Citation Nr: 1549855 Decision Date: 11/25/15 Archive Date: 12/03/15 DOCKET NO. 11-23 832A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating higher than 10 percent for dermatitis of the right arm, axilla, and neck. 2. Entitlement to an initial compensable rating for alopecia. 3. Entitlement to an initial rating higher than 10 percent for hemorrhoids. 4. Entitlement to an initial compensable rating for right foot bunion with postoperative hammertoe deformity, right fifth digit. 5. Entitlement to an initial compensable rating for left foot bunion with postoperative hammertoe deformity, left fifth digit. 6. Entitlement to service connection for a bilateral knee disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from October 1985 to October 1993, April 1994 to September 1994, December 1995 to November 2000, and December 2000 to December 2009. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In April 2010 the RO granted service connection for dermatitis of the right arm and axilla, and alopecia and assigned 0 percent ratings, effective January 1, 2010. The RO also denied service connection for disabilities of the bilateral knees. The RO granted service connection for hemorrhoids and bilateral fifth toe hammertoe deformities in an August 2011 rating decision, assigning noncompensable (0 percent) ratings, effective January 1, 2010. In April 2013, the Veteran testified before the undersigned Veterans Law Judge at a Board hearing in Washington, DC, regarding the initial rating claims for dermatitis of the right arm and axilla and alopecia, and service connection for bilateral knee disabilities. The Veteran separately appealed the other claims on appeal and did not request a Board hearing in those matters. In May 2014 the Board remanded the claim for additional development, including to provide examinations addressing the present severity of the dermatitis of the right arm and axilla, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities, and to clarify whether the Veteran had arthritis in her knees. After the requested examinations were provided, the RO granted an increased rating of 10 percent for dermatitis of the right arm, axilla, and neck, and an increased rating of 10 percent for hemorrhoids. Both ratings are effective January 1, 2010. The case is now returned for appellate review. The issue of service connection for a bilateral knee disability is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's dermatitis of the right arm, axilla, and neck covers 5 to 20 percent of both, the exposed area and entire body; and the Veteran only uses topical corticosteroids, not systemic corticosteroids or other systemic immunosuppressive medication. 2. The Veteran's scarring alopecia affects less than 20 percent of the scalp, but does involve one of the characteristics of disfigurement in that the scarring measures 2 cm (i.e., at least 0.6 cm) in width at its widest. 3. The Veteran's hemorrhoids are moderate, and irreducible, with excessive redundant tissue evidencing frequent recurrences; but there is no evidence of persistent bleeding with secondary anemia due to hemorrhoids, or fissures on examination. 4. The impairment associated with the Veteran's bilateral fifth hammertoe deformities is more akin to a moderate foot disability, including pain, swelling, and stiffness in the metatarsal joints, with flare-ups occurring weekly or more often; difficulty standing or walking for prolonged periods and inability to run due to pain in the bilateral fifth digits; tenderness and abnormal weightbearing, pain on movement, pain on weight-bearing, deformity, instability of station, and disturbance of locomotion. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 10 percent for dermatitis of the right arm, axilla, and neck have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2015). 2. The criteria for a 10 percent rating for scarring alopecia have been met, effective January 1, 2010. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.118, Diagnostic Code 7800 (2015). 3. The criteria for a rating higher than 10 percent for hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2015). 4. The criteria for a 10 percent rating for right foot bunion with postoperative hammertoe deformity, right fifth digit, have been met, effective January 1, 2010. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2015). 5. The criteria for a 10 percent rating for left foot bunion with postoperative hammertoe deformity, left fifth digit, have been met, effective January 1, 2010. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. See, e.g., 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). The Veteran's claim of entitlement to an increased rating higher than 10 percent for dermatitis of the right arm and axilla; compensable rating for alopecia; increased rating higher than 10 percent for hemorrhoids; compensable rating for right fifth hammertoe deformity; and compensable rating for left fifth hammertoe deformity, arises from her disagreement following the initial grant of service connection. The Veteran received notice regarding her initial service connection claim for hemorrhoids in April 2010. With respect to the increased rating claims for dermatitis of the right arm and axilla and alopecia, and service connection for the knees, the Veteran participated in the Benefits Delivery on Discharge program and received a Notice to Claimants of Information and Evidence Necessary to Substantiate a Claim for VA Disability Compensation, which included the criteria for substantiating claims for service connection, and the information and evidence VA would make efforts to obtain and the responsibilities of the Veteran. The Veteran signed the acknowledgment of receipt of the notice of the evidence necessary to substantiate these claims in August 2009, indicating that she had no further evidence to submit and that she wanted VA to decide the claim as soon as possible. The Board notes that with respect to the increased rating claims on appeal, once the underlying claim, such as service connection, is granted, the claim is substantiated; therefore, additional notice is not required and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Regarding the duty to assist, the Veteran's claims file includes VA treatment records, including VA examination reports, and the Veteran's lay statements. After a complete and thorough review of the claims file, the Board concludes that all known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file. The Veteran was provided with relevant VA examinations in August 2009, September 2009, and November 2009. As noted above, these matters also were previously remanded by the Board in May 2014, specifically to provide examinations addressing the present severity of the dermatitis of the right arm, axilla, and neck, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities. Following the Board remand, VA examinations were provided in January 2015. The January 2015 dermatology evaluation appeared to examine the dermatitis during an active stage, as it was noted that there were scattered hyperpigmented scaly patches. See Ardison v. Brown, 6 Vet. App. 405, 408 (1994) (If Appellant's condition is subject to active and inactive stages (skin conditions generally), an examination should be conducted during the active stage.). While the examination of the Veteran's alopecia did not include an unretouched, colored photo, the examination findings were sufficient to ascertain the full disability picture with respect to the scarring alopecia. The examination reports are adequate to decide the issues addressed herein. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the prior medical history and examinations, and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). No further examination is warranted. Also, given the development discussed, the Board finds there has been substantial compliance with the requested development. See Stegall, 11 Vet. App. 268; see also Dyment, 13 Vet. App. 141. Neither the Veteran nor her representative has identified any additional evidence relevant to the claim on appeal. Hence, no further notice or assistance is required with respect to the issues decided herein. Also of record and considered in connection with the appeal is the transcript of the April 2013 Board hearing. The Veteran was provided an opportunity to set forth her contentions with respect to the issues of entitlement to increased ratings for dermatitis of the right arm and axilla and alopecia, as well as service connection for a bilateral knee disability, during the hearing before the undersigned Veterans Law Judge. As noted above, the Veteran declined a hearing on the other issues appealed. In Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the April 2013 hearing, the undersigned Veterans Law Judge enumerated the issues on appeal that the Veteran sought to testify about. Also, information was solicited regarding the severity of the Veteran's dermatitis and alopecia, and problems the Veteran experienced with her knees in service and after service. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) , and the hearing was legally sufficient. The Veteran has been accorded the opportunity to present evidence and argument in support of her claim. II. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2015). The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2015). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2015). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arises from the initial rating assigned, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). A. Dermatitis of the Right Arm, Axilla, and Neck The Veteran's dermatitis of the right arm, axilla, and neck is rated as 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7806 for dermatitis or eczema. Under Diagnostic Code 7806, a 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. The Veteran testified at the Board hearing in April 2013 that her dermatitis "comes and goes." See April 2013 Board hearing transcript, p. 4. She noted that some days her condition was not inflamed, while on other days, she had itching and uses creams. She further testified that during the flare-ups, her dermatitis extended approximately from her elbow to her wrist, and sometimes up to her axilla or underarm area. Id. at 6-7. The Veteran testified that her dermatitis would flare-up about three times per year. Id. at 6. Prior to her separation from service, the Veteran underwent a VA examination in August 2009 to address her skin disability. The Veteran indicated that in approximately 2005 she developed an itchy eruption on the right forearm, which spread up the forearm into the axillary area. The condition was intermittent and consisted of an itchy rash. She reportedly had several biopsies of the rash (records were noted to be unavailable) and was told that it was either "lichen planus" or "granuloma annulare." The Veteran was treated with various topical steroids, of which she did not recall the names, and currently used the topical steroids as needed when the rash recurred. She had no work limitations. It was noted that the Veteran used a topical corticosteroid of unknown strength for greater than six weeks in the past 12 months, as needed. On physical examination, the Veteran's dermatitis covered less than 5 percent of the total body area affected. The examiner observed that the Veteran's right extensor forearm and right axilla had scattered patches of very dark hyperpigmentation mixed with biopsy scars, with no active dermatitis present. The right flexor aspect of the forearm had a solitary 2 mm hyperpigmented papule that was typical of an early lesion according to the Veteran. The diagnosis was history of dermatitis of the right arm and axilla. The examiner commented that the profound hyperpigmentation and distribution was consistent with healed lichen planus but that a lack of biopsy report made a definitive diagnosis only speculative in nature. The Veteran underwent the most recent examination in January 2015 to address the severity of her skin disorder. The examination report notes that the Veteran had a history of chronic eczema involving the bilateral upper extremities to include the right arm and eczema. She also recently developed eczematous patches with frequent outbreaks of the neck. She used multiple topical steroids and presently used a prescription topical steroid of unknown name. The outbreaks reportedly never completely resolved and were highly pruritic. It was noted that the Veteran used constant or near-constant topical corticosteroids in the past 12 months. The eczema covered 5 to 20 percent of the total body area, and 5 to 20 percent of the exposed area. There were scattered hyperpigmented scaly patches on the bilateral antecubital fossa and anterior and lateral aspects of the neck bilaterally, involving 6 percent of the exposed area, and 6 percent of the total body surface area. The Veteran's skin condition did not impact her ability to work. These findings do not support the next higher 30 percent rating for dermatitis under Diagnostic Code 7806. Specifically, the area affected by the dermatitis is 5 to 20 percent of both, the exposed area and entire body; and the Veteran only uses topical corticosteroids, not systemic corticosteroids or other systemic immunosuppressive medication. Therefore, the impairment pertaining to the Veteran's dermatitis is most adequately compensated by a 10 percent disability rating under Diagnostic Code 7806; and a rating higher than 10 percent is not warranted. B. Alopecia The Veteran's alopecia is rated as 0 percent disabling (i.e., noncompensable) under 38 C.F.R. § 4.118, Diagnostic Code 7830 for scarring alopecia. Under Diagnostic Code 7830, scarring alopecia affecting less than 20 percent of the scalp warrants a 0 percent rating. Scarring alopecia affecting 20 to 40 percent of the scalp warrants a 10 percent rating. Scarring alopecia affecting more than 40 percent of the scalp warrants a 20 percent rating. The Veteran testified at the April 2013 Board hearing that she was given Rogaine for men for her alopecia but that the treatment failed. See April 2013 Board hearing, p. 4. She noted that she was given a prescription that she was to use but was told the hair probably would not grow back. An August 2009 VA examination report shows the Veteran described a six to seven-year history of hair loss on the crown of the scalp in a discrete patch, along with thinning of the frontal hairline. She had not been treated or evaluated for the hair loss to date. On physical examination, the examiner commented that the extent of scalp involvement for the scarring alopecia was less than 20 percent. The examiner noted that there were small patches of scarring alopecia on the crown of the scalp, constituting less than 5 percent of the scalp. It was subjectively tender to palpation. The examiner further commented that the view of the scalp was limited due to the Veteran wearing cornrows. The diagnosis was alopecia, combined scarring and non-scarring. Total involvement of the scarring was less than 5 percent of the scalp; non-scarring was 5 percent of the scalp. Total involvement was less than 10 percent of the scalp. A January 2015 VA examination report shows that the Veteran had a chronic history of alopecia of the scalp consistent with scarring alopecia. She reported progressive hair loss of the central scalp vertex over time with chronic pruritus and irritation. There was no recent formal treatment. The Veteran's alopecia caused scarring or disfigurement of the head, face, or neck. She used constant or near constant topical corticosteroids for treatment. There had been no debilitating or non-debilitating episodes within the past 12 months. The Veteran's skin conditions did not impact her ability to work. It was noted that none of the scars of the head, face, or neck were painful, had frequent loss of covering of skin, were unstable, or were due to burns. It was noted that there was a scarred patch of alopecia on the central scalp vertex involving the area of 6 x 2 cm consistent with a scarring alopecia and involving 10 percent of the scalp. The length and width (at widest part) was 6 x 2 cm. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There also was no gross distortion or asymmetry of facial features or visible or palpable tissue loss. In addition none of the scars resulted in limitation of function or involved any other pertinent physical findings or complications, such as muscle or nerve damage. Finally, it was noted that the Veteran's scars did not impact her ability to work. The Veteran's alopecia does not warrant a compensable rating, i.e., at least a 10 percent rating, under Diagnostic Code 7830. Specifically, the alopecia affects less than 20 percent of the scalp. However, the Veteran's scarring alopecia does involve one of the characteristics of disfigurement under Diagnostic Code 7800. Specifically, the scarring measures 6 cm in length and 2 cm in width at its widest. One of the characteristics of disfigurement is 0.6 cm in width at its widest. Scars of the head, face, or neck with one characteristic of disfigurement warrant a 10 percent rating under Diagnostic Code 7800. There are no additional characteristic of disfigurement, i.e., scar 5 or more inches (13 or more cm.) in length; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); or skin indurated or inflexible in an area exceeding six square inches (39 sq. cm.). Therefore, a rating higher than 10 percent is not warranted under Diagnostic Code 7800. Other diagnostic codes pertaining to scars have been considered, but do not warrant a rating higher than 0 percent. The Veteran complained on examination in August 2009 that her scalp was painful to touch. One or two scars that are painful warrants a 10 percent rating under Diagnostic Code 7804. However, examination in January 2015 shows that none of the scars on the Veteran's head, face, or neck were painful. Given the complete findings of record, the evidence does not support that the Veteran's scarring alopecia is akin to painful scars under Diagnostic Code 7804. In addition, a higher rating also is not warranted for scars that are unstable or cause limitation of function, as the January 2015 examination report shows that the Veteran did not have any of this type of impairment due to the scarring alopecia. Thus, the Veteran's scarring alopecia warrants a 10 percent rating under Diagnostic Code 7800 as it involves one characteristic of disfigurement. However, a rating higher than 10 percent is not warranted; nor is a separate compensable rating warranted under any of the other scar diagnostic codes, including the code for painful scars. C. Hemorrhoids The Veteran's hemorrhoids are rated as 10 percent disabling under 38 C.F.R. § 4.118, Diagnostic Code 7336. Under Diagnostic Code 7336, a 10 percent rating is warranted for external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted for external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. A September 2009 VA examination report notes the Veteran developed hemorrhoids with her pregnancy and that she had them off and on while she was in the military. She used suppositories. The Veteran was diagnosed with hemorrhoids with no significant effects on her usual occupation as a training manager. There were effects on daily activities including moderate effects on chores, shopping, exercise, and recreation; and severe effects on traveling and toileting. There were mild effects on feeding and no effects on sports, bathing, dressing, or grooming. A January 2015 VA examination report shows that the Veteran has anal pain twice per week and bright red blood on the tissue after wiping twice per week (after bowel movement). She used a stool softener and ate a high fiber diet on a daily basis. Her hemorrhoids were determined to be mild or moderate. On physical examination she had 3 external hemorrhoids, measuring 0.5 cm each; none were thrombosed. No internal hemorrhoids could be found. The Veteran had normal sphincter tone and there was no blood on examining finger. The Veteran's hemorrhoids impacted her ability to work in that her job required her to sit at her desk and the Veteran had difficulty sitting during flare-ups of hemorrhoid pain, which occurred once or twice per month. In the past 12 months, the Veteran did not miss any days out of work due to the claimed condition. The physical examination indicated that the Veteran's hemorrhoids were moderate; they were irreducible, with excessive redundant tissue evidencing frequent recurrences. There was no evidence of persistent bleeding with secondary anemia due to hemorrhoids. There also was no evidence of fissures on examination. The medical evidence does not show that a rating higher than 10 percent is warranted for hemorrhoids. Specifically there is no medical evidence of persistent bleeding with secondary anemia or fissures. A November 2009 VA examination report shows the Veteran has anemia, but this has not been related to her hemorrhoids. The report suggests other causes for the anemia including heavy monthly menses lasting seven days. Based on these findings, the Veteran's claim for a rating higher than 10 percent for hemorrhoids is denied. D. Bilateral Fifth Hammertoe Deformities The Veteran's bilateral fifth hammertoe deformities are actually characterized as bilateral foot bunions with postoperative hammertoe deformities of the fifth digits. Each foot is rated as 0 percent disabled under 38 C.F.R. § 4.71a, Diagnostic Codes 5282-5280. Under Diagnostic Code 5280, hallux valgus unilateral is rated as 10 percent for severe, if equivalent to amputation of the great toe; or with operated with resection of metatarsal head. Under Diagnostic Code 5282, hammer toe of a single toe is rated as 0 percent disabling. Hammer toe of all toes, unilateral without claw foot is rated as 10 percent disabling. Another potentially applicable diagnostic code is Diagnostic Code 5284 for other foot injuries. A 10 percent rating is warranted for moderate foot injuries; a 20 percent rating is warranted for moderately severe foot injuries; and a 30 percent rating is warranted for severe foot injuries. A November 2009 VA examination report shows the Veteran stated that she developed hammertoe deformities of her 5th digits on both feet gradually over the years during active duty enlistment. She noted that she underwent surgical correction but still had problems with pain in certain shoes and lack of motion of the toes. She also stated that bunions had gradually developed during her enlistment and that she had pain at the medial aspect of both toes, with the left worse than the right. She had a hammertoe correction surgery in March 2007. Symptoms on the feet including pain, swelling, and stiffness on the one through five metatarsal joints and fifth toes. Flare-ups occurred weekly or more often and lasted less than one day. Shoes precipitated the pain and the flare-ups resulted in decreased mobility. Functional limitations were that the Veteran could only stand for up to one hour and could walk more than one quarter mile but less than one mile. Physical examination showed tenderness and abnormal weightbearing. There was objective evidence of tenderness on palpation of the first metatarsal joint on the left foot and callosities with unusual shoe wear pattern on both feet. The fifth toes were surgically corrected; the left fifth toe was tender to touch; the right fifth toe was non-tender. On the left foot, there was deviation of the hallux laterally with mild joint stiffness and prominent dorsal medial eminence. On the right, there was no angulation or joint stiffness and a mild dorso-medial eminence There was no evidence of skin or vascular foot abnormality, pes cavus, malunion or nonunion of the tarsal or metatarsal bones, flatfoot, or muscle atrophy on either foot. The Veteran's gait was propulsive with no limp. The diagnosis was bilateral bunions, left worse than right, and surgically corrected fifth hammer toe deformities. In addressing whether the Veteran's hammer toe deformities affected her employment, it was noted that the Veteran was not employed. Regarding daily activities, it was noted that the hammer toe deformities resulted in mild effect on driving and chores; moderate effect on shopping, recreation, and traveling; and severe effect on exercise and sports. There was no effect on feeding, bathing, dressing, or toileting. With respect to the bunions, it was noted that there was mild effect on chores and shopping, severe effect on exercise; and no effect on the rest of the activities of daily living. A January 2015 VA examination report shows the Veteran was service-connected for bilateral hallux valgus and post-surgical deformity of the fifth toes due to hammertoes bilaterally. The Veteran stated that she had difficulty walking and standing due to her service-connected condition and that she had to wear bigger shoes due to post-surgical deformity of the fifth toes. She indicated that she had difficulty standing for more than 20 minutes while wearing shoes and difficulty walking more than three city blocks. She was unable to run due to pain in the fifth toes bilaterally. She reported pain in the fifth toes of both feet, which flare-up if she wore shoes all day. On physical examination there was a well-healed linear scar on the right fifth toe parallel to the bone, which was 2.0 cm long and 0.1 cm wide. The scar was painless and did not affect joint motion; there also was no keloid. On the left fifth toe, there was a well-healed linear superficial scar parallel with the bone, which was 1.5 cm long and 0.1 cm wide. The scar also was painless and did not affect joint motion or involve a keloid. The Veteran had a mild hallux valgus deformity. She did not have surgery for the hallux valgus. Functional loss included pain on movement, pain on weight-bearing, deformity, instability of station, disturbance of locomotion, and interference with standing. There was no weakness, fatigability, or incoordination during the flare-up, or after repetitive use over the period of time. In addressing the functional impact on employment, the Veteran was an analyst, which required her to sit at her desk and also travel. She had difficulty walking more than 3 city blocks and standing longer than 20 minutes when commuting between different points related to her job. In the past 12 months, she had not missed any days of work due to the feet disabilities. The examiner determined that the Veteran did not have a post-operative hallux valgus deformity. She never had surgical treatment for hallux valgus deformity so her hammer toe deformity was not analogous to post-operative hallux valgus deformity with resection of metatarsal head and/ or severe hallux valgus deformity, which is equivalent to amputation of the great toe. There was post-surgical deformity on the bilateral fifth toes; no other toes were involved. There was no claw foot deformity on either foot. The examiner also determined that the Veteran's symptoms could not be analogously rated as foot injury, as the Veteran did not have a foot injury; and her symptoms were related to bilateral post-surgical toe deformity of the fifth toe and hallux valgus. In addressing these findings, a compensable rating is not warranted under either Diagnostic Code 5280 or Diagnostic Code 5282. While the Veteran has hallux valgus deformities, she has never had an operation with resection of metatarsal head; and there is no indication that the hallux valgus deformity is equivalent to amputation of the big toe. Also, with respect to Diagnostic Code 5282, the hammer toe deformity is only in the fifth toe on each foot, and not all toes. Therefore a rating of at least 10 percent is not warranted under these diagnostic codes. However, notwithstanding the January 2015 examiner's finding that the Veteran's foot disabilities are not akin to a foot injury, the medical evidence shows impairment in the feet that is equivalent to a moderate foot injury under Diagnostic Code 5284. The Veteran has pain at the medial aspect of both toes, with the left worse than the right, swelling, and stiffness in the metatarsal joints, with flare-ups occurring weekly or more often. She has functional limitations in that she had difficulty standing or walking for prolonged periods, and was unable to run due to pain in the bilateral fifth digits. She also has tenderness and abnormal weightbearing, pain on movement, pain on weight-bearing, deformity, instability of station, and disturbance of locomotion. These findings more closely approximate the criteria for a moderate foot injury under Diagnostic Code 5284. While the January 2015 examiner correctly observed that the Veteran did not have a history of injury to her feet, the impairment associated with her service-connected bilateral fifth hammer toe deformities is akin to the type of impairment associated with a moderate foot injury. A moderately severe foot injury is not shown. While the Veteran has significant functional impairment as a result of her bilateral fifth hammertoe deformities, she still is able to walk and stand unassisted. The diagnostic criteria do not define "moderate" or "moderately severe" under the diagnostic codes. However, the Board infers that based on the medical evidence of record, the Veteran's bilateral fifth hammertoe deformities are not consistent with a moderately severe foot injury. The operation to correct the hammertoe deformities resulted in scars on the fifth toes. However, the findings on the examination in January 2015 show that a compensable rating is not warranted for the scars based on functional limitation, pain, or size of the scars. See generally 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804, and 7805. For this reason, 10 percent ratings for each foot, but no higher, are warranted for the bilateral fifth hammertoe deformities, effective January 1, 2010. III. Extraschedular Consideration The evaluations of the Veteran's dermatitis of the right arm, axilla, and neck, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities with bunions do not warrant referral for extraschedular consideration. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008); aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this regard, because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id; 38 C.F.R. § 3.321(b)(1). These criteria have been broken up into a three-step inquiry: (1) The schedular criteria must be inadequate to describe the claimant's disability level and symptomatology; (2) There must be related factors such as marked interference with employment or frequent periods of hospitalization; (3) If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the claimant's disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 114. Here, a comparison of the Veteran's dermatitis of the right arm, axilla, and neck, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities with bunions with the schedular criteria does not show "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Specifically, her dermatitis of the right arm, axilla, and neck has been manifested by scattered hyperpigmented scaly patches on the bilateral antecubital fossa and anterior and lateral aspects of the neck bilaterally, involving 6 percent of the exposed area, and 6 percent of the total body surface area. These manifestations are contemplated by Diagnostic Code 7806, which contemplates dermatitis covering at least 5 percent, but less than 20 percent of the entire body or exposed areas affected. The alopecia affects less than 20 percent of the scalp, and includes scarring that measures 6 cm in length and 2 cm in width at its widest. These manifestations are contemplated by Diagnostic Code 7800, which compensates a Veteran for having at least one characteristic of disfigurement for scar of the head, including a scar that is at least 0.6 cm wide at its widest. The Veteran's hemorrhoids are moderate, irreducible, with excessive redundant tissue evidencing frequent recurrences, and no evidence of persistent bleeding with secondary anemia due to hemorrhoids, or fissures. These findings are contemplated by Diagnostic Code 7336, which assigns a 10 percent rating for external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Finally, the bilateral fifth hammertoe deformities with bunions have been manifested by impairment in the feet that is equivalent to a moderate foot injury, which is contemplated by Diagnostic Code 5284. Thus, there are no manifestations of the Veteran's dermatitis of the right arm, axilla, and neck, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities with bunions not accounted for in evaluating it under the schedular criteria such as to render their application impractical. See Thun, 22 Vet. App. at 115; 38 C.F.R. § 3.321(b). The available schedular evaluations are adequate to rate these disabilities, and the first step of the inquiry is not satisfied. See id. In the absence of this threshold finding, the second step of the inquiry, namely whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization, is moot. See Thun at 118-19. Therefore, the Board will not refer the evaluation of the Veteran's dermatitis of the right arm, axilla, and neck, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities with bunions for extraschedular consideration. See id.; 38 C.F.R. § 3.321(b). The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that the combined effects of a veteran's service-connected disabilities is also for consideration in determining whether the schedular evaluations are adequate under § 3.321(b)(1). Johnson v. McDonald, 762 F.3d 1362, 1365 (Fed. Cir. 2014) (observing that "§ 3.321(b)(1) performs a gap-filling function [that] accounts for situations in which a veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a veteran's disabilities are nonetheless inadequately represented"). In this case, all symptoms and functional impairment associated with the Veteran's dermatitis of the right arm, axilla, and neck, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities have been considered in determining whether a higher rating is warranted, including whether the schedular criteria are adequate to rate these disabilities, as shown in the above discussion. Neither the adequacy of the individual ratings assigned other service-connected disabilities, nor the adequacy of their combined evaluation, has been raised. Accordingly, the evaluation of the Veteran's dermatitis of the right arm, axilla, and neck, alopecia, hemorrhoids, and bilateral fifth hammertoe deformities with bunions does not encompass the issue of whether the schedular criteria are adequate to compensate for the combined effects of multiple service-connected disabilities. (Continued on the next page) ORDER Entitlement to an initial rating higher than 10 percent for dermatitis of the right arm, axilla, and neck, is denied. Entitlement to an initial rating of 10 percent, but no higher, for alopecia, is granted, effective January 1, 2010, subject to the rules governing the payment of monetary benefits. Entitlement to an initial rating higher than 10 percent for hemorrhoids is denied. Entitlement to an initial rating of 10 percent, but no higher, for right foot bunion with postoperative hammertoe deformity, right fifth digit, is granted, effective January 1, 2010, subject to the rules governing the payment of monetary benefits. Entitlement to an initial rating of 10 percent, but no higher, for left foot bunion with postoperative hammertoe deformity, left fifth digit, is granted, effective January 1, 2010, subject to the rules governing the payment of monetary benefits. REMAND The Board remanded the issue of service connection for a bilateral knee disability in May 2014 for an examination to properly address whether the Veteran has arthritis in the knees and to conduct range of motion studies. The opinion provided was to specifically consider the Veteran's in-service diagnosis of knee strain in 2006 and her statements concerning symptoms in her knees in service and since her discharge from service. Thereafter, an examination was provided in January 2015. Range of motion studies were conducted, which were found to be normal. However, in assessing whether the Veteran had arthritis of the knees, the examiner referenced a November 2009 x-ray examination report, rather than conducting a new study to determine if arthritis had since developed. Of note, the service treatment records show findings of crepitus and laxity in the knees on examination in September 2006. The examiner determined that the Veteran's bilateral knee condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that the only record of knee complaints was on the separation physical. The examiner also determined that there was no objective evidence of injury or condition in service. After the RO sought further clarification from the examiner, in a later supplemental statement, the examiner noted that the history by definition is the Veteran's statements regarding the problem and that therefore the examiner had "clearly acknowledged veterans[sic] statement asserting symptoms in service". In a May 2015 supplemental opinion the examiner noted that previously on examination he had found that the Veteran had full range of motion in both knees and no objective evidence of injury or condition in service. The only record of knee complaints was on the separation physical. Therefore, the examiner determined that in the absence of any actual evaluation of the knees in service by a medical professional, there is no objective evidence connecting any current knee complaints to service. The examination report provided in 2015 is inadequate because the examiner relied on a November 2009 x-ray examination to determine that the Veteran did not have arthritis in 2015. The findings in the service treatment records in September 2006 of crepitus and laxity in the knees are significant, in this regard, as well, and are not consistent with the examiner's comments that there was no objective of a knee condition in service. In addition, while the examiner has asserted that the Veteran's statements regarding knee pain in service were considered, the examiner dismisses those comments by instead relying on the fact that there was no record of treatment for knee pain until the complaint at separation. However, the Veteran is competent to state that the knee pain had occurred more than just once. Unless there is reason to show that the Veteran is not credible, her assertions regarding her symptoms that she is competent to observe must be taken as true. For these reasons, another examination is warranted to resolve whether the Veteran has a present bilateral knee disability related to her military service. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain any recent treatment pertaining to the knees from the VAMC in Richmond, Virginia dated since February 2015 2. Ask the Veteran to identify all private medical care providers that have treated her for her knees. Make arrangements to obtain all records that she adequately identifies. 3. Schedule the Veteran for a VA orthopedic examination. The claims file must be made available to, and reviewed by, the examiner. All appropriate testing should be conducted including x-ray and/or other studies to rule out arthritis of the knees. X-ray examination in November 2009 should not be relied on to determine if the Veteran presently has arthritis. Then the examiner also should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any present bilateral knee disability had its clinical onset during active service or is related to any in-service disease, event, or injury. In providing this opinion, the examiner should acknowledge the Veteran's statements asserting symptoms in service and since her discharge from service and the in-service diagnosis of knee strain in 2006, as well as the findings of laxity and crepitus in September 2006. The examiner should note that the Veteran is competent to state that her knees have been hurting since service, and unless there is a medical reason shown to doubt her credibility, her statements must be accepted as true, regardless of whether there is evidence of treatment in the records. A complete rationale for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 4. Ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, return the case to the examiner for completion of the inquiry. 5. Finally, readjudicate the remaining claim on appeal. If the benefit remains denied, issue the Veteran and her representative a Supplemental Statement of the Case and allow for a reasonable period to respond. 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). (Continued on the next page) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs