Citation Nr: 0812180 Decision Date: 04/11/08 Archive Date: 04/23/08 DOCKET NO. 04-36 330 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Washington, DC THE ISSUES 1. Entitlement to an increased evaluation for bilateral pes planus, currently rated as 10 percent disabling for the right foot and as 10 percent disabling for the left foot. 2. Entitlement to a separate compensable rating for mild degenerative changes at the first metatarsophalangeal joint of the right and left foot. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The veteran had active military service from December 1952 to November 1954. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia that in pertinent part granted service connection and assigned separate 10 percent ratings for pes planus with mild degenerative changes at the first metatarsophalangeal joint of the right foot and of the left foot, effective July 31, 2002. The issue of entitlement to a higher disability evaluation for pes planus remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). In March 2005, the veteran testified during a hearing before a Veterans Law Judge (VLJ) from the Board in Washington, D.C. A transcript of the hearing is of record. In February 2007, the Board remanded these matters to RO via the Appeals Management Center (AMC) for additional development and adjudication. In a February 2008 letter, the Board notified the veteran that the VLJ who conducted the March 2005 hearing was no longer employed by the Board and informed him of his right to another Board hearing. The veteran responded in February 2008, indicating that he did not want another hearing. Thus, the Board will proceed with appellate review. In February 2008, a Deputy Vice-Chairman of the Board granted the September 2007 motion of the veteran's representative to advance this case on the Board's docket, pursuant to the provisions of 38 U.S.C.A. § 7107 (West 2002) and 38 C.F.R. § 20.900(c) (2007). In September 2007, November 2007, and March 2008, the veteran and his representative submitted to the Board additional evidence for consideration in connection with the claims on appeal, along with a waiver of RO jurisdiction of such evidence. The Board accepts this evidence for inclusion in the record on appeal. See 38 C.F.R. § 20.1304 (2007). As a final preliminary matter, in August 2002, the veteran again raised the issues of service connection for myositis of the right leg and knee, a right ankle disability, a bilateral knee disability, and a dental condition. In August 2003, the veteran raised the issue of an earlier effective date of the award of service connection and compensation for bilateral pes planus. In December 2007, the veteran claimed entitlement to service connection for a dental condition. As each of the issues has not been adjudicated, they are again referred to the RO for appropriate action. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate each claim on appeal has been accomplished. 2. Competent medical evidence demonstrates that the veteran's service-connected bilateral pes planus is manifested by bilateral and severe pes planus with objective evidence of marked deformity, abducted and apropulsive gait, pain on use, indication of swelling on use, and characteristic callosities. 3. Competent medical evidence demonstrates that the veteran's service-connected mild degenerative changes at the first metatarsophalangeal joint of the right and left foot are manifested by X-ray evidence of degenerative changes involving two minor joint groups. CONCLUSIONS OF LAW 1. The criteria for the assignment of a 30 percent, but no higher, rating for bilateral pes planus have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.31, 4.40, 4.45, 4.71a, Diagnostic Code 5276 (2007). 2. The criteria for the assignment of a 10 percent, but no higher, rating for mild degenerative changes at the first metatarsophalangeal joint of the bilateral feet have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.31, 4.40, 4.45, 4.71a, Diagnostic Code 5003 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the veteran's claim for entitlement to an increased rating for pes planus was received in July 2002. He was notified of the provisions of the VCAA by the RO and AMC in correspondence dated in November 2003, March 2007, and May 2007. These letters notified the veteran of VA's responsibilities in obtaining information to assist the veteran in completing his claim, identified the veteran's duties in obtaining information and evidence to substantiate his claim, and requested that the veteran send in any evidence in his possession that would support his claim. Thereafter, the claims were reviewed and a supplemental statement of the case was issued in September 2007. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Mayfield v. Nicholson (Mayfield III), 07-7130 (Fed. Cir. September 17, 2007). During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to this matter was provided in May 2007. The Court also recently issued a decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), concerning increased- compensation claims and finding that section § 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a 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. See 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 claimant 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 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 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. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). In this case, the November 2003, March 2007, and May 2007 letters informed the veteran of the necessity of providing on his own or by VA, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on his daily life and employment. The VCAA notice letters also provided examples of pertinent medical and lay evidence that the veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to increased rating for pes planus. The veteran was further 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 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 and daily life. The Board notes these letters did not make specific reference to rating criteria necessary for entitlement to a higher disability rating for degenerative arthritis or pes planus under Diagnostic Codes 5003 and 5276. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the Federal Circuit Court held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial and that once an error is identified, the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. In order for the Court to be persuaded that no prejudice resulted from a notice error, the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair. See also Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). The Court has stated that "Nothing in law or common sense supports a conclusion that the Court should put on blinders and ignore [the 'extensive administrative appellate process'] or a conclusion that a notice error prior to the initial decision by the Secretary could not be rendered non- prejudicial when the full panoply of administrative appellate procedures established by Congress are provided to the claimant. It is well settled that a remand is not warranted when no benefit would flow to the claimant." See Vazquez- Flores. In this case, the veteran demonstrated that there was actual knowledge of what was needed to establish his increased rating claim for pes planus in multiple written statements of record, in his subjective complaints documented in VA treatment notes, and in his March 2005 hearing testimony. Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrates an awareness of what was necessary to substantiate his claim. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007); see also Short Bear v. Nicholson, 19 Vet. App. 341, 344 (2005). In sum, the veteran was provided the information necessary such that any defective pre-decisional notice error was rendered non-prejudicial in terms of the essential fairness of the adjudication. Thus, the Board finds that although there was VCAA deficiency, the evidence of record is sufficient to rebut this presumption of prejudice as the record shows that this error was not prejudicial to the veteran and the essential fairness of the adjudication process in this case was preserved. As there is no indication that any failure on the part of VA to provide additional notice of assistance reasonably affects the outcome of this case, the Board finds that such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file also shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records and all relevant VA treatment records pertaining to his claim have been obtained and associated with his claims file. He has also been provided with multiple VA medical examinations to assess the current state of his service-connected foot disabilities. Furthermore, the veteran has not identified any additional, relevant evidence that has not otherwise been requested or obtained. He has been notified of the evidence and information necessary to substantiate his claim, and he has been notified of VA's efforts to assist him. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating his claim. II. Increased Ratings The severity of a service-connected disability is ascertained, for VA rating purposes, by the application of rating criteria set forth in VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (2007) (Schedule). To evaluate the severity of a particular disability, it is essential to consider its history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2 (2007). Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. §§ 3.102, 4.3 (2007). In addition, where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2007). The Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Historically, the veteran was granted service connection for bilateral pes planus and assigned a 10 percent rating effective from June 1987. In a March 2004 rating decision, the RO awarded the veteran service connection and assigned separate 10 percent ratings for pes planus with mild degenerative changes at the first metatarsophalangeal joint of the right foot and of the left foot pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5276- 5003 (2007), effective from the date of his increased rating claim on July 31, 2002. In the selection of code numbers assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With diseases, preference is to be given to the number assigned to the disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. See 38 C.F.R. § 4.27 (2007). The hyphenated diagnostic code in this case indicates that pes planus under Diagnostic Code 5276 is the service-connected disorder, and degenerative arthritis under Diagnostic Code 5003 is a residual condition. Laws and Regulations 5276 Flatfoot, acquired: Pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances: Bilateral 50 Unilateral 30 Severe; objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities: Bilateral 30 Unilateral 20 Moderate; weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral 10 Mild: symptoms relieved by built-up shoe or arch support 0 See 38 C.F.R. § 4.71a, Diagnostic Code 5276 (2007). 5003 Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct 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, rate as below: With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations 20 With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups 10 Note (1): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 pct and 10 pct ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic code 5013 to 5024, inclusive. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2007). The United States Court of Appeals for Veterans Claims (the Court) held that in evaluating a service-connected disability, functional loss due to pain under 38 C.F.R. § 4.40 (2007) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2007) must be considered. The Court also held that, when a Diagnostic Code does not subsume 38 C.F.R. §§ 4.40 and 4.45, those provisions are for consideration, and that the rule against pyramiding set forth in 38 C.F.R. § 4.14 does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use, including use during flare-ups. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Factual Background VA treatment records dated in July and August 2001 reflected treatment for plantar fasciitis. He was provided with orthopedic shoes. A January 2002 VA treatment note reflected findings of pes planus, plantar fasciitis, callosities on the sole of the right foot, and fallen arches. In February 2002 VA treatment record, the veteran complained of difficulty standing at work, using orthopedic shoes, and chronic foot pain. Right foot X-ray findings were noted to be within normal limits with no fracture or soft tissue swelling. Physical examination findings were listed as multiple right foot calluses present on the right heel, tenderness to palpation of the right heel, full range of motion, wide shuffling gait, sensation intact, no cellulitis, and tenderness on the plantar surface. It was revealed in an April 2002 VA treatment note that the veteran complained of right foot pain, overpronation of the right foot and right heel pain. Physical examination revealed that light touch sensation was intact, nucleated porokeratosis of the right plantar medial heel, with pain on palpation, flexible pes planus valgus deformity, and mild ankle edema, non-pitting, right greater than left. The examiner listed an assessment of painful keratosis of the right heel and pes plano valgus. A June 2002 VA podiatry treatment note indicated that the veteran complained of foot problems and was given orthotics and knee support. August 2002 and May 2003 VA outpatient treatment notes reported essentially the same findings as in April 2002. In a December 2003 VA feet examination report, the veteran complained of increased plantar foot pain and was noted to be a vague historian. The examiner indicated that there was no weakness, fatigability, decreased endurance, incoordination, or flare-ups of the feet observed, although claimed by the veteran. Physical examination findings were noted as walks with a limp, uses a cane, bilateral pes planus, and tenderness to palpation over the plantar surface of foot. The examiner listed a diagnosis of pes planus. X-ray findings were revealed as bilateral small plantar spurs and mild degenerative changes at the 1st metatarsophalangeal joints of the bilateral feet. VA treatment notes dated in January 2004 listed findings of arch pain in the right foot, loss of plantar arch, and no swelling or tenderness. In a February 2004 VA treatment note, the veteran was assessed as having heel spurs and questionable fasciitis. During his March 2005 Central Office hearing, the veteran testified that his foot disability had increased in severity. He indicated that he suffered from calluses, foot cramps, and difficulty walking and working as a part-time barber due to his service-connected pes planus. Additional VA treatment notes dated in June 2005, October 2005, and October 2006 reflected findings of painful keratosis of the right heel, flexible pes plano valgus, mild ankle edema, right ankle pain, left heel pain, and nonreducible hammertoe contracture. VA treatment records dated in June 2006 noted complaints of left heel pain and right ankle pain as well as findings of right plantar fasciitis. In a June 2007 VA foot examination report, the veteran complained of foot pain and indicated that his orthopedic shoes did not relieve his pain. It was further noted that the veteran walked with a cane partially due to foot pain and was unable to stand or walk without pain. The examiner indicated that the veteran walked abducted and apropulsive. While the examiner could not determine whether the weight bearing line was medial to the great toe, he indicated that the neutral position was in varus and caused compensatory pronation on weight bearing. Physical examination findings were noted as limited ankle range of motion. There was +2 edema of bilateral ankles, normal subtalar range of motion; however, neutral position was in varus and caused a compensatory pronation on weightbearing. There were nontender bilateral tendo Achilles with bowing on weight bearing. Also on weightbearing, there was depression of bilateral arch with talar bulging. The veteran experienced pain on palpation at the talar navicular joint. There was normal bilateral 1st metatarsal joint motion, normal lower extremity strength, pain along the course of the plantar fascia, and no sign of hallux abducto valgus (HAV) deformity. The diagnoses was bilateral pes planus and bilateral equinus of the ankles. The podiatrist further indicated that the veteran's pes planus would cause a decrease in shock absorption and combined with his apropulsive gait would yield an increase in weakness and fatigue. In an August 2007 VA treatment note noted that the veteran had plantar fasciitis, a shuffling gait, and nearly collapsed when trying to stand. Continued findings of bilateral pes planus were noted in a February 2008 VA treatment record. The veteran has also submitted treatise information concerning the foot and copies of newspaper articles of the Washington Post. Analysis As an initial matter, the Board notes that in December 2004, the RO awarded the veteran service connection and assigned separate 10 percent ratings for pes planus with mild degenerative changes at the first metatarsophalangeal joint of the right foot and of the left foot. However, the Board finds that bilateral pes planus and degenerative changes at the first metatarsophalangeal joint of the bilateral feet constitute separate disabilities with different symptomatology. Consequently, the Board will evaluate these conditions separately. Bilateral Pes Planus After a review of the evidence, the Board finds that the evidence does support the assignment of a 30 percent rating for bilateral pes planus. During this time period, the Board finds that the veteran's pes planus symptomatology more nearly approximates the criteria for a 30 percent rating under Diagnostic Code 5276. The evidence of record since the veteran's July 2002 increased rating claim clearly shows that the veteran's bilateral pes planus was manifested by characteristic callosities, fallen arches, chronic foot pain, use of orthopedic shoes, wide shuffling gait, tenderness of the plantar surface of the foot, overpronation of the right foot, ankle edema, loss of plantar arch, complaints of foot cramps, abducted and apropulsive gait, and bowing on weight bearing. However, competent medical evidence during this time period clearly does not support the assignment of a 50 percent rating, as the veteran's bilateral pes planus is not shown to be pronounced with marked pronation, extreme tenderness of plantar surfaces of the feet, or marked inward displacement. While the veteran complained of foot cramps during his March 2005 hearing, objective medical findings of record during this time period do not reflect that the veteran suffers from severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. Additional diagnostic codes for the foot, which might also provide for assignment of a higher disability rating, are also not applicable. It is neither contended nor shown that the veteran's service-connected pes planus disability residuals include symptoms of weak foot, claw foot, metatarsalgia (Morton's disease), hammer toe, hallux valgus, or hallux rigidus. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276 - 5283 (2007). Consequently, entitlement to a 30 percent rating, but no higher, for bilateral pes planus is warranted. Mild Degenerative Changes at the First Metatarsophalangeal Joint After a review of the evidence, the Board also finds that the evidence does support the assignment of a separate 10 percent rating for mild degenerative changes at the first metatarsophalangeal joint of the left and right foot. As noted above, December 2003 VA X-ray findings revealed mild degenerative changes at the 1st metatarsophalangeal joints of the bilateral feet. Competent medical evidence demonstrates that the veteran's service-connected mild degenerative changes at the 1st metatarsophalangeal joint of the right and left foot are manifested by X-ray evidence of degenerative changes involving two minor joint groups. However, competent medical evidence during this time period clearly does not support the assignment of a 20 percent rating, as the veteran's mild degenerative changes at the 1st metatarsophalangeal joint of the bilateral feet are not shown to cause any type of incapacitating exacerbation. Consequently, entitlement to a 10 percent rating, but no higher, for mild degenerative changes at the 1st metatarsophalangeal joint of the bilateral feet is warranted. Both Disabilities The Board has considered staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, No. 05- 2424 (U.S. Vet. App. Nov. 19, 2007), but concludes that they are not warranted in this case. The Board also finds that there is no basis for the assignment of any higher ratings based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-7. Competent medical evidence reflects that the currently assigned 30 percent and 10 percent ratings properly compensate the veteran for the extent of functional loss resulting from any such symptoms. Although it was noted that the veteran's pes planus would cause a decrease in shock absorption that combined with his apropulsive gait would yield an increase in weakness and fatigue in the June 2007 VA examination report, these findings have already been taken into consideration in the assignment of the current 30 percent and 10 percent ratings. In this regard, the Board notes that the June 2007 VA examiner further detailed that it would be speculative to comment further on range of motion, fatigability, incoordination, pain on flare-ups beyond what was already described in his report. The Board also finds there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization related to these service-connected disabilities that would take the veteran's case outside the norm so as to warrant the assignment of any extraschedular rating. While the Board notes that the veteran complained of foot pain that interfered with his job as a part-time barber, there is simply no objective evidence showing that either service- connected foot disability has resulted in marked interference with employment (i.e., beyond that contemplated in the assigned 30 and 10 percent ratings). Consequently, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER A 30 percent rating, but no higher, is granted for bilateral pes planus. A separate 10 percent rating, but no higher, is granted for mild degenerative changes at the first metatarsophalangeal joint of the right and left foot. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs