Citation Nr: 0812080 Decision Date: 04/11/08 Archive Date: 04/23/08 DOCKET NO. 05-41 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUES 1. Entitlement to service connection for a right knee disability, claimed as the residual of inservice injury. 2. Entitlement to service connection for pes planus (flat feet), to include as secondary to a service-connected left ankle disability. 3. Entitlement to an evaluation in excess of 10 percent for headaches as the residual of trauma above the right eye. 4. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of the right foot with heel spurs. 5. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of the left foot with heel spurs. REPRESENTATION Appellant represented by: J. S. Berry, Attorney ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran served on active duty from August 1986 to August 1990, and from January 31 to March 8, 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal of August 2004, January 2005, February 2007, and June 2007 decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. This case was previously before the Board in April 2005, at which time the issue of service connection for a chronic right knee disability was remanded for additional development. The case is now, once more, before the Board for appellate review. In correspondence of February 2005, and once again in July 2006, the veteran's attorney indicated that the veteran was not, in fact, claiming that his current right knee disability was in some way causally related to his service-connected left ankle disability. Accordingly, the issue of entitlement to service connection for a chronic right knee disability will be considered on a direct-incurrence basis only. FINDINGS OF FACT 1. A chronic right knee disability, including osteoarthritis, is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the veteran's period of active military service. 2. The veteran's pes planus clearly and unmistakably preexisted his periods of active military service. 3. The veteran's preexisting pes planus clearly and unmistakably underwent no clinically-identifiable permanent increase in severity, including beyond natural progress, during his periods of active military service. 4. The veteran's pes planus is not in any way causally related to a service-connected disability or disabilities, including service-connected ligamentous laxity of the left ankle. 5. The veteran's service-connected headaches as the residual of trauma above the right eye are characterized by no more than purely subjective complaints, with no evidence of prostrating attacks or of multi-infarct dementia associated with brain trauma. 6. The veteran's service-connected degenerative changes of the right foot with heel spurs are representative of no more than moderate foot injury, with X-ray evidence of arthritis and accompanying pain, but essentially normal range of motion. 7. The veteran's service-connected degenerative changes of the left foot with heel spurs are representative of no more than moderate foot injury, with X-ray evidence of arthritis and accompanying pain, but essentially normal range of motion. CONCLUSIONS OF LAW 1. A chronic right knee disability was not incurred in or aggravated by active military service, nor may osteoarthritis of the right knee be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2007). 2. The veteran's preexisting pes planus was not aggravated during active military service. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2007). 3. The veteran's pes planus is not proximately due to, the result of, or aggravated by a service-connected disability or disabilities, including ligamentous laxity of the left ankle. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2007). 4. The criteria for an evaluation in excess of 10 percent for headaches as the residual of trauma above the right eye have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.124a, 4.130, and Part 4, Codes 8045, 8100, 9304 (2007). 5. The criteria for an initial evaluation in excess of 10 percent for degenerative changes of the right foot with heel spurs have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a and Part 4, Codes 5003, 5284 (2007). 6. The criteria for an initial evaluation in excess of 10 percent for degenerative changes of the left foot with heel spurs have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a and Part 4, Codes 5003, 5284 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In reaching this determination, the Board wishes it to make it clear that it has reviewed all the evidence in the veteran's claims file, which includes his multiple contentions, as well as service medical records, and both VA and private treatment records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the veteran's claims, and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The veteran in this case seeks service connection for a chronic right knee disability, as well as for pes planus (flat feet). In that regard, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of the incurrence or aggravation of a disease or injury during service; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Moreover, where a veteran served for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and degenerative joint disease (i.e., osteoarthritis) becomes manifest to a degree of 10 percent within one year of date of termination of such service, such disease shall be presumed to have been incurred in service, even there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137 (West 2007); 38 C.F.R. §§ 3.307, 3.309 (2007). A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2007). A preexisting injury or disease will be considered to have been aggravated during active military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2007). Service connection may additionally be granted for disability which is proximately due to or the result of a service- connected disease or injury. Moreover, the United States Court of Appeals for Veterans Claims (Court) has held that when aggravation of a veteran's nonservice-connected disability is proximately due to or the result of a service- connected disease or injury, it too shall be service connected to the extent of the aggravation. See Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). The Board notes that 38 C.F.R. § 3.310, the regulation which governs claims for secondary service connection, has recently been amended. Under the revised § 3.310(b) [the existing provision at 38 C.F.R. § 3.310(b) was moved to subsection (c)], the regulation provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to what the competent evidence establishes as the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by the service-connected condition), in comparison to the medical evidence establishing the current level of severity of the nonservice-connected disease or injury. These findings as to baseline and current levels of severity are to be based upon application of the corresponding criteria under the Schedule for Rating Disabilities (38 C.F.R. Part 4) for evaluating that particular nonservice-connected disorder. See 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2007). Service Connection In the present case, service medical records disclose that, on various occasions in service, and as early as July 1987, there was noted the presence of bilateral pes planus. However, the great majority of the veteran's service medical records are entirely negative for any evidence whatsoever of pes planus. In point of fact, at the time of a service separation examination in May 1990, the veteran specifically denied that he had ever had "foot trouble." A physical examination of the veteran's feet conducted at that time was entirely within normal limits, and no pertinent diagnosis was noted. Nor was there evidence of pes planus on VA general medical examination in April 1991, shortly following the veteran's final discharge from service. The earliest post service clinical indication of the presence of pes planus is revealed by a VA orthopedic examination dated in August 2006, more than 15 years following the veteran's discharge from service. Significantly, at the time of that examination, it was "abundantly evident" that the veteran's flat feet had existed for a "considerable" period of time. Moreover, following a VA podiatric examination in May 2007, it was noted that, upon questioning, the veteran endorsed the presence of "preservice flat feet." According to the examiner, the evidence of record (including the veteran's claims folder) led to the medical conclusion that the veteran's pes planus was a "congenital condition" which existed prior to his entry upon active duty, and which had not progressed beyond the expected state for a person of the veteran's age. Further noted was that the veteran's pes planus was "less likely than not" due to, caused by, or aggravated by his active military service. In the opinion of the examiner, there was no clinical or diagnostic evidence indicating that the veteran's preservice pes planus had been caused or aggravated by his service-connected left ankle condition, in particular, given the absence of radiographic evidence of left ankle pathology. The Board observes that, in an addendum to the aforementioned VA podiatric examination dated in late May 2007, it was noted that the evidence of record, including current subjective and objective evidence, led to the clear and unmistakable medical conclusion that the veteran's pes planus preexisted his active military service, and that any treatment in service represented only the natural progress of that preexisting condition, without evidence of any permanent abnormal worsening. Based on the aforementioned, it is clear that the veteran's pes planus preexisted his periods of active military service. Similarly clear is that the veteran's preexisting pes planus underwent no clinically-identifiable permanent increase in severity beyond its natural progress during his period or periods of active military service. Finally, there exists no evidence that the veteran's pes planus is in any way proximately due to, the result of, or aggravated by his service-connected left ankle disability. Under the circumstances, service connection for bilateral pes planus must be denied. Turning to the issue of service connection for a chronic right knee disability, the Board observes that, on numerous occasions during service, the veteran received treatment for various right knee pathology, culminating in diagnoses of retropatellar pain syndrome and/or right knee strain. However, on VA general medical examination in April 1991, a physical examination of the veteran's right knee revealed not only good stability, but a normal range of motion. The earliest clinical indication of the presence of truly chronic right knee pathology is revealed by private medical records dated in 2001, more than 10 years following the veteran's discharge from service, at which time there was noted the presence of synovitis and/or patellofemoral joint chondromalacia of the veteran's right knee. Significantly, at the time of the rendering of those diagnoses, there was no indication that the veteran's right knee pathology was in any way the result of any incident or incidents of his periods of active military service. The Board observes that, following a VA orthopedic examination in August 2005, it was the opinion of the examiner that the veteran suffered from bilateral degenerative joint disease of the knees, though radiographic studies failed to demonstrate any significant difference between the right and left knees. While examination findings suggested the presence of patellofemoral syndrome on the right, a diagnosis which had also been given in the past, according to the examiner, it was impossible to connect that pathology directly to the veteran's military service. Significantly, in an addendum to the aforementioned examination dated in October 2005 (which addendum it should be noted, followed a full review of the veteran's claims folder), the same examiner who had conducted the August 2005 examination rendered the opinion that the veteran's right knee pain was not caused by or the result of his active military service. This was particularly the case given the absence of any specific injury during the veteran's period of active military service, and the fact that the normal aging process could very likely be aggravating the veteran's patellar pain. Significantly, following the aforementioned VA orthopedic examination in August 2006, it was the opinion of the examiner that the veteran's current right knee pathology was not caused by any injury in service, but rather the result of his (nonservice-connected) flat feet. Based on the aforementioned, the Board is unable to reasonably associate the veteran's current right knee disability, first persuasively documented many years following service discharge, with any incident or incidents of his periods of active military service. Under the circumstances, service connection for that disability must be denied. Increased Evaluations Turning to the issues of increased evaluations for the veteran's service-connected headaches, as well as degenerative changes of the right and left foot, the Board notes that disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). While the Board must consider the veteran's medical history as required by various provisions under 38 C.F.R. Part 4, including Section 4.2 [see Schafrath v. Derwinski, 1 Vet. App. 589 (1991)], the regulations do not give past medical reports precedence over current findings. Headaches In the present case, at the time of a VA neurologic examination in November 2006, the veteran gave a history of migraine-type headaches which had begun as early as February 1989. According to the veteran, his headaches were "intermittent, with remissions," and were precipitated by being "overstressed or overtired," or by bright lights. When questioned, the veteran indicated that he currently took medication at the inception of a headache, which tended to keep the headache from intensifying. Further noted was that the veteran had not missed any work as a result of his headaches, and had experienced only two episodes of headaches so severe that they had resulted in nausea and/or vomiting. Significantly, these "severe headaches" had occurred prior to the veteran's beginning medication in 2002. When further questioned, the veteran stated that his headaches tended to occur on a weekly basis, but were not prostrating, with the result that ordinary activity was still possible. Physical examination showed normal motor and sensory findings, with no evidence of any clinical abnormality. The pertinent diagnosis noted was migraine-type headaches, with no significant effects on the veteran's usual occupation or daily activities. The Board notes that, pursuant to applicable law and regulation, purely subjective complaints such as headache, recognized as symptomatic of brain trauma, are to be rated as 10 percent and no more under Diagnostic Code 9304 (which is to say, dementia due to head trauma). That 10 percent rating is not to be combined with any other rating for disability due to brain trauma. Moreover, ratings in excess of 10 percent for brain disease due to trauma under Diagnostic Code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma. 38 C.F.R. §§ 4.124a, 4.130, and Part 4, Codes 8045, 9304 (2007). If rated by analogy to migraine headaches, a 10 percent evaluation is warranted where there is evidence of characteristic prostrating attacks averaging one in two months over the course of the past several months, with a 30 percent evaluation requiring evidence of characteristic prostrating attacks occurring on average once a month over the past several months. 38 C.F.R. § 4.124a and Part 4, Code 8100 (2007). Based on the aforementioned, it is clear that the 10 percent evaluation currently in effect for the veteran's service- connected headaches as the residual of trauma above the right eye are adequately represented by the 10 percent evaluation now in effect. There is no evidence that the veteran currently suffers from anything other than purely subjective complaints of headaches. Nor is there is evidence of any diagnosis of multi-infarct dementia associated with brain trauma. While on occasion, the veteran's headaches have been described as "migraine-type" in nature, as of the time of the aforementioned VA neurologic examination in November 2006, there was no evidence that the veteran had on any occasion suffered from prostrating attacks attributable to migraine headaches. Nor is there evidence that, as a result of the veteran's service-connected headaches, he has experienced frequent periods of hospitalization and/or any marked interference with employment. See 38 C.F.R. § 3.321(b)(1) (2007). Under the circumstances, an increased evaluation for service-connected headaches as the residual of trauma above the right eye must be denied. In reaching this determination, the Board has given due consideration to the recent holding of the Court in Hart v. Mansfield, 21 Vet. App. 505 (2007) addressing the issue of whether it is appropriate to apply "staged" ratings when assigning an increased rating in a manner similar to what is done at the initial rating stage pursuant to the Court's holding in Fenderson v. West, 12 Vet. App. 119 (1999). However, in the case at hand, it is clear that, over the course of the veteran's current appeal, symptomatology attributable to his service-connected headaches has remained relatively stable. In any case, based on a review of the entire evidence of record, the Board is of the opinion that, throughout the time period that the veteran's increased rating claim has been pending, symptomatology attributable to his service-connected headaches has not, in fact, undergone varying and distinct levels of severity. Degenerative changes of the right and left foot with accompanying heel spurs Turning to the issue of respective initial evaluations in excess of 10 percent for the veteran's service-connected degenerative changes of the right and left foot with accompanying heel spurs, the Board notes that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to the absence of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. See DeLuca v. Brown v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2007); see also 38 C.F.R. § 4.45 (2007). Where, as in this case, an appeal stems from an initial rating, VA must frame and consider the issue as to whether separate or "staged" ratings may be assigned for any or all of the retroactive period from the effective date of the grant of service connection to a prospective rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In the case at hand, in a rating decision of June 2007, service connection and initial 10 percent evaluations were granted for degenerative changes of the right and left feet, with accompanying heel spurs, effective from March 8, 2007, the date of receipt of the veteran's claim. The veteran voiced his disagreement with the assignment of the respective 10 percent evaluations, and the current appeal ensued. The Board notes that, at the time of a VA podiatric examination in May 2007, the veteran complained of bilateral foot pain. When questioned, the veteran indicated that he currently worked as a letter carrier for the US Postal Service, during the course of which he delivered mail from a delivery vehicle. When further questioned, the veteran indicated that, in April 2007, orthotic inserts were made for him, which he wore in his work boots, and which had resulted in decreased foot pain. Also noted was treatment with pain medication, which according to the veteran, had produced "good results." On physical examination, the veteran's gait was described as even and his balance steady, with no evidence of any ambulatory aids or braces. Further examination showed no evidence of any callosities, breakdown, or unusual shoe wear indicating abnormal weightbearing, and alignment of the Achilles tendon was medial. At the time of examination, there was no evidence of hammer toes, pes cavus, claw foot, or other foot deformity. Heel/toe and tandem walking demonstrated good coordination, with the veteran able to stand on one leg while performing shallow knee bends with no loss of balance. There was no evidence of any abnormal posture while standing or squatting, or on supination, pronation, or rising on the toes and heels. Nor was there any evidence of fatigue, weakness, or lack of endurance following repetitive use, or any objective evidence of instability, weakness, or tenderness. Radiographic studies of the veteran's feet were consistent with the presence of bilaterally symmetrical, tiny dorsal heel spurs, somewhat larger on the right than the left, but with no evidence of any plantar heel spur, foreign body, infection, or fracture. Also noted was a tiny bunion deformity on the veteran's right foot. According to the examiner, the veteran's mild degenerative changes and small heel spurs represented the most likely etiology for his subjective complaints of pain following long periods of weightbearing. Based on the aforementioned, it is clear that the veteran suffers from at least some degree of osteoarthritis of his feet. However, such pathology has been described as no more than "mild." Pursuant to applicable law and regulation, degenerative arthritis established by X-ray findings is to be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, 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 or group of minor joints affected by limitation of motion, to be combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is in order where there is X-ray evidence of the involvement of two or more major joints or two or more minor joint groups, with a 20 percent evaluation requiring demonstrated evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a and Part 4, Code 5003 (2007). When rated on the basis of foot injury, a 10 percent evaluation is warranted where there is evidence of moderate injury to one or both feet. A 20 percent evaluation, under those same laws and regulations, requires demonstrated evidence of moderately severe injury to the feet. 38 C.F.R. § 4.71a and Part 4, Code 5284 (2007). As noted above, the veteran's osteoarthritis of the feet has been described as no more than "mild." While at present, there is clear radiographic evidence of arthritis of both feet, range of motion of both the veteran's right and left foot is essentially within normal limits. Even if evaluated by analogy to foot injury, there currently exists no evidence that the veteran suffers from anything other than moderate symptomatology attributable to his service-connected degenerative changes with heel spurs of the right and left feet. Under the circumstances, since service connection has been in effect initial evaluations in excess of 10 percent for such degenerative changes of the feet are not in order. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2003). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the United States Court of Appeals for Veterans Claims (Court) held that VA must (1) inform the veteran about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the veteran about the information and evidence that VA will seek to provide; (3) inform the veteran about the information and evidence the claimant is expected to provide; and (4) request that the veteran provide any evidence in his possession which pertains to the claim. For an increased compensation claim, Section 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate the claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the veteran demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a 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 and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples 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., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. Vazquez-Flores, 22 Vet. App. 37 (2008). The Board finds that the VCAA notice requirements have been satisfied by March 2004, October 2004, March 2006, September 2006, April 2007, and September 2007 VCAA letters. In those letters, VA informed the veteran that, in order to substantiate a claim for service connection, the evidence needed to show that he had a current disability, a disease or injury in service, and evidence of a nexus between the postservice disability and the disease or injury in service, which was usually shown by medical records and medical opinions, or, in the alternative, that a service-connected disability or disabilities had caused or aggravated the condition under consideration. The veteran was further advised that, in order to substantiate his claims for increased ratings, he needed to show that his service- connected disabilities had undergone an increase in severity. To the extent that there existed any error by VA in providing the notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1), such error was nonprejudicial in that it did not affect the essential fairness of the adjudicatory process. In point of fact, based on a review of the entire file, it is clear that the veteran had a full understanding and/or actual knowledge of the elements required to prevail on his claims. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). As to informing the veteran of which information and evidence he was to provide to VA, and which information and evidence VA would attempt to obtain on his behalf, VA informed him that it had a duty to obtain any records held by any federal agency. It also informed him that, on his behalf, VA would make reasonable efforts to obtain records which were not held by a federal agency, such as records from private doctors and hospitals. The RO told the veteran that he could obtain private records himself and submit them to VA. Finally, he was told to submit any evidence in his possession which pertained to his claims. The veteran was also informed of the general regulations on disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). However, since his claims are being denied, any such downstream matters are now moot. VA must also make reasonable efforts to assist the veteran in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has obtained the veteran's service medical records, as well as both VA and private treatment records and examination reports. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims. The evidence of record provides sufficient information to adequately evaluate the claims, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. Therefore, no further assistance to the veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). ORDER Service connection for a right knee disability, claimed as the residual of in-service injury, is denied. Service connection for pes planus (flat feet), to include as secondary to a service-connected left ankle disability, is denied. An evaluation in excess of 10 percent for headaches as the residual of trauma above the right eye is denied. An initial evaluation in excess of 10 percent for degenerative changes of the right foot with heel spurs is denied. An initial evaluation in excess of 10 percent for degenerative changes of the left foot with heel spurs is denied. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs