Veteran's period of active service. B. Anemia After review of the record, the Board finds that the criteria for service connection for anemia have not been met. The Board acknowledges that a history of anemia was noted in her service treatment records. However, in November 2010, a VA examiner stated that the Veteran is not anemic and that her iron stores are within normal range, explaining that the problem with low iron had resolved and that she had not had this condition in years. 11/29/2010, VA Examination. The Veteran's post-service treatment records are otherwise absent of a diagnosis of anemia. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding anemia during or just before the period on appeal. Without competent evidence of anemia, the Board must deny the Veteran's claim. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997). In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. C. Keloid scars of the breast After review of the record, the Board finds that the criteria for service connection for keloid scars of the breast have not been met. As previously noted, a May 2014 rating decision granted service connection for tender scars of the anterior trunk. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14 (2017); Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board finds that the Veteran is already receiving compensation for her claim of keloid scars of the breast for the entire period on appeal, and additional compensation for the same scars would constitute impermissible pyramiding. See id. Accordingly, the claim of service connection for keloid scars of the breast must be denied as a matter of law. II. Increased Ratings Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the course of the appeal. Id. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3; see Gilbert, 1 Vet. App. at 57-58. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disorder. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath, 1 Vet. App. at 593. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27 (2017). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 262. The Veteran is competent to report symptoms and experiences observable by her senses. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). A. UTIs The Veteran contends that she is entitled to a disability rating in excess of zero percent prior to June 6, 2013; in excess of 10 percent as of June 6, 2013, and prior to September 17, 2015; and in excess of 40 percent as of September 17, 2015, for chronic UTIs, also claimed as yeast infections, evaluated under Diagnostic Codes 7599-7542. Diagnostic Code 7542, for neurogenic bladder, directs the evaluator to rate as voiding dysfunction under 38 C.F.R. § 4.115a. 38 C.F.R. § 4.115b. Voiding dysfunction should be rated as a particular condition of urine leakage, frequency, or obstructed voiding, based on the specific symptoms experienced. 38 C.F.R. § 4.115a. Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day warrants a 60 percent disability rating. A 40 percent rating is warranted for continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent materials which must be changed two to four times per day. Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent materials which must be changed less than two times per day warrants a 20 percent disability rating. 38 C.F.R. § 4.115a. Urinary frequency with daytime voiding interval less than one hour or awakening to void five or more times per night warrants a 40 percent disability rating. A 20 percent rating is warranted for daytime voiding interval between one and two hours or awakening to void three to four times per night. Daytime voiding interval between two and three hours or awakening to void two times per night warrants a 10 percent disability rating. 38 C.F.R. § 4.115a. With regard to obstructive voiding, urinary retention requiring intermittent or continuous catheterization warrants a 30 percent rating. A 10 percent rating is warranted by the presence of marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: post void residuals greater than 150 cc; uroflowmetry showing markedly diminished peak flow rate (less than 10 cc/second); recurrent urinary tract infections secondary to obstruction; or stricture disease requiring periodic dilatation every two to three months. 38 C.F.R. § 4.115a. If urinary tract infection is predominant and results in poor renal function, the disability should be rated as renal dysfunction. Otherwise, long-term drug therapy, one to two hospitalizations per year, and/or requiring intermittent intensive management warrants a 10 percent rating for UTI. A 30 percent rating is warranted for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times per year), and/or requiring continuous intensive management. 38 C.F.R. § 4.115a. At the outset, the Board notes that the competent medical evidence does not show renal dysfunction; thus, the rating criteria based on renal dysfunction is inapplicable and will not be discussed. 1. Prior to July 28, 2014 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 10 percent, but no higher, for chronic UTIs is warranted prior to July 28, 2014. The Board finds that the competent and probative evidence is at least in equipoise as to whether the Veteran's genitourinary disorder required long-term drug therapy prior to July 28, 2014, thus warranting a 10 percent rating for that period. See 11/09/2010, STR-Medical; 11/29/2010, VA Examination; 11/30/2011, NOD; 05/02/2014, C&P Exam; see also 38 C.F.R. § 4.115a. The Board finds that the Veteran is not entitled to a rating in excess of 10 percent prior to July 28, 2014. To warrant a rating in excess of 10 percent, the evidence must show recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management; daytime voiding interval of less than two hours, or awakening to void at least three times per night; or requiring the wearing of absorbent materials due to urine leakage. See 38 C.F.R. § 4.115a. In November 2010, a VA examiner noted the Veteran's report of UTIs occurring about once per month. The most recent prior diagnosed UTI was in July or August 2010, which was treated with antibiotics. The Veteran denied any hospitalizations related to UTIs. She reported urinary urgency and frequency, but denied other symptoms, such as problems with urine flow or incontinence. 11/29/2010, VA Examination. In May 2014, a VA examiner noted the Veteran's report of experiencing about four UTIs per year, with a daytime voiding interval between two to three hours, and awakening to void twice per night. She denied leakage, obstructed voiding symptoms, or use of an appliance. The examiner indicated that her genitourinary disorder requires long-term drug therapy, as the Veteran takes medication daily as a preventative measure. 05/02/2014, C&P Exam. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management; daytime voiding interval of less than two hours, or awakening to void at least three times per night; or requiring the wearing of absorbent materials due to urine leakage prior to July 28, 2014. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. §§ 4.115a, 4.115b. The benefit of the doubt has been applied as applicable. 2. As of July 28, 2014, and prior to September 17, 2015 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 20 percent, but no higher, for chronic UTIs is warranted as of July 28, 2014, and prior to September 17, 2015. On July 28, 2014, VA received correspondence from the Veteran in which she described experiencing leakage and voiding more than 10-12 times per day. 07/28/2014, VA 21-4138. The Veteran is competent to describe her urinary frequency and the Board has no reason to doubt her credibility on this matter. The Board finds that the competent and probative evidence is at least in equipoise as to whether the Veteran's genitourinary disorder resulted in urinary leakage and daytime voiding interval between one and two hours, thus warranting a 20 percent rating. See 38 C.F.R. § 4.115a. The Board finds that the Veteran is not entitled to a rating in excess of 20 percent prior September 17, 2015, as the weight of the competent and probative medical and lay evidence is against finding urinary leakage requiring the wearing of absorbent materials that must be changed at least two times per day; a daytime voiding interval of less than one hour; awakening to void five or more times per night; or recurrent symptomatic infection requiring drainage and/or frequent hospitalization (greater than two times per year), and/or requiring continuous intensive management during the relevant period. See 38 C.F.R. § 4.115a. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. §§ 4.115a, 4.115b. The benefit of the doubt has been applied as applicable. 3. As of September 17, 2015 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that the criteria for an initial disability rating in excess of 40 percent for chronic UTIs as of September 17, 2015, have not been met. A September 17, 2015 VA examination reflects the Veteran's report of urinary leakage requiring wearing absorbent materials which must be changed less than twice per day, a daytime voiding interval of less than one hour, and awakening to void five or more times per night. The Veteran denied use of an appliance. The Board finds that the Veteran is not entitled to a rating in excess of 40 percent as of September 17, 2015, as the weight of the competent and probative medical and lay evidence is against finding that the Veteran's genitourinary disorder results in urinary leakage requiring the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. See 38 C.F.R. § 4.115a. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. §§ 4.115a, 4.115b. The benefit of the doubt has been applied as applicable. B. Right shoulder The Veteran contends that she is entitled to an initial compensable rating prior to September 17, 2015, and a rating in excess of 20 percent thereafter, for her right shoulder disability, evaluated under Diagnostic Code 5201. Disabilities of the shoulder and arm are evaluated under rating criteria that contemplate ankylosis of scapulohumeral articulation (Diagnostic Code 5200), limitation of motion of the arm (Diagnostic Code 5201), other impairment of the humerus (Diagnostic Code 5202), or impairment of the clavicle or scapula (Diagnostic Code 5203). Diagnostic Code 5201 is used to evaluate injuries resulting in limited motion of the arm. A 20 percent rating is warranted for limitation of motion of either arm at shoulder level, or midway between side and shoulder level of the minor arm. A 30 percent rating is warranted for motion limited to midway between side and shoulder level for the major arm, or to 25 degrees from the side for the minor arm. A 40 percent rating is the maximum schedular rating for limitation of motion of the arm, and is warranted for limitation of motion to 25 degrees from the side for the major arm. 38 C.F.R. § 4.71a, DC 5201. The terms "major" and "minor" are used in the rating criteria to refer to the dominant or non-dominant upper extremity. See 38 C.F.R. § 4.69 (2017). The evidence demonstrates that the Veteran's right arm is her dominant upper extremity. 11/29/2010, VA Examination. Standard range of motion of the shoulder is as follows: forward elevation (flexion) to 180 degrees; abduction to 180 degrees; internal rotation to 90 degrees; and external rotation to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. See id. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of Sections 4.40 and 4.45 pertaining to functional impairment. 38 C.F.R. §§ 4.40, 4.45 (2017). The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain during flare-ups and after repetitive use over time. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 208 (1995); 38 C.F.R. § 4.59 (2017). The Board notes that 38 C.F.R. § 4.59, entitled "Painful motion," states, in pertinent part: "The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint." In Burton v. Shinseki, the Court stated that the scope of § 4.59 is not limited to arthritis claims. 25 Vet. App. 1, 5 (2011). After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 20 percent, but no higher, is warranted for the right shoulder disability during the entire period on appeal. A November 2010 VA examination reflects the Veteran's report of soreness and stiffness of the right shoulder when she lies on it at night, pain from active use (to include when doing push ups), and occasional pain at rest, however, the examiner found no objective signs of pain at rest or in motion. It was noted that the Veteran is right hand dominant. The VA examiner found forward flexion of the right shoulder to 180 degrees, with mild discomfort starting at 90 degrees, and abduction to 180 degrees, with pain starting at 90 degrees. There was no additional limitation of function or range of motion after three repetitions. The Veteran denied signs of inflammation and flare-ups. Additionally, the examiner found no instability, weakness, or incoordination. 11/29/2010, VA Examination. A January 2012 treatment note indicates pain on movement of the right shoulder, with pain beginning at 90 degrees flexion. 12/26/2013, CAPRI. A September 2015 VA examiner found flexion to 80 degrees and abduction to 60 degrees. Pain was noted on the examination, but did not result in or cause functional loss. The Veteran declined to perform repetitive motion testing. The examiner acknowledged the Veteran's report of flare-ups resulting in restlessness and shoulder pain, but found that pain, fatigue, instability, and weakness do not significantly limit functional ability after repeated use over time or during flare-ups. The Veteran described the functional impact of the right shoulder disability as affecting her ability to lift heavy objects. The examiner found no reduction in muscle strength, ankylosis, or impairment of the humerus, and did not suspect a rotator cuff condition or instability, dislocation, or labral pathology. This examination report also reflects that the Veteran is right hand dominant. 12/03/2015, C&P Exam. The Board finds the November 2010 and September 2015 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, medical expertise, scientific testing, proper consideration of the Veteran's lay statements, and adequate rationales. Accordingly, the Board finds that a 20 percent rating is warranted prior to September 17, 2015, based on painful motion of the right shoulder. See Sowers v. McDonald, 27 Vet. App. 472, 478-79, 482 (2016) (stating that application of 38 C.F.R. § 4.59 warrants at least the minimum compensable rating for painful motion of a joint); see also 38 C.F.R. § 4.71a, DC 5201; Downey v. McDonald, No. 15-3283, 2016 U.S. App. Vet. Claims LEXIS 1997, *9 (Dec. 28, 2016) (nonprecedential Memorandum Decision) (recognizing that 20 percent is the minimum compensable rating based on application of 38 C.F.R. § 4.59 to Diagnostic Code 5201) (citing Sowers, 27 Vet. App. at 482). The Board finds that a rating in excess of 20 percent for the right shoulder is not warranted, as the weight of the competent and probative evidence is against finding limitation of motion to midway between side and shoulder level. See38 C.F.R. § 4.71a. The Board has considered the 38 C.F.R. §§ 4.40, 4.45, and 4.59, and Mitchell and DeLuca criteria, and in fact herein assigns a 20 percent rating prior to September 17, 2015, on the basis of such criteria, but finds that the competent and probative evidence weighs against finding weakened movement, excess fatigability, incoordination, and/or pain during flare-ups or after repeated use over time resulting in motion limited to midway between side and shoulder level. In other words, the Board finds that the Veteran's right shoulder disability does not more closely approximate the criteria for a 30 percent evaluation. See 38 C.F.R. § 4.71a. Moreover, the evidence does not show ankylosis, other impairment of the humerus, or impairment of the clavicle or scapula. See 12/03/2015, C&P Exam. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. § 4.71a. The benefit of the doubt has been applied as applicable. C. Knees The Veteran contends that she is entitled to initial disability ratings in excess of 10 percent for the right and left knee disabilities. Before the Board analyzes these issues, a review of the pertinent diagnostic codes pertaining to the knee would be useful. Standard motion of a knee joint is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of leg motion is governed by Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 concerns limitation of leg flexion. A 10 percent rating is warranted where flexion is limited to 45 degrees; a 20 percent rating is warranted where flexion is limited to 30 degrees; and a 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Diagnostic Code 5261 pertains to limitation of leg extension. A 10 percent rating is warranted where extension is limited to 10 degrees; a 20 percent rating is warranted where extension is limited to 15 degrees; a 30 percent rating is warranted where extension is limited to 20 degrees; a 40 percent rating is warranted where extension is limited to 30 degrees; and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight subluxation or lateral instability. A 20 percent rating is warranted for moderate subluxation or lateral instability. A maximum 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. Under Diagnostic Code 5258, a 20 percent rating is warranted where there is evidence of dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the knee joint. 38 C.F.R. § 4.71a, DC 5258. Symptomatic removal of semilunar cartilage warrants a 10 percent rating under Diagnostic Code 5259. 38 C.F.R. § 4.71a, DC 5259. Under Diagnostic Code 5262, malunion of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating; moderate knee or ankle disability warrants a 20 percent rating; and marked knee or ankle disability warrants a 30 percent rating. A 40 percent rating is warranted for nonunion of the tibia and fibula with loose motion that requires a brace. 38 C.F.R. § 4.71a, DC 5262. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 262. However, a claimant who has both limitation of flexion and limitation of extension of the same leg may be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. VAOPGCPREC 9-2004 (2004), 69 Fed. Reg. 59,990 (Oct. 6, 2004). Additionally, a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. However, separate ratings require separate compensable symptomatology. VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56,704 (Oct. 22, 1998); VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63,604 (Dec. 1, 1997); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). As previously discussed, for disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of Sections 4.40, 4.45, and 4.59 pertaining to functional impairment. See 38 C.F.R. §§ 4.40, 4.45, and 4.59, Mitchell, 25 Vet. App. at 37; DeLuca, 8 Vet. App. at 208. 1. Right knee After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating in excess of 10 percent for the right knee disability is not warranted. The right knee disability is evaluated as 10 percent disabling under Diagnostic Codes 5003-5261. Diagnostic Code 5003 provides that degenerative arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasms, or satisfactory evidence of painful motion. In the absence of limitation of motion, degenerative arthritis with x-ray evidence of involvement of two or more major joints or two or more minor joint groups is to be rated as 10 percent disabling, or as 20 percent disabling if there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. The Board notes that the evidence does not demonstrate occasional incapacitating episodes of the right knee. A November 2010 VA examination reflects the Veteran's report of right knee pain after playing sports, ascending and descending stairs, and wearing high heels. She further reported pain and swelling after strenuous workouts and stiffness after prolonged sitting, but denied flare-ups, inflammation, and other symptoms. The examination indicated use of a knee brace. The examiner found full range of motion with mild tenderness to palpation and upon valgus stress. The examiner noted that there was no additional loss of range of motion or function after repetitive use testing, no weakness or incoordination, no objective signs of pain at rest or in motion, no abnormal weight bearing, and no joint laxity or instability. Her knee stiffened with prolonged driving and prolonged sitting, but she had not lost any time at work due to her right knee. 11/29/2010, VA Examination. In November 2011, the Veteran reported constant pain of the knees, difficulty climbing stairs, use of knee braces for support, and being unable to perform physical activities without pain medication. She indicated the use of heat and medication to make the pain tolerable at a level of 6-7/10. 11/30/2011, NOD. In an August 2012 treatment note, the Veteran reported mostly experiencing knee pain after running a few miles and while ascending and descending stairs. 12/26/2013, CAPRI. In June 2013, the Veteran reported stiffness and swelling of the knees with associated difficulty climbing stairs, exercising, and sitting for extended periods of time. She also reported missing 2-5 days of work per month due to her knees. 06/06/2013, NOD. In a statement received by VA in June 2014, the Veteran reported flexion of the right knee limited to 30 degrees with joint pain, swelling, and recurrent dislocation and instability preventing lateral movement. She also reported use of a knee brace for stability, difficulty with stairs, and that she cannot sit for extended periods of time without her knee locking up. 06/24/2014, VA 21-4138. Although the Veteran is competent to report symptoms such as pain and swelling and her knee giving way, she is not competent to provide range of motion measurements or diagnose dislocation or lateral instability, as such requires medical expertise. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). In light of the lack of competency on these matters, the Board places no weight on such statements. A September 2015 VA examination reflects the Veteran's report of flare-ups of the right knee resulting in constant pain and intermittent swelling, with functional loss described as limited range of motion, locking, pain, and decreased ability to exercise and use stairs. The examiner found flexion to 90 degrees and extension to zero degrees, with no pain noted on the examination and no additional loss of function or range of motion after three repetitions. The examiner noted that range of motion does not contribute to functional loss and that pain, fatigue, incoordination, and weakness do not significantly limit functional ability during flare-ups or with repeated use over time. The examiner further noted no ankylosis, normal muscle strength, no history of recurrent subluxation or lateral instability, no history of recurrent effusion, and no joint instability shown on testing. The examination indicates a right meniscal condition resulting in frequent episodes of join pain, but no patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. Residuals of a 2003 ACL repair were noted as pain, stiffness, instability, swelling, and locking. The right knee had 5/5 muscle strength and no atrophy. 12/03/2005, C&P Exam. The Board finds the November 2010 and September 2015 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, medical expertise, scientific testing, proper consideration of the Veteran's lay statements, and adequate rationales. Accordingly, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent based on limitation of motion of the right knee, as the weight of the competent and probative evidence is against finding flexion limited to 30 degrees or less or extension limited to 15 degrees or less. See 38 C.F.R. § 4.71a. The November 2010 VA examiner found full range of motion and the September 2015 VA examiner found flexion to 90 degrees and extension to zero degrees. The Board has considered the 38 C.F.R. §§ 4.40, 4.45, and 4.59, and Mitchell and DeLuca criteria, and in fact the 10 percent rating for the right knee is based on painful motion, but finds that the competent and probative evidence weighs against finding weakened movement, excess fatigability, incoordination, and/or pain during flare-ups or after repeated use over time resulting in flexion limited to 30 degrees or less or extension limited to 15 degrees or less. In other words, the Board finds that the Veteran's right knee disability does not more closely approximate the criteria for a 20 percent evaluation based on limitation of motion. The Board notes that the Veteran's June 2013 NOD indicated that she can miss up to 5 days of work per month due to her knees. The Board finds that such is already contemplated by the rating schedule and her current 10 percent rating. Indeed, this is precise what this rating is meant compensate. In this regard, the Board notes that the percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2017). The Board also finds that the Veteran is not entitled to a higher rating based on a meniscal disorder, as the weight of the competent and probative evidence is against finding dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. See 38 C.F.R. § 4.71a, DC 5258. The Board acknowledges that the September 2015 examination indicates residuals of an ACL repair as pain, swelling, and locking; however, the September 2015 VA examiner found no history of patellar dislocation or recurrent effusion. The examiner noted frequent episodes of joint pain as a symptom of a meniscal disorder, but indicated the absence of frequent episodes of locking and joint effusion. A meniscal tear was not marked on the examination report. Accordingly, the Board finds that the symptoms of the right knee disorder do not more nearly approximate the criteria for a 20 percent rating under Diagnostic Code 5258. Nor is the Veteran entitled to a separate rating for a meniscal disorder under Diagnostic Code 5259. Because the Veteran's 10 percent rating under Diagnostic Code 5261 is based on painful motion (as it would be otherwise noncompensable based on limited range of motion), a separate rating for a meniscal disorder based on pain would constitute impermissible pyramiding. See 38 C.F.R. §§ 4.14, 4.71a, DC 5259; Esteban, 6 Vet. App. at 262. In other words, if the right knee disorder were evaluated as 10 percent disabling under Diagnostic Code 5259, the Veteran would not be entitled to a separate rating under Diagnostic Codes 5260 or 5261 based on painful motion, as pain is expressly contemplated by the rating criteria under Diagnostic Code 5259. The Board further finds that a separate and/or higher rating is not warranted under Diagnostic Codes 5256, 5257, or 5262, as the weight of the competent and probative evidence is against finding ankylosis, recurrent subluxation or lateral instability, or tibial or fibular impairment. For example, the December 2015 examination report reflects that the Veteran did not have and has not had recurrent patellar dislocation. See 12/03/2015, C&P Exam. All possibly applicable diagnostic codes have been considered in compliance with Schafrath, 1 Vet. App. at 593, but the Veteran could not receive a higher and/or additional evaluation for her right knee disability based on the evidence. See 38 C.F.R. § 4.71a. The Board notes that the benefit of the doubt has been applied, where applicable. 2. Left knee After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating in excess of 10 percent is not warranted for the left knee disability, evaluated under Diagnostic Code 5261. A November 2010 VA examination reflects the Veteran's report of left knee pain after playing sports, ascending and descending stairs, and wearing high heels. She further reported pain and swelling after strenuous workouts and stiffness after prolonged sitting, but denied flare-ups, inflammation, and other symptoms. The examination indicates use of a knee brace. The examiner found full range of motion with mild tenderness to palpation and upon valgus stress. The examiner noted that there was no additional loss of range of motion or function after repetitive use testing, no weakness or incoordination, no objective signs of pain at rest or in motion, no abnormal weight bearing, and no joint laxity or instability. 11/29/2010, VA Examination. In November 2011, the Veteran reported constant pain of the knees, difficulty climbing stairs, use of knee braces for support, and being unable to perform physical activities without pain medication. 11/30/2011, NOD. In an August 2012 treatment note, the Veteran reported mostly experiencing knee pain after running a few miles and while ascending and descending stairs. 12/26/2013, CAPRI. A January 2013 MRI found no significant joint effusion of the left knee. 02/27/2013, Medical-Government. In June 2013, the Veteran reported stiffness and swelling of the knees with associated difficulty climbing stairs, exercising, and sitting for extended periods of time. She also reported missing 2-5 days of work per month due to her knees. 06/06/2013, NOD. In a statement received by VA in June 2014, the Veteran reported flexion of the left knee limited to 15 degrees with joint pain, swelling, and recurrent dislocation and instability preventing lateral movement. She also reported use of a knee brace for stability, difficulty with stairs, and that she cannot sit for extended periods of time without her knee locking up. 06/24/2014, VA 21-4138. Although the Veteran is competent to report symptoms such as pain and swelling and her knee giving way, she is not competent to provide range of motion measurements or diagnose dislocation or lateral instability, as such requires medical expertise. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). In light of the lack of competency on these matters, the Board places no weight on such statements. A September 2015 VA examination reflects the Veteran's report of flare-ups of the left knee resulting in constant pain, with functional loss described as limited range of motion, locking, pain, and decreased ability to exercise and use stairs. The examiner found flexion to 90 degrees and extension to zero degrees, with no pain noted on the examination and no additional loss of function or range of motion after three repetitions. The examiner noted that range of motion does not contribute to functional loss and that pain, fatigue, incoordination, and weakness do not significantly limit functional ability during flare-ups or with repeated use over time. The examiner further noted no ankylosis, normal muscle strength, no history of recurrent subluxation or lateral instability, no history of recurrent effusion, no atrophy, and no joint instability shown on testing. The examination indicates a left meniscal condition resulting in frequent episodes of join pain, but no patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. Residuals of an ACL repair and meniscectomy were noted as pain, stiffness, instability, swelling, and locking. 12/03/2005, C&P Exam. The Board finds the November 2010 and September 2015 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, medical expertise, scientific testing, proper consideration of the Veteran's lay statements, and adequate rationales. Accordingly, the Board finds that the Veteran is not entitled to a rating in excess of 10 percent based on limitation of motion of the left knee, as the weight of the competent and probative evidence is against finding flexion limited to 30 degrees or less or extension limited to 15 degrees or less. See 38 C.F.R. § 4.71a. The November 2010 VA examiner found full range of motion and the September 2015 VA examiner found flexion to 90 degrees and extension to zero degrees. The Board has considered the 38 C.F.R. §§ 4.40, 4.45, and 4.59, and Mitchell and DeLuca criteria, and in fact the 10 percent rating for the left knee is based on painful motion, but finds that the competent and probative evidence weighs against finding weakened movement, excess fatigability, incoordination, and/or pain during flare-ups or after repeated use over time resulting in flexion limited to 30 degrees or less or extension limited to 15 degrees or less. In other words, the Board finds that the Veteran's left knee disability does not more closely approximate the criteria for a 20 percent evaluation based on limitation of motion. Additionally, similar to the right knee, the Board finds that the 10 percent rating for the left knee is contemplated by the rating schedule and adequately compensates her for her missed days from work. 38 C.F.R. § 4.1. The Board finds that the Veteran is not entitled to a higher rating based on a meniscal disorder, as the weight of the competent and probative evidence is against finding dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. See 38 C.F.R. § 4.71a, DC 5258. The Board acknowledges that the September 2015 examination indicates residuals of an ACL repair and meniscectomy as pain, swelling, and locking; however, the September 2015 VA examiner found no history of patellar dislocation or recurrent effusion. The examiner noted frequent episodes of joint pain as a symptom of a meniscal disorder, but indicated the absence of frequent episodes of locking and joint effusion. Accordingly, the Board finds that this competent medical evidence weighs against a finding the these symptoms of the left knee disorder more nearly approximate the criteria for a s20 percent rating under Diagnostic Code 5258. Nor is the Veteran entitled to a separate rating for a meniscal disorder under Diagnostic Code 5259. Because the Veteran's 10 percent rating under Diagnostic Code 5261 is based on painful motion (as it would be otherwise noncompensable based on limited range of motion), a separate rating for a meniscal disorder based on pain would constitute impermissible pyramiding. See 38 C.F.R. §§ 4.14, 4.71a, DC 5259; Esteban, 6 Vet. App. at 262. In other words, if the right knee disorder were evaluated as 10 percent disabling under Diagnostic Code 5259, the Veteran would not be entitled to a separate rating under Diagnostic Codes 5260 or 5261 based on painful motion, as pain is expressly contemplated by the rating criteria under Diagnostic Code 5259. The Board further finds that a separate and/or higher rating is not warranted under Diagnostic Codes 5256, 5257, or 5262, as the weight of the competent and probative evidence is against finding ankylosis, recurrent subluxation or lateral instability, or tibial or fibular impairment. See 12/03/2005, C&P Exam. All possibly applicable diagnostic codes have been considered in compliance with Schafrath, 1 Vet. App. at 593, but the Veteran could not receive a higher and/or additional evaluation for her left knee disability based on the evidence. See 38 C.F.R. § 4.71a. The Board notes that the benefit of the doubt has been applied, where applicable. D. Bilateral feet The Veteran contends that she is entitled to an initial compensable rating prior to September 17, 2015, and a rating in excess of 10 percent thereafter, for a bilateral foot disability, evaluated under Diagnostic Codes 5276-5280. Under Diagnostic Code 5276, a noncompensable rating is warranted for acquired flatfoot that is mild in severity, which is relieved by built-up shoe or arch support. A 10 percent rating is assigned for unilateral or bilateral moderate flatfoot, characterized by weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, and pain on manipulation and use of the feet. A 30 percent rating is warranted for bilateral severe flatfoot (and 20 percent for unilateral severe flatfoot) with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A maximum 50 percent rating is warranted for bilateral pronounced flatfoot (and 30 percent for unilateral pronounced flatfoot) with marked pronation, extreme tenderness of plantar surfaces, marked inward displacement and severe spams of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. Under Diagnostic Code 5280, a 10 percent disability rating is warranted for unilateral hallux valgus, if severe, equivalent to amputation of the great toe or if operated upon with resection of the metatarsal head. 38 C.F.R. § 4.71a, DC 5280. Diagnostic Code 5284 applies to non-specified feet disabilities and provides for a 10 percent rating for a moderate injury, a 20 percent rating for a moderately severe injury, and a 30 percent rating for a severe injury. 38 C.F.R. § 4.71a, DC 5284. After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 10 percent, but no higher, is warranted for the bilateral foot disability for the entire period on appeal. A November 2010 VA examination reflects the Veteran's report of pain of the great toes bilaterally and use of custom inserts. The Veteran denied limitations in walking or standing, swelling, or pain in the dorsum or plantar surface, and stated that she is still able to run. Regarding the right foot, the examiner noted tenderness to palpation of the metatarsophalangeal joint of the great toe, hallux valgus at a 26 degree angle, no abnormal weight bearing, and no abnormal shoe wear noted on the right tennis shoe. She had pain in her right great toe upon standing on her toes. Regarding the left foot, the examiner noted tenderness to palpation of the metatarsophalangeal joint of the great toe, the second toe overlapped onto the great toe, hallux valgus at a 28 degree angle, no other tenderness to palpation (to include plantar aspect, posterior heel, arch, and site of insertion of plantar fascia), no abnormal weight bearing, and no abnormal shoe wear noted on the left tennis shoe. The examiner opined that the Veteran had moderate hallux valgus on the left and slight hallux valgus on the right, with minimal degenerative changes at the first metatarsophalangeal joints bilaterally. 11/29/2010, VA Examination. A September 2015 VA examination reflects the Veteran's report of bilateral foot pain with flare-ups, intermittent swelling with exercise, and spasm. Functional impairment was described as affecting the ability to exercise. The examiner noted pain on use of feet and pain accentuated on use, but none of the following symptoms for either foot: pain on manipulation; swelling on use; characteristic calluses; extreme tenderness of plantar surfaces; decreased longitudinal arch height on weight bearing; marked deformity; marked pronation; weight-bearing line over or medial to great toe; inward bowing of achillis tendon; or marked inward displacement and severe spasm of achillis tendon. The examiner further noted that there was no pain on physical examination, and that pain can be related to wearing inappropriate footwear. The examiner found no functional loss of the bilateral lower extremities due to the bilateral foot disability and that pain, fatigue, instability, and weakness do not significantly limit functional ability during flare-ups or after repeated use over time. 12/03/2015, C&P Exam. The Board finds the November 2010 and September 2015 VA examinations to be competent, credible, and highly probative, as they are supported by in-person examinations, medical expertise, proper consideration of the Veteran's lay statements, and adequate rationales. Accordingly, the Board finds that the competent and probative evidence is at least in equipoise as to whether the symptoms of the Veteran's bilateral foot disability more closely approximate moderate pes planus, to include based on foot pain; over the entire period on appeal. Thus, a 10 percent rating is warranted prior to September 17, 2015. See 38 C.F.R. § 4.71a. However, the Board finds that a higher rating is not warranted under Diagnostic Code 5276, as the weight of the competent and probative evidence is against finding objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, extreme tenderness of plantar surfaces of the feet, or marked inward displacement and severe spasm of the tendo achillis on manipulation not improved by orthopedic shoes or appliances. In other words, the Board finds that the Veteran's disability picture does not more nearly approximate severe or pronounced flatfoot. See 38 C.F.R. § 4.71a, DC 5276. The Board also finds that a higher rating is not warranted under another diagnostic code, as the weight of the competent and probative evidence is against finding claw foot, malunion or nonunion of tarsal or metatarsal bones, or an unspecified moderate foot injury. The Board acknowledges the Veteran's report of pain of the bilateral feet and/or great toes and swelling, but notes that the Veteran is able to run and there is no indication of functional impairment other than in athletic activities. The 2015 VA examination report reflects that the impairment from the bilateral foot disability does not impact her ability to perform any type of occupational task. In other words, the reported symptoms are contemplated by the 10 percent rating for bilateral moderate pes planus. Accordingly, the Board finds that the Veteran's disability picture does not more nearly approximate a moderate foot injury of either foot. See 38 C.F.R. § 4.71a, DC 5284. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. § 4.71a. The benefit of the doubt has been applied as applicable. E. GERD The Veteran contends that she is entitled to an initial compensable rating for GERD with gastritis, evaluated under Diagnostic Codes 7307-7346. Under Diagnostic Code 7346, a 10 percent rating is applicable to conditions with two or more of the symptoms listed in the 30 percent criteria of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Finally, the maximum, 60 percent disability rating requires pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of serious impairment of health. 38 C.F.R. § 4.114, DC 7346. Under Diagnostic Code 7307, a 10 percent rating is warranted for chronic hypertrophic gastritis with small nodular lesions and symptoms. Chronic hypertrophic gastritis with multiple small eroded or ulcerated areas and symptoms warrants a 30 percent rating. Finally, the maximum, 60 percent rating requires chronic hypertrophic gastritis with severe hemorrhages, or large ulcerated or eroded areas. Atrophic gastritis is a complication of a number of diseases and is to be rated based on the underlying condition. 38 C.F.R. § 4.114, DC 7307. After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 10 percent, but no higher, is warranted for GERD for the entire period on appeal. The reasons with support evidence follows. A November 2010 VA examination reflects the Veteran's report of heartburn and feeling as if food is stuck in her throat whenever she does not take her GERD medication. In this regard, the Veteran stated that she takes Prilosec and indicated that it does help her symptoms. She also endorsed indigestion from acidic food, but denied other symptoms. The examiner noted normal swallowing function with mild esophageal dysmotility and a small sliding hiatal hernia with minimal reflux, concluding that the Veteran had minimal GERD with no stomach ulcers. 11/29/2010, VA Examination. In November 2011, the Veteran reported experiencing regurgitation and substernal pain, as well as heartburn and feeling as if food is stuck in her throat when she does not take her medication. 11/30/2011, NOD. In July 2014, the Veteran stated that she has recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, as well as small nodular lesions. Although the Veteran is competent to report symptoms such as regurgitation and heartburn, she is not competent to diagnose substernal pain or nodular lesions, as such requires medical expertise. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). Due to the lack of competence regarding these medically complex diagnoses, the Board finds the Veteran's statements lack weight on such matters. In September 2015, a VA examiner found no current symptoms associated with GERD. The VA examiner further indicated that the Veteran does not currently have, nor has she ever had, hypertrophic gastritis. 12/03/2015, C&P Exam. The Board notes that the ameliorative effects of medication cannot be considered when evaluating service-connected GERD. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012); see also Vanderslice v. Shulkin, No. 16-0305, 2017 U.S. App. Vet. Claims LEXIS 312, *2-3 (Mar. 3, 2017) (finding the holding in Jones applicable to evaluations for GERD). Indeed, the 2010 VA examination report reflects that the Veteran reported heartburn (pyrosis) and a feeling that food was stuck in her throat (difficulty swallowing), especially when she did not take Prilosec. Accordingly, the Board finds that the competent and probative evidence is at least in equipoise as to whether the Veteran's esophageal disorder results in dysphagia, pyrosis, and/or regurgitation, thus warranting a 10 percent rating. See 38 C.F.R. § 4.114, DC 7346. The Board finds that a higher rating is not warranted, as the weight of the competent and probative evidence is against finding persistently recurrent epigastric distress, or that GERD-related symptoms result in considerable impairment of the Veteran's health during the period on appeal. In this regard, the September 2015 VA examination report reflects that the Veteran did not have any of the listed signs or symptoms, to include, but not limited to, dysphagia, pyrosis, reflux, and substernal arm/shoulder pain, due to GERD or other esophageal conditions. The Board recognizes the Veteran's report of experiencing reflux, regurgitation, heartburn, and feeling as if food is stuck in her throat, but finds that these symptoms are contemplated by the 10 percent rating, which is assigned for two or more symptoms under the 30 percent rating of less severity. In other words, the Board finds that the Veteran's GERD-related symptoms do not result in considerable impairment of her health. A higher and/or separate rating under Diagnostic Code 7307 is not warranted, as the evidence does not demonstrate hypertrophic gastritis or small nodular lesions. See 38 C.F.R. § 4.114, DC 7307. To the extent the Veteran contends any of her claimed symptoms are due to gastritis, the rating criteria under Diagnostic Code 7346 allow for all other symptom combinations. Thus, a separate rating for gastritis based on such symptoms would constitute impermissible pyramiding. See 38 C.F.R. §§ 4.14 (pyramiding), 4.114 ("Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture."); Esteban, 6 Vet. App. at 262. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. § 4.1114. The benefit of the doubt has been applied as applicable. F. Scars of the anterior trunk and bilateral knees; Breast reduction residuals The Veteran contends that she is entitled an initial disability rating in excess of 10 percent prior to September 17, 2015, for scars of the anterior trunk, evaluated under Diagnostic Code 7804. She further claims entitlement to initial compensable ratings for scars of the right and left knees, evaluated under Diagnostic Code 7805, and breast reduction residuals, evaluated under Diagnostic Code 7802. A review of the pertinent diagnostic codes governing scars would be useful. Diagnostic Code 7800 applies to scars of the head, face, or neck. 38 C.F.R. § 4.118, DC 7800. As the scars of the trunk and knees are not of the head, face, or neck, Diagnostic Code 7800 is not applicable. Diagnostic Code 7801 provides for a compensable rating for scars other than of the head, face, or neck that are deep and nonlinear and cover an area of at least 39 square centimeters. 38 C.F.R. § 4.118, DC 7801. A deep scar is one associated with underlying soft tissue damage. Id., Note (1). Under Diagnostic Code 7802, a 10 percent evaluation is assigned for scars other than of the head, face, or neck that are superficial and nonlinear and that cover an area of at least 929 square centimeters. A 10 percent disability evaluation represents the maximum schedular rating available under Diagnostic Code 7802. 38 C.F.R. § 4.118, DC 7802. Diagnostic Code 7804 provides for a 10 percent rating for one or two scars that are unstable or painful; a 20 percent rating is warranted for three or four painful or unstable scars; and the maximum 30 percent rating is assigned for five or more scars that are painful or unstable. 38 C.F.R. § 4.118, DC 7804. Diagnostic Code 7805, which applies to other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804, instructs the rater to evaluate any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-7804 under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. 1. Scars of the anterior trunk prior to September 17, 2015 After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial disability rating of 20 percent, but no higher, is warranted for scars of the anterior trunk prior to September 17, 2015. A November 2010 VA examination indicates five scars of the anterior trunk resulting from a breast reduction and subsequent procedure to remove excess skin. The examiner found three of the scars to be tender to palpation. 11/29/2010, VA Examination. Accordingly, the Board finds that the competent and probative evidence is at least in equipoise as to whether there were three or four painful scars of the anterior trunk prior to September 17, 2015; thus, a 20 percent rating is warranted for that period. See 38 C.F.R. § 4.118, DC 7804; see also VBA Adj. Manual M21-1, III.iv.4.L.3.b (finding by a VA examiner that a scar is tender to palpation constitutes objective evidence of a painful scar). A higher 30 percent rating is not warranted as the evidence, to include that from the 2010 VA examination report, does not show 5 or more scars that are unstable or painful. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. § 4.118. The benefit of the doubt has been applied as applicable. 2. Residuals of breast reduction After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial compensable rating for residuals of breast reduction surgery is not warranted. The Veteran's original claim for residuals of breast surgery described the residuals as pain, numbness, and scars. 06/09/2010, VA 21-526. The Board finds that residuals of breast surgery are currently contemplated by the rating for service-connected scars of the anterior trunk, to include being unstable or painful. The five scars of the anterior trunk were identified as residuals of the Veteran's breast surgeries. To the extent that the Veteran claims numbness and/or pain of the nipples/areolas as residuals of breast surgery, the Board finds that those symptoms are also contemplated by the rating for scars of the anterior trunk, as some of the service-connected scars of the trunk involve and/or are in close proximity to the nipples. See 11/29/2010, VA Examination. Thus, a separate rating based on the same symptoms would constitute impermissible pyramiding. See 38 C.F.R. § 4.14; Esteban, 6 Vet. App. at 262. 3. Scars of the left and right knees After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that initial compensable ratings for scars of the right and left knees is not warranted. The November 2010 VA examiner noted a non-painful scar of the right knee measuring 8 centimeters by 1 centimeter, and four scattered 1 centimeter round scars. The examiner further identified two non-painful scars of the left knee both measuring 6 centimeters by 1 centimeter, and four scattered 1 centimeter round scars. There were no associated symptoms and the scars did not impact knee function. Additionally, none of the scars involve soft tissue damage. 11/29/2010, VA Examination. In a statement from the Veteran received by VA in July 2014, the Veteran stated that the scars of her knees were painful. 07/28/2014, VA 21-4138. However, the Veteran's subjective report of painful scars does not constitute objective evidence that the scars are painful. See VBA Adj. Manual M21-1, III.iv.4.L.3.b. While the M21-1 is not binding on the Board, it can be used for guidance. 38 C.F.R. § 19.5. The Board finds that the competent medical evidence obtained at the 2010 VA examination outweighs the Veteran's 2014 lay statement regard her knee scars. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding scars of the right and left knees that are painful, unstable, or larger than 39 square centimeters in area. The Board further notes that the maximum schedular rating for painful scars was assigned effective September 17, 2015; thus, a higher rating based on painful scars of the left and right knees cannot be assigned as of September 17, 2015. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. 589; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. § 4.118. The benefit of the doubt has been applied as applicable. ORDER Service connection for a corneal scar of the right eye is granted. Service connection for anemia is denied. Service connection for keloid scars of the breast is denied. An initial disability rating of 10 percent, but no higher, for chronic UTIs prior to June 6, 2013, is granted. An initial disability rating in excess of 10 percent for chronic UTIs as of June 6, 2013, and prior to July 28, 2014, is denied. An initial disability rating of 20 percent, but no higher, for chronic UTIs as of July 28, 2014, and prior to September 17, 2015, is granted. An initial disability rating in excess of 40 percent for chronic UTIs as of September 17, 2015, is denied. An initial disability rating of 20 percent, but no higher, for a right shoulder disability prior to September 17, 2015, is granted. An initial disability rating in excess of 20 percent for a right shoulder disability as of September 17, 2015, is denied. An initial disability rating in excess of 10 percent for a right knee disability is denied. An initial disability rating in excess of 10 percent for a left knee disability is denied. An initial disability rating of 10 percent, but no higher, for a bilateral foot disability prior to September 17, 2015, is granted. An initial disability rating in excess of 10 percent for a bilateral foot disability as of September 17, 2015, is denied. An initial disability rating of 10 percent, but no higher, for GERD with gastritis is granted. An initial compensable rating for a scar of the right knee is denied. An initial compensable rating for scars of the left knee is denied. An initial disability rating of 20 percent, but no higher, for scars of the anterior trunk prior to September 17, 2015, is granted. An initial compensable rating for residuals of breast reduction surgery is denied. ____________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs