Citation Nr: 1202514 Decision Date: 01/24/12 Archive Date: 02/07/12 DOCKET NO. 07-21 148 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to a higher initial evaluation for hypertension, currently assigned a 10 percent evaluation. 2. Entitlement to an initial compensable evaluation for hepatitis B. 3. Entitlement to an initial compensable evaluation for hepatitis C. 4. Entitlement to an initial compensable evaluation for hiatal hernia, gastroesophageal reflux disease (GERD), and esophageal stricture. 5. Entitlement to a higher initial evaluation for left knee patellofemoral pain syndrome, currently assigned a 10 percent evaluation. 6. Entitlement to an initial compensable evaluation for bilateral pes planus. 7. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION There is some conflict in the Veteran's dates of service, as reported on DD Forms 214 in the file. It is undisputed, however, that the Veteran had active duty from April 1977 to November 1985, and that he was discharged in June 2005 after more than 20 years of active duty. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a regional office (RO) rating decision of April 2006. Subsequently, in June 2008, the RO denied service connection for adjustment disorder/depression; as discussed in the REMAND below, this has been included as part of the expanded issue of service connection for an acquired psychiatric disability, to include PTSD. In December 2010, the originally assigned noncompensable rating for hypertension was increased to 10 percent, effective the day after separation from service in July 2005. That issue remains on appeal, a grant of less than the maximum available rating does not terminate the appeal, unless the veteran expressly states he is satisfied with the assigned rating. See AB v. Brown, 6 Vet.App. 35, 38 (1993). Although the Veteran has submitted evidence of medical disability, and made claims for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable, due to service-connected. Indeed, the file contains a medical report dated in March 2010 which specifically clears the Veteran for employment, including overseas employment. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU rating) has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The issue of service connection for bilateral plantar fasciitis has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over the claim, and it is referred to the AOJ for appropriate action. The issue of entitlement to an acquired psychiatric disability, to include PTSD, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Since the effective date of service connection, hypertension has been manifested by diastolic blood pressure readings predominantly less than 110, and systolic readings less than 200, with the use of medication required. 2. Since the effective date of service connection, hepatitis B has been asymptomatic. 3. Prior to June 28, 2006, hepatitis C was manifested by complaints of fatigue, without malaise, anorexia, or incapacitating episodes. 4. For the period from June 28, 2006, through April 30, 2007, the Veteran was undergoing interferon therapy for hepatitis C which resulted in medically established side effects causing symptoms comparable to daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly. 5. Beginning May 1, 2007, hepatitis C has been asymptomatic. 6. Since the effective date of service connection, hiatal hernia with GERD has been manifested by dysphagia and pyrosis (heartburn) with reflux, which requires constant medication to control. 7. Since the effective date of service connection, patellofemoral pain syndrome of the left knee has been manifested by flexion, at worst, slightly limited, and crepitation on motion, without limitation of extension, instability, or arthritis. 8. Since the effective date of service connection, pes planus, if present, is mild in degree and symptoms are relieved by orthotics. 9. The schedular criteria are adequate. CONCLUSIONS OF LAW 1. Since the effective date of service connection, the criteria for an evaluation in excess of 10 percent for hypertension have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7101 (2011). 2. Since the effective date of service connection, the criteria for a compensable evaluation for hepatitis B are not met, but the diagnostic code is changed. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7345 (2011). 3. For the period from June 28, 2006, through April 30, 2007, only, the criteria for a compensable evaluation of 40 percent are met, and the diagnostic code is changed. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7354 (2011). 4. Since the effective date of service connection, the criteria for a 10 percent rating for hiatal hernia with GERD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7346 (2011). 5. Since the effective date of service connection, the criteria for a rating in excess of 10 percent for patellofemoral pain syndrome of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.44, 4.45, 4.59, 4.71a, Diagnostic Code 5014-5260 (2011). 6. Since the effective date of service connection, the criteria for a compensable for bilateral pes planus have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.44, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notification and Assistance Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claims, and of his and VA's respective obligations in obtaining various types of evidence. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Such notice was provided in by a letter from the RO dated in January 2006, prior to the initial decision in this appeal. The rating issues in this case are initial rating issues, and the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); see also Sutton v. Nicholson, 20 Vet. App. 419 (2006). Nevertheless, in an August 2008 letter, the Veteran was informed of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., treatment records, or statements of personal observations from other individuals. He was informed that a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment. This notice was in accordance with Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008); other notice requirements mandated by that decision were found to be beyond the scope of notice required by the VCAA in a Federal Circuit Court decision which vacated that decision. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Specifically, the Federal Circuit held that that VCAA notice need not be veteran specific, or refer to the effect of the disability on "daily life." VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2011). The Veteran's service treatment records have been obtained, as have other treatment records identified by the Veteran, including VA treatment records and records of treatment at a military facility as a retiree. VA examinations were provided in April 2005, March 2008, June 2008, and October 2010, and were based upon consideration of the Veteran's prior medical history, including medical records and examinations and also describe the disability in sufficient detail for the Board to make an informed decision. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There is no evidence indicating that there has been a material change in the service-connected disorders addressed on the merits since this last evaluation. 38 C.F.R. § 3.327(a). Thus, the Board finds that all necessary notification and development has been accomplished, and therefore appellate review may proceed. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Higher Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A § 1155; 38 C.F.R. Part 4. Although the disability must be considered in the context of the whole recorded history, including service medical records, the present level of disability is of primary concern in determining the current rating to be assigned. See 38 C.F.R. § 4.2 (2011); Francisco v. Brown, 7 Vet. App. 55 (1994); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The period for consideration in this case extends from the effective date of the grant of service connection (July 1, 2005) to the present. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the disability has undergone varying and distinct levels of severity throughout this time period, staged ratings may be assigned. Id. Hypertension The Veteran contends that his blood pressure fluctuates a great deal, and is still not controlled despite two prescribed medications. Hypertension or isolated systolic hypertension with diastolic blood pressure of predominantly 100 or more, or systolic pressure predominately 160 or more, or a history of diastolic pressure predominately 100 or more which requires continuous medication for control, warrants a 10 percent evaluation. A 20 percent evaluation requires diastolic blood pressure of predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent evaluation is warranted for diastolic blood pressure of predominantly 120 or more, and a 60 percent evaluation is warranted for diastolic blood pressure of predominantly 130 or more. 38 C.F.R. § 4.104, Code 7101 (2011). On a VA examination in April 2005, the Veteran reported that his hypertension medication had been changed four months earlier. He complained of headache. He had no dizziness, chest pain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, or lower limb edema. On examination, blood pressures of 142/84, 144/86, and 138/80 were obtained. He was diagnosed as having hypertension on medication, with no complications. At a Decision Review Officer (DRO) hearing in February 2008, the Veteran stated that he still had blood pressure of 160/100 with medication. On a VA examination in March 2008, the Veteran said that his blood pressure had been slightly elevated over the past 4 to 5 months. He denied any history of renal insufficiency. He currently exercised 2 hours 3-4 times per week at a gym. His exercise regimen included aerobic activities, weightlifting, and calisthenics. Cardiac examination was normal. Blood pressure readings were 162/91, 161/90, and 186/102. On the VA examination in October 2010, the Veteran again denied dizziness, chest pain, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and lower limb edema. He had no subjective complaints, or complaints of functional impairment. On examination, blood pressure was 126/78. Examination of the heart was normal. He was diagnosed as having hypertension, on medication, no complications. Although the Veteran states that his hypertension has been difficult to control, a diastolic blood pressure of 110 or higher has only been indicated on one occasion since his discharge from service, in May 2006, when the Veteran obtained a reading of 160/110 at home. At that time, the Veteran's diastolic blood pressure was not predominantly 110 or more. Systolic blood pressures have all been below 200. Therefore, a rating in excess of 10 percent is not warranted. In this regard, neither the treatment records nor the examinations have disclosed any complications or functional limitations related to hypertension. Moreover, the Veteran's symptoms have not more closely approximated the criteria for a higher rating at any identifiable time during the appeal period, despite some fluctuations in blood pressure. In reaching this determination, the Board is mindful that all reasonable doubt is to be resolved in the Veteran's favor. The preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hepatitis B and C The rating schedule provides for hepatitis B, confirmed by serologic testing, to be rated under diagnostic code 7345. Hepatitis C, confirmed by serologic testing, is rated under diagnostic code 7354. For unknown reasons, the RO rated these conditions under diagnostic codes 7346 and 7345, respectively. The Board may change a diagnostic code, if the reason for the change is adequately explained. Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, for hepatitis B, the RO rated the condition under diagnostic code 7346, which pertains to hiatal hernia. Diagnostic code 7345, however, expressly includes hepatitis B. Moreover, the Veteran is separately service-connected for hiatal hernia with GERD, rated under diagnostic code 7346. As diagnostic code 7345 specifically includes hepatitis B, the diagnostic code for rating hepatitis B should be changed to 7345. With respect to hepatitis C, the RO rated this condition under diagnostic code 7345, which expressly pertains to liver conditions other than hepatitis C. Hepatitis C, on the other hand, is explicitly provided for in diagnostic code 7354. Not only does the rating schedule expressly provide that hepatitis C be rated under diagnostic code 7354, but under diagnostic code 7345 explicitly excludes hepatitis C. Therefore, the diagnostic code for rating hepatitis C must be changed to diagnostic code 7354. Despite these explicit provisions as to the diagnostic code under which to rate hepatitis B and hepatitis C, the rating criteria under diagnostic codes 7345 and 7354 are identical. For chronic liver disease, including hepatitis B (DC 7345), and for hepatitis C (DC 7354), manifested by intermittent fatigue, malaise, and anorexia, or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period, a 10 percent rating is warranted. A 20 percent evaluation contemplates daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. 38 C.F.R. § 4.114, Codes 7345, 7354. A 40 percent evaluation is assigned in cases of daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. A 60 percent evaluation is warranted for daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly. A 100 percent evaluation is assigned in cases of near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). Id. Under Diagnostic Code 7345 and 7354, an "incapacitating episode" means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. Id, Note (2). On a VA examination in April 2005, it was noted that the Veteran had positive hepatitis B and C tests in service. In January 1999, he underwent a liver biopsy, and the impression was moderate chronic hepatitis C with mild to moderate fibrosis, and he was subsequently given a course interferon therapy. He complained of feeling fatigued, with low energy level after walking for 30 minutes. He did not have nausea, vomiting, hematemesis, melena, loss of weight, change of color stool or urine, or abdominal pain. On examination, no hepatosplenomegaly was palpable. SGPT was elevated at 69. He was diagnosed as having positive hepatitis C and hepatitis B tests, with persistent chronic hepatitis. Naval medical center treatment records show the Veteran's treatment as a retiree after his discharge from active duty. From June 2006 to March 2007, he underwent a course of interferon treatment for hepatitis C, which resulted in a number of significant temporary side effects, including, at various times during the therapy, a pruritic dermatitis, fatigue, insomnia, diarrhea, nausea, and retinopathy, all of which were medically attributed to his interferon treatment, and which resolved subsequent to the cessation of the treatment. In April 2007, it was noted that the Veteran had an 80 percent chance of having been cured. No symptoms such as intermittent fatigue, malaise, and anorexia, or incapacitating episodes have been shown since that time. On a VA examination in March 2008, the Veteran said that he had been diagnosed as having hepatitis B in about 1997 and had been advised that this had resolved uneventfully. In the mid-1990s, hepatitis C was diagnosed, and he underwent treatment with interferon. He said he was treated with interferon and Ribavirin from April 2006 to February 2007 at the Naval Medical Center. He said he no longer had detectable amounts of hepatitis C. He estimated that his weight had increased from 184 to 191 pounds. He denied any symptoms suggesting incapacitating illness secondary to chronic liver disease, such as chronic nausea or vomiting, fatigue, malaise, arthralgia, or right upper quadrant pain. He was not currently undergoing any treatment. He said that he had been told that an ultrasound demonstrated improvement with shrinkage of a nodule of his liver. On examination, he was 70 inches tall and weighed 195 pounds. Liver panel within normal limits and alpha fetoprotein was less than 11.0. The diagnoses were status post hepatitis B with no sequelae, by history, and status post hepatitis C with favorable response to treatment, by history. On a VA examination in October 2010, the Veteran said that in 1998, he had been found to have positive hepatitis C antibody. He denied subjective complaints, but was concerned about relapses of hepatitis C infection with symptoms. On examination, he weighed 178 pounds. There was no hepatosplenomegaly, tenderness, dilated abdominal veins, ascites, or jaundice. Liver enzymes and hepatitis panel were obtained, and he was diagnosed as having hepatitis B core antibody which represented past infection of hepatitis B, and chronic hepatitis C infection, with no cirrhosis, asymptomatic. At the DRO hearing in February 2008, the Veteran described symptoms he said were side effects of chemotherapy for his liver condition, including skin conditions, insomnia, vomiting, and spots on his retina. He stated that these side effects were the major reason that his interferon treatment was discontinued. The medical evidence, as well as the histories provided by the Veteran on the VA examinations, however, indicates that he successfully completed his course of chemotherapy, and in April 2007, it was noted that there was an 80 percent chance of that his hepatitis C was cured. Nevertheless, the medical evidence bears out the Veteran's report of significant side effects during the course of treatment. These temporary side effects included a pruritic, dermatitis, fatigue, insomnia, diarrhea, nausea, and retinopathy, all of which were medically attributed to his interferon treatment, and which resolved subsequent to the cessation of the treatment. It is the Board's opinion that these symptoms were of sufficient severity as to warrant the assignment of a rating of 40 percent for the period from June 28, 2006, when the chemotherapy began, through April 30, 2007, by which time the side effects had largely resolved. The Board acknowledges that the side effects included symptoms, such as dermatitis and retinopathy, which are not included in the rating criteria for hepatitis. The symptoms of fatigue and nausea, however, were not alone of significant severity as to warrant a 40 percent rating; the Board finds that it was the side effects as a whole that resulted in symptoms analogous to the criteria for a 40 percent rating. Furthermore, inasmuch as these symptoms were medically determined to be a temporary side effect of the medication interferon, and fluctuated during the period of the chemotherapy, separate service connection for these non-chronic conditions is not warranted. Therefore, the solution which best fits the facts in this case is to rate the side effects based on overall impairment resulting from the side effects as a whole, which more closely approximates daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, contemplated for a 40 percent rating. See Mauerhan v. Principi, 16 Vet.App. 436 (2002). For the remainder of the appeal period, a compensable rating is not warranted. Prior to the initiation of the interferon therapy, the only symptom noted was fatigue, and he had an elevated SGPT; all other symptoms were denied. Since the resolution of the side effects after the completion of the interferon treatment, he has been asymptomatic. The most recent examination indicates his primary concern is a relapse or worsening of the condition in the future; if such occurs, he should file a claim for an increased evaluation. In sum, a staged rating of 40 percent for hepatitis C for the period from June 28, 2006, through April 30, 2007, is warranted. For the remainder of the appeal period, however, the preponderance of the evidence is against a compensable rating for hepatitis C. In reaching this determination, the benefit-of-the-doubt rule has been applied. See 38 U.S.C.A. § 5107(b). As no symptoms have been attributed to hepatitis B, the preponderance of the evidence is against a compensable rating for hepatitis B, for the entire appeal period. Hiatal Hernia with GERD The Veteran's service-connected condition has been identified by the RO as "hiatal hernia/gastroesophageal reflux/esophageal stricture at C5 level," although esophageal stricture has not been clinically identified. This condition has been rated under diagnostic code 7346, which pertains to hiatal hernia. Under that code, a 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Lastly, a 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Code 7346. On a VA examination in April 2005, the Veteran complained of heartburn and regurgitation of acid content of the stomach into the esophagus, especially when lying down after eating spicy and fatty food. The examiner noted that an upper endoscopy in December 2003 had shown mild hiatal hernia, question of short segment Barrett's esophagus, and normal gastroesophageal junction, stomach, and jejunum. He complained of heartburn with reflux after spicy, fatty, and acidic food. His symptoms were under control most of the time. There was no nausea, vomiting, hematemesis, or melena, but he had occasional dysphagia. He had no loss of weight. He was diagnosed as having no esophageal stricture due to C5 osteophytes, but as having hiatal hernia with gastroesophageal reflux disease (GERD). At his DRO hearing in February 2008, the Veteran indicated that his GERD was irregularly symptomatic. He said he had nausea 3 to 4 times a week. In an April 2008 report of a March 2008 VA examination, the Veteran said that he currently experienced gastroesophageal reflux which he treated daily with Nexium. He denied dysphagia, but said he took small bites as he found them easier to chew. He denied any problems with epigastric pain, hematemesis or melena, unexplained weight loss or cough. He stated that his weight had increased over the past year. Approximately a week prior to the examination, he had experienced some nausea, which had decreased secondary to increasing his Nexium to twice daily. He denied any esophageal symptoms which affected his usual activity or occupation. On examination, the Veteran was noted be well nourished and well developed. He was 70 inches tall and weighed 195 pounds. The examiner noted that in service, he had been found to have short segment Barrett's in 2003, and that he had not had an endoscopic test since 2003. An esophagram in April 2008 was negative. He was diagnosed as having GERD with history of hiatal hernia and Barrett's esophagus. On an October 2010 VA examination, the Veteran said that he had to watch his diet, or he would become symptomatic. On examination, he weighed 178 pounds. Abdominal examination was normal. He was diagnosed as having hiatal hernia with GERD, with symptoms controlled with Nexium. These examinations reflect that the Veteran suffers at times from dysphagia. He has reflux on occasion, which is often related to the type of food he has eaten, and whether he lies down after eating. Currently, his symptoms are largely controlled with the medication Nexium. The outpatient treatment records also note heartburn. Under these circumstances, with his history of dysphagia and pyrosis (heartburn) with reflux, which requires constant medication to control, the Board finds that the symptoms more closely approximate the criteria for an evaluation of 10 percent, but no higher. See 38 C.F.R. § 4.7. In this regard, there is no indication of symptoms suggesting considerable impairment of health. Further, there are no distinct periods of time during the appeal period during which hiatal hernia with GERD would warrant a higher rating. Although he was more symptomatic prior to taking Nexium, his symptoms still did not reach the point where they approximated the considerable impairment of health contemplated for a 30 percent rating. Instead, his symptoms before taking the Nexium consisted of the occasional dysphagia, heartburn, and reflux, without impairment of overall health, which more closely approximate a 10 percent rating. These symptoms are, for the most part, well-controlled with Nexium, but the Board finds that the need for constant medication to control the symptoms is analogous to the symptoms contemplated for a 10 percent rating, in this case. In reaching this determination, the benefit-of-the-doubt rule has been applied. See 38 U.S.C.A. § 5107(b). Pes Planus Pes planus, or flatfoot, is rated as a single condition, whether bilateral or unilateral; ratings for severe and pronounced disabilities are higher if the condition is bilateral. Mild pes planus, with symptoms relieved by built-up shoe or arch support, is rated noncompensable. Moderate pes planus, unilateral or bilateral, with weight-bearing line over or medial to great toe, inward bowing of the tendo Achilles, pain on manipulation and use of the feet, warrants a 10 percent rating. Severe pes planus, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, warrants a 20 percent rating if unilateral or a 30 percent rating if bilateral. For pronounced pes planus, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances, a 30 percent rating is warranted if unilateral; for a bilateral condition, a 50 percent rating is warranted. 38 C.F.R. Part 4, Code 5276 (2011). On a VA examination in April 2005, the Veteran said that he had worn orthotics off and on for the previous 22 years. He denied any specific injuries. He denied instability, incoordination, weakness, or fatigability. Examination showed that he had a mild degree of pes planus but was able to heel and toe walk without difficulty. He had minimal tenderness over the posteromedial heel in the region of the plantar fascia. He had minimal tenderness in the calcaneus. He had no abnormal shoe wear, and motor power was 5/5 to resistive plantar flexion, dorsiflexion, inversion, and eversion resistive strength testing of both feet. X-rays were normal. Outpatient treatment records from a military facility show that X-rays of the feet in May 2007 did not report pes planus. In August 2007, the Veteran sustained a fracture of the 5th phalangeal joint of the right foot; any manifestations of this injury are not part of the service-connected disability picture. At his February 2008 DRO hearing, the Veteran said that standing without his orthotics caused his feet to go numb. A VA examination in June 2008 disclosed complaints of painful feet, controlled with the use of orthotics. He said that the pain was in the plantar aspect of the longitudinal arch. On examination, there was tenderness to pressure in the plantar aspect of the longitudinal arch in both feet. Otherwise, findings were negative. There was no evidence of abnormal weight bearing; indeed, the examiner stated that there was no evidence of pes planus. X-rays of the feet demonstrated excellent arches without evidence of pes planus. The Veteran was diagnosed as having chronic plantar fasciitis without evidence of pes planus. On a VA examination in October 2010, the Veteran complained of bilateral foot pain, 5/10. He said symptoms at rest were 0/10, increasing to 5/10 with prolonged waking and standing of greater than a mile. He denied any flare-ups, surgery, or injections. He had been prescribed inserts in the 1980's. On examination, there was no evidence of callosity, skin breakdown, or unusual shoe wear. He had mild flat feet, and mild hallux valgus. Repetitive motion showed no increased pain, weakness, fatigability, or additional limitation of function secondary to repetitive motion. Sensory examination was normal except in the area of the big toe. The clinical impression was bilateral plantar fasciitis with no evidence of pes planus by radiographic examination. He had mild to moderate functional limitations with activities of daily living, especially with prolonged walking of more than a mile. As can be seen, there is conflicting evidence as to whether the Veteran even has pes planus. It is not severe enough to have shown up on X-rays, and abnormal weight-bearing has not been shown. At his hearing, he indicated that the orthotics relieved his symptoms, which were present when he stood in his bare feet. Symptoms relieved by orthotics are specifically contemplated by the noncompensable evaluation for mild pes planus. The two most recent VA examinations found that the Veteran had plantar fasciitis, but service connection is not in effect for this condition. The medical treatment records do not indicate that the condition is more symptomatic than reflected in the examinations. In sum, the Veteran's bilateral pes planus, if present, is no more than mild. The evidence does not more closely approximate the criteria for a compensable rating, and the preponderance of the evidence is against the claim for a compensable rating for pes planus. Further, there are no distinct periods of time during the appeal period during which pes planus would warrant a compensable rating. 38 U.S.C.A. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Left knee The RO has rated the Veteran's condition by analogy under diagnostic code 5014, which provides that osteomalacia is to be rated as arthritis. Degenerative or traumatic arthritis, established by X-ray findings, is rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Limitation of a leg (knee) flexion is rated 0 percent when limited to 60 degrees, 10 percent when limited to 45 degrees, 20 percent when limited to 30 degrees, and 30 percent when limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Limitation of extension of a leg (knee) is rated 0 percent when limited to 5 degrees, 10 percent when limited to 10 degrees, 20 percent when limited to 15 degrees, 30 percent when limited to 20 degrees, 40 percent when limited to 30 degrees, and 50 percent when limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Separate ratings may be assigned based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint. VAOPGCPREC 09-04, 69 Fed. Reg. 59990 (2004). Factors affecting functional impairment, such as pain on motion, weakened movement, excess fatigability, lost endurance, swelling, or incoordination, must also be considered, in evaluating a disability based on limitation of motion. See 38 C.F.R. §§ 4.40, 4.45 (2006), DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional impairment must be supported by adequate pathology. Johnson v. Brown, 9 Vet. App. 7, 10 (1996). On the VA examination in April 2005, the Veteran said that he had knee pain going up and down stairs, with prolonged standing, prolonged sitting, and with bending, stooping, squatting, and kneeling. On examination, he had no erythema or redness. Range of motion was from 0 to 140 degrees. He had positive crepitation throughout the entire range of motion. He had positive patellar compression and positive patellar inhibition tests. He had negative tenderness and negative McMurray's. He had a 1+ Lachman's with negative pivot shift. X-rays were normal. He was diagnosed as having left knee patellofemoral pain syndrome, chronic, with mild functional impairment. The left knee range of motion and joint function were not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use. On a VA examination in June 2008, the Veteran complained of left knee pain. He said he was able to stand for 15-30 minutes. There were no functional limitations on walking. He reported he had pain, but no deformity, giving way, instability, stiffness, or weakness. He reported a cracking sensation with deep knee bending, squatting. There were no episodes of dislocation, subluxation, or locking. He did not have effusion. There were no flare-ups. He had pain going down stairs. Gait was normal on examination. Range of motion was from 0 to 160 degrees. There was no additional limitation of motion on repetitive use. There were no significant clinical findings. X-rays of the left knee in June 2008 were unremarkable. He was diagnosed as having chronic patellofemoral syndrome, left knee. There were no significant occupational effects. On a VA examination in October 2010, he said he had had a rupture of his left tendo-Achilles in February 2009. He complained of left knee pain, 2.5/10. He had not had treatment for the knee since the last examination. He denied flare-ups. He said that his knee affected prolonged walking of more than one mile. On examination, there was no swelling and the knee was nontender. Range of motion was from 0 to 130 degrees. There was no evidence of instability by varus-valgus, Lachman, drawer or McMurray. Repetitive motion showed some mild cracking sensations but no pain, weakness, fatigability, or additional limitation of function secondary to repetitive range of motion. Strength was symmetric, and sensory examination was normal. He was diagnosed as having left knee patellofemoral syndrome with normal radiographic examination of the left knee. Although the RO identified the service-connected as "patellofemoral osteoarthritis," X-rays, in fact, have not demonstrated the presence of arthritis, and on all three examinations, the Veteran was diagnosed as having patellofemoral syndrome. Likewise, the remainder of the evidence does not show that osteoarthritis has been found in the left knee. In a recent decision, however, the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 4.59 , which concerns painful motion, was not limited to arthritis. Burton v. Shinseki, 25 Vet. App. 1 (2011). This regulation provides, in 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." 38 C.F.R. § 4.59. In this case the Veteran is already in receipt of the minimum compensable rating, i.e., 10 percent, for his left knee condition. The Veteran contended, at his February 2008 hearing, that he had limitation of motion in the left knee, as well as weakness, stiffness, and crepitation. He said that the knee became stiff and sore after use. He said that extension was limited by pain. Except for crepitation, however, the remainder of the evidence does not show such symptoms. On the examination 4 months later, in June 2008, he denied weakness and stiffness. Flexion was slightly below normal, at 130 degrees on the most recent examination in October 2010, but still considerably in excess of the 45 degrees warranted for even the 10 percent rating which is currently in effect. The objective evidence shows that the veteran has full or nearly full range of motion of the left knee, with no additional limitation due to pain. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet.App. 202 (1995). His manifestations of crepitation, and complaints of pain resulting in no more than mild functional impairment, do not more closely approximate a rating higher than 10 percent. As noted above, the medical evidence, as well as the Veteran's history as reported on the VA examinations, do not corroborate his contentions of limitation of extension made at the hearing. Limitation of extension, by pain or otherwise, has not been demonstrated. With respect to other potentially applicable diagnostic codes, the veteran does not have a dislocated or absent semilunar cartilage, nor has any subluxation or lateral instability been shown. Accordingly, a separate compensable rating under diagnostic code 5257, 5258, or 5259 is not warranted. The weight of the credible evidence establishes that the Veteran's left knee symptoms do not more closely approximate the criteria for a higher or separate rating. See 38 C.F.R. § 4.7. Moreover, there have been no periods of time, since the effective date of service connection, during which the left knee disability has been more than 10 percent disabling, and thus higher "staged ratings" are not warranted. As the preponderance of the evidence is against the claim for a higher rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz, supra; Gilbert, supra. III. Extraschedular Ratings The Board finds that the question of an extraschedular evaluation has not been raised with respect the higher rating claims addressed in this decision. See Barringer v. Peak, 22 Vet. App. 242 (2008); Thun v. Peake, 22 Vet. App. 111 (2008). The United States Court of Appeals for Veterans Claims (Court) has set forth a three-step analysis which provides additional guidance in determining whether referral for extraschedular consideration is appropriate. According to Thun, the initial step is a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In addressing the first step, the Board finds that the Veteran's symptoms are contemplated by the rating schedule, which provides for higher evaluations for the service-connected conditions at issue. The symptoms which were side effects of interferon therapy for hepatitis C have been rated on the basis of analogous impairment to the listed criteria. See Mauerhan. There is no symptomatology pertaining to any of the disabilities which the Board has not considered in its evaluations. Therefore, the ratings are adequate, and referral for extraschedular consideration is not required. Because the schedular criteria are adequate, it is not necessary to proceed to the second step, a discussion of whether the exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms," such as "marked interference with employment" and "frequent periods of hospitalization." Moreover, inasmuch as the schedular criteria are adequate, referral for extraschedular consideration is not appropriate in this case. ORDER Entitlement to a rating in excess of 10 percent for hypertension is denied. Entitlement to a compensable rating for hepatitis B is denied. Entitlement to a 40 percent rating for hepatitis C, for the period from June 28, 2006, through April 30, 2007, but only that period, is granted. Entitlement to a compensable rating for hepatitis C is otherwise denied. Entitlement to a 10 percent rating for hiatal hernia with GERD is granted. Entitlement to a rating in excess of 10 percent for patellofemoral syndrome of the left knee is denied. Entitlement to a compensable rating for pes planus is denied. REMAND With respect to the claim for an acquired psychiatric disability, this issue has been developed for appellate consideration solely as entitlement to service connection for PTSD. Service connection for adjustment disorder and depression was separately denied by the RO in a rating decision dated in June 2008, which the Veteran did not appeal. The United States Court of Appeals for Veterans Claims (Court), however, pointed out that the Veteran is not competent to diagnose his various conditions, in concluding, in a case involving service connection for PTSD when the record showed diagnoses of other mental conditions, that such conditions were part of the claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In that decision, the Court held that it is the symptoms, rather than the diagnosis, which defines the claim. In this regard, in his stressor statement, the Veteran said he had been "depressed" since the claimed in-service incident. Later, he filed a claim for service connection for adjustment disorder and depression, claiming that the condition was secondary to treatment received for service-connected hepatitis C. A separate theory of entitlement is not a new claim, however, and must be addressed as part of the current claim. See Bingham v. Principi, 18 Vet. App. 470 (2004) aff'd sub nom. Bingham v. Nicholson, 421 F.3d 1346 (Fed. Cir. 2005); Ashford v. Brown, 10 Vet. App. 120 (1997). The Veteran's current treatment records show an adjustment disorder as an ongoing problem, although recent treatment is not shown. The evidence, however, is sufficient to trigger the need for an examination concerning the claim for service connection for an acquired psychiatric disability, particularly inasmuch as the VA examination in 2005 did not address the question service connection for an acquired psychiatric disability other than PTSD. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA psychiatric examination to determine whether he has PTSD or other chronic acquired psychiatric disability, which had its onset during or is otherwise related to service, or to service-connected disability. Specifically, the diagnoses for all psychiatric conditions currently present should be identified. The examiner must address whether it is at least as likely as not that any such disorder had its onset during service, or is related to any events in service, including the claimed personal assault which reportedly occurred in July 1978. The opinion must also address whether any chronic acquired psychiatric disability is proximately due to or aggravated by service-connected hepatitis C, in particular, interferon therapy for hepatitis C provided from June 2006 to March 2007. The claims files must be available to the examiner for review in conjunction with the examination. 2. After completion of the above and any additional development deemed necessary, adjudicate the claim for service connection for an acquired psychiatric disability, to include PTSD, on a direct and secondary basis. If the VA examination concludes that PTSD or other acquired psychiatric disability is due to a specific in-service stressor or event, the RO must make a factual determination as to whether such event actually occurred. If the claim remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case, and afforded an opportunity to respond, before the case is returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs