Citation Nr: 0319648 Decision Date: 08/11/03 Archive Date: 08/25/03 DOCKET NO. 01-06 990A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an increased rating for hallux valgus of the left foot, with calluses, currently rated as 10 percent disabling. 2. Entitlement to an increased (compensable) rating for hallux valgus of the right foot, with calluses. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. Pomeranz, Associate Counsel INTRODUCTION The appellant had active military service from July 1970 to July 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a February 2001 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in St. Louis, Missouri. The Board observes that in March 2002, the appellant underwent a VA examination. At that time, it was noted that the appellant had a scar on the dorsum of his left foot over the first toe and first metatarsophalangeal joint due to recent surgery for his service-connected left foot disability. Thus, in light of the above, the Board finds that the evidence of record raises the issue of entitlement to service connection for a scar of the left foot. This issue has not been developed for appellate consideration and is referred to the RO for appropriate action. FINDINGS OF FACT 1. The appellant's service-connected hallux valgus of the left foot, with calluses, is manifested by "mild to moderate" discomfort and a limp on the left. 2. The appellant's service-connected hallux valgus of the left foot, with calluses, results in disability that is no more than moderate. 3. The appellant's service-connected hallux valgus of the right foot, with calluses, has not resulted in resection of the metatarsal head, is not equivalent to amputation of the great toe, and is less than moderate. CONCLUSIONS OF LAW 1. The schedular criteria for an evaluation in excess of 10 percent for hallux valgus of the left foot, with calluses, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5280, 5284 (2002). 2. The schedular criteria for an increased (compensable) rating for hallux valgus of the right foot, with calluses, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5280, 5284 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background In October 1994, the appellant underwent a VA examination. At that time, the examining physician stated that the appellant had calluses on the heads of his right first and fifth metatarsal bones. On the appellant's left foot, the examiner noted that the appellant had calluses on the heads of his first, second, and fifth metatarsal bones. The examiner stated that the appellant's calluses all measured about one-half by one-half inch and were slightly tender on deep palpation. He also noted that the appellant had calluses on the dorsums of the interphalangeal joints of both fifth toes. According to the examiner, the appellant reported that he had developed bunions about 10 years ago on both first metatarsophalangeal joints, and that the left was worse than the right. The examiner noted that there was a moderate lateral deviation of the appellant's first big toe on the left side because of the bunions, but that they were not tender to palpation. He indicated that when the appellant bent his toes, the second toe tended to overlap the big toe, but the right was worse than the left in regard to the overlapping. The appellant's gait was normal, and he could tiptoe and heel walk. There was no problem with supination or pronation of the feet. The diagnoses were the following: (1) calluses, diagnosed as plantar warts while in the service, on the head of the right foot and fifth metatarsal bone, and on the left first, second, and fifth metatarsal bones; also on the dorsum of the interphalangeal joint of the fifth toe, bilaterally, (2) bunions, bilaterally, with marked lateral deviation of the left big toe, and (3) fungal infection of the plantar surfaces of both feet and toenails. In a November 1994 rating action, the RO granted the appellant's claims of entitlement to service connection for calluses of the left foot, and entitlement to service connection for calluses of the right foot. The RO assigned a zero percent disability rating under Diagnostic Code 5284, effective from June 15, 1993, for the appellant's service- connected left foot disability, and a zero percent disability rating under Diagnostic Code 5284, effective from June 15, 1993, for the appellant's service-connected right foot disability. In March 1996, the RO received outpatient treatment records from the VA Medical Center (VAMC) in St. Louis, from November 1994 to July 1995. The records show intermittent treatment at the podiatry clinic for the appellant's service-connected bilateral foot disabilities. A VA examination was conducted in April 1996. At that time, the appellant stated that the VA had issued him shoes. The examining physician noted that the appellant was "kind of" favoring his left foot. The examiner indicated that according to the appellant, his calluses, especially the one on the head of the second metatarsal bone, were tender, and that he tended to walk on the lateral side of the foot. The examiner reported that the appellant's tendency to walk on the lateral side of his foot was shown by examining the appellant's shoes which showed that the lateral side of the heel of his shoe was "more eaten," bilaterally, but worse on the left. The appellant indicated that he sought treatment from the VA podiatry clinic and that he had the calluses scraped twice a year. According to the appellant, he also went to a private podiatrist, but he did not know the name of the podiatrist. Upon physical examination, the appellant could tip-toe with some discomfort on the left. Heel walk, supination, and pronation were all "okay." As far as the left foot, he did have a bunion which was "kind of" prominent. There was a nodulation of about one by one inch which was tender to palpation. The appellant also had a bunion on the right, but that was very mild and was non-tender. There was flexion on the first metatarsophalangeal joints, bilaterally, "and seem[ed] to be equal about five degrees," but he could not bend the interphalangeal joint of the left big toe. On the left foot, the calluses were on the heads of the first, second, and fourth metatarsal bones. The calluses were all tender, but the worst one was the one on the head of the second metatarsal bone. There was also another callous on the medial side of the distal part of the heel of the left foot which was tender on deep palpation. The bunion on the left had produced a hallux valgus, and the big toe "kind of" deviated laterally, which was not true on the right one. The appellant also had a callous on the left foot, on the distal phalanz of the third toe, on the undersurface of the third toe so that when he heel walked, there was some discomfort. On the dorsum of the interphalangeal joint of the fifth toe, there was another callous. The side of the big toe showed thickening of the skin and that was true on both big toes. In the appellant's April 1996 VA examination, upon physical examination of the appellant's right foot, there was a callous on the dorsum of the fifth toe, just like the one on the left fifth toe. In addition, there were also calluses on the heads of the first and fifth metatarsal bones on the undersurface of the foot. There was also some tenderness on deep palpation, and there was a slight thickening, like a callous, on the mid portion of the lateral side of the right foot. The diagnoses were the following: (1) bunion, left metatarsophalangeal joint, with hallux valgus, and with discomfort and tenderness on palpation of the bunion, (2) calluses on the heads of the left metatarsal bones of the first, second, and fourth toes, all tender but worse on the second metatarsal bone; also a callous on the dorsum of the fifth metatarsal bone, tip of the distal phalanx of the third toe, and also on the medial side of the distal heel; and (3) on the appellant's right foot, there were also calluses on the heads of the first and fifth toes, and on the dorsum of the interphalangeal joint of the fifth toe, and some thickening of the skin and callous on the mid portion of the foot. The examiner noted that in regard to the appellant's left foot calluses, because of the pain on those calluses, especially the one on the second metatarsal bone, the appellant tended to walk on the lateral side of the foot to prevent pressure on it. Thus, in summary, the examiner stated that the appellant had calluses on both feet that were producing some discomfort and making him walk more on the lateral side of the foot. The examiner reported that although the appellant was given special shoes which helped "a little bit," the shoes were "not helping totally." In a May 1996 rating action, the RO increased the appellant's disability rating for his service-connected left foot condition, from zero percent to 10 percent disabling under Diagnostic Code 5284, effective from February 14, 1996. In March 1999, the appellant underwent a VA examination. At that time, he stated that he had a history of plantar warts. He indicated that at present, he had a lot of pain with walking due to his warts, and that he wore corrective shoes. The appellant noted that he trimmed the warts himself. He reported that his difficulties with prolonged standing inhibited his ability to find steady work. Upon physical examination, there was no pain with range of motion, and there was no edema, instability, weakness, or tenderness. There was no joint swelling, and the appellant's gait was normal. The appellant had dry skin and his pulses were good in the feet. He did not have hammertoes. The appellant had three plantar warts located on the bottom of the left foot and two on the bottom of the right foot. There was pain with palpation. The diagnosis was plantar warts bilaterally, with valgus deformity of 25 degrees noted on the left. At the time of the appellant's March 1999 VA examination, the appellant had x-rays taken of his feet. The x-rays were interpreted as showing bilateral hallux valgus, much worse on the left, with early degenerative changes in the first left metatarsophalangeal joint. It was also noted that the changes in the left first metatarsophalangeal joint showed slight progression when compared to October 1994 x-rays. Following a review of the x-rays, the examiner from the appellant's March 1999 VA examination provided an addendum to the March 1999 VA examination report and diagnosed the appellant with early degenerative joint disease (DJD) of the first left metatarsophalangeal joint. The examiner noted that the appellant's DJD was not related to his calluses. The examiner also reported that the appellant's valgus deformity was not related to his warts/calluses. In November 2000, the appellant requested that his service- connected bilateral foot disabilities be reevaluated for higher ratings. At that time, he submitted a private x-ray report from A.M.J., D.P.M., dated in September 2000. The report shows that at that time, the appellant had x-rays taken of his left foot and right foot. The x-rays were interpreted as showing the following: (1) hallux rigidus, acquired, (2) hallux valgus, acquired, (3) porokeratoma, and (4) viral warts. A VA examination was conducted in January 2001. At that time, the appellant stated that he was currently working full time as a manual laborer for a local townhouse apartment complex. The appellant indicated that his job involved a lot of walking, bending, stooping, and repair work which necessitated long hours on his feet. According to the appellant, his employment aggravated his service-connected left and right foot disabilities, and caused him to develop pain, tenderness, and swelling, along with lack of endurance, in his feet. The appellant complained of frequent foot pain which was made worse by prolonged standing and walking. He revealed that his treatment included nonsteroidal, anti- inflammatory, over-the-counter drugs, daily warm foot soaks, and callous and corn products from Dr. Scholls. The appellant noted that he had to wear shoes that were at least three sizes too big to accommodate the numerous bunions, corns, and cushions which were on his feet. Upon physical examination, the examiner noted that the appellant's gait was one of limping in nature, favoring the right leg. The skin on both lower extremities was warm to the touch, and extremely dry and scaly in nature. Flexion of the forefoot was limited by 45-50 degrees. The appellant was having trouble flexing his toes upon command. He was unable to toe or heel walk, and when strongly encouraged to do so, he had difficulty with pain and loss of balance. There was slight edema and the pulses were 2+, bilaterally and equally, and vibratory senses were intact. The right foot had calluses on the plantar surface, with a total of four on the bony prominences. The appellant had a corn on the fifth digit and a bunion on the great toe. The left foot appeared worse than the right. The appellant had a larger bunion over the first digit of the metatarsophalangeal joint. There was a corn on the fifth digit, and there were viral warts on the plantar surfaces of his feet at the first and fifth digits. The diagnoses were the following: (1) degenerative joint disease of the left foot involving the first metatarsophalangeal joint, with reduced joint space; moderate hallux valgus with tenderness over the medial bony prominence, (2) right foot mild degenerative joint disease hallux vulgaris, bunion, corn, calluses, (3) bilateral viral warts on the plantar surfaces, and (4) dyshidrosis. X-rays of the appellant's feet were interpreted as showing the following: (1) bilateral hallux valgus, more marked on the left, and (2) degenerative changes, bilateral, first metatarsophalangeal joints. In January 2001, the RO received a private medical statement from Dr. A.M.J, dated in September 2000. In the letter, Dr. J. stated that he had recently examined the appellant for complaints of constant pain in both of his feet, with the left foot being more symptomatic than the right foot. Dr. J. noted that according to the appellant, he had used custom- made orthotics at one time, but that he had not experienced any relief from the pain. The appellant noted that he had received regular care at the VA for many years. He reported that they would routinely debride his plantar lesions, as well as the lesion over the left bunion, and that he would debride the lesion himself with a straight blade razor in the interim. According to the appellant, he stopped such care six months ago. The appellant revealed that the pain was very debilitating and that he was having a hard time at work due to the constant pain. In the September 2000 letter from Dr. J., Dr. J. noted that physical examination of the appellant's feet revealed 5/5 in all directions, with the exception of eversion, which the appellant was 3/5 bilaterally, with the left being less strong than the right. Upon weightbearing, there was a slight collapse in the appellant's arch. Upon range of motion of the left hallux, there was a decrease in dorsiflexion. Also, crepitus was noted at the sesamoids plantarly on the left hallux with range of motion, as well as palpation. Pain was palpated dorsally directly over the dorsomedial bump, as well as the sesamoids. On the right hallux, there was a dorsomedial bump with less intensity compared to the left side. It was also painful to palpation on the dorsomedial bump and upon range of motion. Both halluces elicited pain upon resisted dorsiflexion and plantar flexion. X-rays revealed shortened first metatarsals, with the left being shorter than the right. There were also some arthritic changes including cystic changes on the dorsomedial bump, as well as a medial spurring and increased calcifications of the tibial sesamoid. In addition, there was a decrease in joint space indicating arthritic changes on the left joint, as well as some arthritic changes and joint space narrowing on the right first metacarpophalangeal joint, with the left being increased in deformity compared to the right. There was a slight increase in intermetatarsal (IM) angle, bilaterally. The halluces were also significantly shorter compared to the second digit. The dorsomedial prominence of the left foot had increased hyperkeratotic and hyperpigmented tissue that significantly rubbed against the appellant's shoe while ambulating. The right dorsomedial bump had slight erythematous changes, much less compared to the left side. The impression was hallux valgus, bilaterally, with the left being more symptomatic and increased deformity compared to the right, as well as tylomas and intractable plantar keratosis (IPK) lesions, as previously noted, of which all lesions were painful to palpation. In an August 2001 supplemental statement of the case (SSOC), the RO recharacterized the appellant's service-connected calluses of the left foot as hallux valgus of the left foot, with calluses. In addition, the RO also recharacterized the appellant's service-connected calluses of the right foot as hallux valgus of the right foot, with calluses. In October 2001, the RO received an Operative Report, dated in September 2001, from the Forest Park Hospital. In the report, it was noted that the appellant had been diagnosed with the following: (1) hallux limitus of the left first metatarsophalangeal joint, and (2) plantar verrucae, multiple spots, bilateral feet. According to the report, in September 2001, the appellant underwent the following operations: (1) carbon dioxide laser excision of plantar verrucae, three on the left and two on the right, and (2) left first metatarsophalangeal joint arthroplasty, with implantation of double-stem Swanson great toe implant with titanium grommets. In a February 2002 rating action, the RO determined that the appellant was entitled to a temporary 100 percent evaluation under 38 C.F.R. § 4.30 for convalescence following surgery of the left foot, from September 20, 2001 to November 30, 2001. The RO further noted that from December 1, 2001, the appellant's 10 percent evaluation for his service-connected left foot disability would be reinstated. In March 2002, the appellant underwent a VA examination. At that time, he stated that he currently worked as a porter at an apartment building. The examiner noted that in September 2001, the appellant underwent a left first metatarsophalangeal joint arthroplasty, with implantation of double stem Swanson toe implant, with titanium grommets, as well as carbon dioxide laser excision of plantar verrucae of three on the left foot and two on the right foot. The appellant revealed that he had constant pain in his feet, and that the pain was aggravated with prolonged walking or standing. He reported that he took medication and that he had to wear wider shoes. According to the appellant, flare- ups occurred intermittently and could last from several hours to all day "to a severity of 7/10." The effects of his flare-ups on his daily activities were that he often had to take an extra break at work. He denied any additional functional impairment during a flare-up. Upon physical examination, the appellant's right foot had very dry skin on the plantar surface of the foot and heel. There was a thickening of the skin at an area of one centimeter (cm.) in diameter, at three cm. below the first metatarsophalangeal joint and below the fifth toe where the plantar verrucae were removed. In regard to flexion of the first metatarsal, dorsiflexion was to 10 degrees and plantar flexion was to 10 degrees as well. The other toes were actively flexed without any pain. There were calluses on the lateral fifth toe and the lateral aspect of the second toe. There was also a callus on the lateral first toe. There was enlargement of the first metatarsophalangeal joint on the right foot, as well. Pedal pulse was 2+. There was decreased plantar flexion of the second toe, but the others moved normally. There was normal ankle range of motion, and there was no evidence of hammertoes, high arch, claw foot, or flat foot. On the left foot, there was an eight cm. scar on the dorsum of the foot over the first toe and first metatarsophalangeal joint. There was moderate edema in the joint area and some slight redness of the scar. The appellant was unable to actively move the first toe. However, passive dorsiflexion was to 10 degrees, with plantar flexion to five degrees in that first toe. Active flexion of the other toes was normal. There was mild hallux valgus of the first toe. The scar and the swollen area at the first metatarsophalangeal joint were somewhat sensitive to touch and to movement. The left foot was also noted to have dry skin, but with less calluses than on the right foot. The appellant was unable to stand or walk on his toes due to discomfort, but walking on his heels "was not a problem." Ambulation barefoot caused a limp on the left foot. However, the examiner noted that when the appellant walked from the waiting room wearing his shoes, there was minimal limp. There was no evidence of high arch, hammertoes, or claw foot on the left foot, and no evidence of flatfoot. The diagnoses were the following: (1) status post first metatarsophalangeal joint arthroplasty, with implant, with decreased range of motion and persistent mild to moderate discomfort, and (2) status post excision and bilateral plantar verrucae. At the time of the appellant's March 2002 VA examination, x- rays were taken of the appellant's feet. The x-rays were interpreted as showing the following: (1) a joint replacement at the left first metatarsophalangeal joint, with adjacent soft tissue swelling, but with no evidence of instability or bone destruction, and (2) mild degenerative changes at the right first metatarsophalangeal joint which were stable compared to the January 2001 study. II. Analysis Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2002). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2002). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2002). Although the evaluation of a service-connected disability requires a review of the appellant's medical history with regard to that disorder, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). As previously stated, the RO has assigned a 10 percent disability rating under Diagnostic Code 5284 for the appellant's service-connected left foot disability, and a zero percent disability rating under Diagnostic Code 5284 for the appellant's service-connected right foot disability. Under Diagnostic Code 5284, moderate residuals of foot injuries warrant a 10 percent evaluation. A 20 percent evaluation requires moderately severe residuals. A 30 percent evaluation is warranted when severe residuals of foot injuries are shown. A 40 percent evaluation requires that the residuals be so severe as to result in actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2002). The appellant's bilateral foot disabilities may also be rated under Diagnostic Code 5280. Under Diagnostic Code 5280, unilateral hallux valgus is assigned a 10 percent rating when there has been surgery involving resection of metatarsal head, or when the condition is severe, if equivalent to amputation of the great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5280 (2002). To summarize, the appellant maintains that his current ratings are not high enough in light of the disability that his bilateral foot disabilities cause him. He indicates that he has chronic pain in his feet which is aggravated with prolonged walking or standing. In this regard, lay statements are considered to be competent evidence when describing symptoms of a disease or disability or an event. However, symptoms must be viewed in conjunction with the objective medical evidence of record. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In regard to the appellant's service-connected left foot disability, as stated above, the appellant is currently receiving a 10 percent disability rating for his service- connected left foot disability, characterized as hallux valgus of the left foot, with calluses. The Board notes that under Diagnostic Code 5280, a 10 percent disability represents the maximum rating allowed for hallux valgus. This being the case, higher schedular ratings are possible for the appellant's left foot disability only if application of another diagnostic code is warranted. The Board notes that as previously stated, Diagnostic Code 5284 allows for rating of other injuries of the foot, and a 20 percent evaluation is assigned for moderately severe foot injuries. The Board has reviewed the evidence of record in light of the rating criteria and finds that the evidence does not support a finding that the appellant suffers from moderately severe foot symptoms in his left foot. In this regard, the Board recognizes that in the appellant's April 1996 VA examination, he was diagnosed with a bunion of the left metatarsophalangeal joint, with hallux valgus, and with discomfort and tenderness on palpation of the bunion. The appellant was also diagnosed with numerous calluses, and the examiner stated that because of the pain on those calluses, especially the one on the second metatarsal bone, the appellant tended to walk on the lateral side of the foot to prevent pressure on it. Thus, the examiner concluded that the appellant had calluses on both feet that were producing some discomfort and making him walk more on the lateral side of the foot. The Board also recognizes that in appellant's March 1999 VA examination, he was diagnosed with plantar warts, bilaterally, with valgus deformity of 25 degrees noted on the left. In addition, in the appellant's January 2001 VA examination, the appellant's gait was one of limping in nature, favoring the right leg. However, the Board notes that the appellant's left foot disability was characterized as "moderate" hallux valgus, with tenderness over the medial bony prominence. X-rays of the appellant's feet were interpreted as showing bilateral hallux valgus, more marked on the left. The Board further recognizes that in the September 2000 private medical statement from Dr. J., Dr. J. diagnosed the appellant with hallux valgus, bilaterally, with the left being more symptomatic and increased deformity compared to the right, as well as tylomas and IPK lesions, of which all lesions were painful to palpation. However, the Board notes that in the appellant's most recent VA examination, dated in March 2002, the appellant was diagnosed with left foot, status post first metatarsophalangeal joint arthroplasty, with implant, with decreased range of motion and his discomfort was characterized as "persistent mild to moderate discomfort." Furthermore, although ambulation barefoot caused a limp on the left foot, the examiner noted that when the appellant walked from the waiting room wearing his shoes, there was "minimal" limp. In light of the above, the Board concludes that there is no evidence that the appellant's hallux valgus of the left foot, with calluses, is more than of a moderate degree. Accordingly, the Board finds no basis on which to assign a higher evaluation under Diagnostic Code 5284 (foot injury) for the appellant's service-connected left foot disability. Such a conclusion is consistent with the sort of disability contemplated by the criteria for a 10 percent rating for the left foot. In other words, concluding that the appellant's left foot disability is tantamount to no more than moderate foot disability is consistent with a conclusion that the sort of problems he experiences are no more disabling than those caused by "severe" hallux valgus. While the Board recognizes that the due to the appellant's left foot disability, the appellant walks with a limp on the left, the Board also notes that the examiner in the appellant's March 2002 VA examination described the limp as a "minimal" limp. In addition, the examiner described the appellant's discomfort from his service-connected left foot disability as "mild to moderate" discomfort. Moreover, the examiner from the appellant's January 2001 VA examination characterized the appellant's service-connected hallux valgus of the left foot as "moderate." Thus, the Board finds that the above evidence suggests that the appellant in fact deserves a rating no greater than a claimant might receive for severe hallux valgus equivalent to an amputation. In other words, even when his functional loss due to pain is taken into account, it is not tantamount to greater than moderate injury. 38 U.S.C.A. §§ 4.40, 4.45 (2002). Consequently, the Board concludes that an evaluation in excess of 10 percent under Diagnostic Code 5284 for the appellant's service- connected left foot disability is not warranted. The preponderance of the evidence is against the claim. In regard to the appellant's service-connected right foot disability, the Board finds that the preponderance of the evidence is against the claim for a compensable evaluation for a right foot disability, characterized as hallux valgus of the right foot, with calluses. The Board notes that, as previously stated, in order to be entitled to a higher rating (compensable) under Diagnostic Code 5280, the medical evidence must show that there has been surgery involving resection of metatarsal head, or show that the condition is severe, if equivalent to amputation of the great toe. The Board notes that the evidence of record is negative for any evidence showing that the appellant has undergone any type of surgery with respect to his service-connected right foot disability. In addition, there is no evidence of record indicating that the appellant's service-connected hallux valgus of the right foot, with calluses, is severe of such a degree that it is equivalent to amputation of a great toe. In this regard, the Board notes that in the appellant's April 1996 VA examination, he was diagnosed with calluses, and in the appellant's January 2001 VA examination, the pertinent diagnosis was right foot mild degenerative joint disease hallux vulgaris, bunion, corn, and calluses. In addition, in the September 2000 private medical statement from Dr. J., the appellant was diagnosed with hallux valgus, bilaterally, with the left being more symptomatic and increased deformity compared to the right, as well as tylomas and IPK lesions of which all lesions were painful to palpation. In light of the above, the Board recognizes that the appellant's numerous VA examinations and the September 2000 private medical statement from Dr. J. show that he continues to suffer from hallux valgus of the right foot with calluses which are sometimes tender or painful. However, given that the Board has found that the appellant's service-connected left foot disability is not tantamount to greater than moderate injury, and also given that the appellant's right foot disability has been consistently described as less symptomatic than his left foot disability, the Board finds that there is no evidence of record showing that the appellant's hallux valgus of the right foot, with calluses, is severe of such a degree that it is equivalent to amputation of a great toe (Diagnostic Code 5280), or that it amounts to disability that warrants a characterization of "moderate," as that term is used in Diagnostic Code 5284. The term "moderate" is not specifically defined by the regulation. However, the Board notes that as previously stated, a 10 percent rating (which is the rating assignable under Diagnostic Code 5284 for "moderate" foot injury) may also be assigned in cases where there is hallux valgus that has been surgically corrected with resection of a metatarsal head, or hallux valgus of such a degree that it is equivalent to amputation of a great toe. See 38 C.F.R. § 4.71a, Diagnostic Code 5280. Thus, although the appellant's right foot disability may be intermittently symptomatic to some extent, given that his right foot disability has been consistently described as less symptomatic than his left foot disability, and that the appellant's left foot disability has not been shown to be more than of a moderate degree, the Board finds that his hallux valgus of the right foot, with calluses, does not rise to such levels. In addition, the Board also finds that even when the appellant's functional loss due to pain is taken into account, it is not tantamount to moderate injury. 38 U.S.C.A. §§ 4.40, 4.45 (2002). In light of the above, absent a finding of surgery involving resection of the right metatarsal head, or more objectively manifested pathology as stipulated by Diagnostic Code 5280, or any clinical indication that the service-connected right foot disability equates to moderate foot disability under Diagnostic Code 5284, the Board finds that the service- connected hallux valgus of the right foot, with calluses, does not warrant an evaluation in excess of zero percent under either Diagnostic Code 5280 or Diagnostic Code 5284. Therefore, the Board concludes that the preponderance of the evidence is against the appellant's claim for an increase. (When the rating criteria do not provide for a zero percent rating, a zero percent rating will be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31 (2002).) Finally, with respect to both feet, as there is no evidence of service-connected flatfeet, weak foot, claw foot, hallux rigidus, hammer toe, or malunion or nonunion of the tarsal or metatarsal bones, Diagnostic Code 5276, 5277, 5278, 5281, 5282, and 5283 are not for application. In addition, the Board further notes that although the evidence of record shows that the appellant has arthritis in both of his feet, the Board observes that the appellant is not service- connected for arthritis of either foot. The Board also finds that the evidence does not show an exceptional or unusual disability picture as would render impractical the application of the regular schedular rating standards. See 38 C.F.R. § 3.321 (2002). The current evidence of record does not demonstrate that the appellant's bilateral foot disabilities have resulted in frequent periods of hospitalization or in marked interference with employment. § 3.321. It is undisputed that his problems have an adverse effect on employment, but it bears emphasis that the schedular rating criteria are designed to take such factors into account. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] 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 (2002). Therefore, given the lack of evidence showing unusual disability not contemplated by the rating schedule, the Board concludes that a remand to the RO for referral of this issue to the VA Central Office for consideration of an extraschedular evaluation is not warranted. In deciding this case, the Board has considered the applicability of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096, et seq. (2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002), which became effective during the pendency of this appeal. It is the Board's conclusion that the new law does not preclude the Board from proceeding to an adjudication of the claims addressed above. The Board finds that further action by the RO in accordance with the VCAA is not necessary in this case. This is so because the requirements of the law have been satisfied. First, VA has a duty to notify the appellant and his representative of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102 and 5103 (West 2002); 38 C.F.R. § 3.159(b) (2002). In this regard, the Board notes that there is no indication that there is additional evidence that has not been obtained and that would be pertinent to the present claims. The evidence of record includes the appellant's service medical records, a VA examination report, dated in October 1994, outpatient treatment records from the St. Louis VAMC, from November 1994 to July 1995, a VA examination report, dated in April 1996, a VA examination report, dated in March 1999, a private x-ray report from Dr. J., dated in September 2000, a private medical statement from Dr. J., dated in September 2000, a VA examination report, dated in January 2001, an Operative Report from the Forest Park Hospital, dated in September 2001, and a VA examination report, dated in March 2002. In addition, the appellant has been afforded the opportunity to present evidence and argument in support of the claims. Moreover, in a letter from the RO to the appellant, dated in April 2003, the appellant was informed of the enactment of the VCAA and its content. The Board also finds that the discussions in the rating decisions, the statement of the case, the supplemental statements of the case, and in the letters sent to the appellant from the RO during the course of the appeal have informed him of the pertinent law and regulations, and information and evidence that would be needed to substantiate his claims. See 38 U.S.C.A. § 5103 (West 2002). Additionally, these documents have indicated to the appellant what would be required of him, and what evidentiary development VA would undertake on his behalf. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In this regard, the Board notes that as previously stated, in the March 2003 SSOC, the appellant was provided with notice of the change in the rating criteria for evaluating the skin. Second, VA has a duty to assist the appellant in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2002). In this regard, the Board notes that the RO has afforded the appellant VA examinations pertinent to his service-connected bilateral foot disabilities. In addition, the Board recognizes that in the March 1999 VA examination report, it was noted that the appellant had a podiatry appointment at the Jefferson Barracks on March 11, 1999. However, the Board notes that a list of the appellant's appointments reflects that he did not report to his March 1999 appointment at Jefferson Barracks. Thus, in sum, the facts relevant to this appeal have been fully developed and there is no further action to be undertaken to comply with the provisions of the VCAA or the implementing regulations. ORDER Entitlement to an evaluation in excess of 10 percent for hallux valgus of the left foot, with calluses, is denied. Entitlement to an increased (compensable) rating for hallux valgus of the right foot, with calluses, is denied. ____________________________________________ Robert E. Sullivan Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.