Citation Nr: 1031966 Decision Date: 08/25/10 Archive Date: 09/01/10 DOCKET NO. 08-31 534 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an initial evaluation higher than 10 percent for left (major) shoulder sprain. 2. Entitlement to an initial evaluation higher than 10 percent for left foot plantar fasciitis. 3. Entitlement to an initial compensable evaluation for hemorrhoids. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Sarah B. Richmond, Counsel INTRODUCTION The Veteran had active military service from October 1978 to October 1981 and November 1988 to June 2007. This matter comes to the Board of Veterans' Appeals (Board) from a September 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which granted service connection for left shoulder sprain with degenerative joint disease assigning a 10 percent rating, effective July 1, 2007, left foot plantar fasciitis assigning a 10 percent rating, effective July 1, 2007, and rectal hemorrhoids assigning a 0 percent rating, effective July 1, 2007. Jurisdiction over this case was subsequently transferred to the RO in Hartford, Connecticut. In July 2009, the Veteran testified before the undersigned Acting Veterans Law Judge at a Board hearing at the RO. A transcript of the hearing is of record. The Board remanded the claims in September 2009 for a VA examination as to the severity of the Veteran's service-connected disabilities on appeal, and to give the Veteran an opportunity to submit or notify VA of any additional evidence. As indicated below, the Appeals Management Center (AMC) substantially complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2009) ("substantial compliance" rather than "strict compliance" is required under Stegall) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999)). FINDINGS OF FACT 1. Left shoulder sprain is manifested pain, stiffness, and limitation of motion to 130 degrees of flexion, 100 degrees of abduction, 90 degrees of external rotation, and 45 degrees of internal rotation, and x-ray findings of mild degenerative changes in the acromioclavicular joint with small osteophyte formation. 2. Left plantar fasciitis is manifested by pain, fatigability, and lack of endurance with prolonged weight-bearing or walking, and some tenderness to palpation at the insertion of the fascia into the calcaneous, but not marked deformity, accentuated pain on manipulation and use, swelling on use, or characteristic callosities. 3. Hemorrhoids are manifested by anal itching, pain, constipation and tenesmus, swelling, and perianal discharge, and bleeding, but are not large or thrombotic, irreducible with excessive redundant tissue, evidence frequent recurrences or with secondary anemia or fissures. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 10 percent for left shoulder (major) strain are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010-5203 (2009). 2. The criteria for an initial evaluation in excess of 10 percent for left foot plantar fasciitis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5020-5276 (2009). 3. The criteria for an initial evaluation in excess of 0 percent for hemorrhoids are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1-4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 7336 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran participated in the Benefits Delivery at Discharge Program and was provided with the general criteria for substantiating a service connection claim including the criteria for assigning disability ratings and effective dates, and the responsibilities of the Veteran and VA to substantiate the record. He submitted this letter as part of his February 2007 original compensation claim. After the RO granted service connection for the disabilities on appeal in a September 2007 rating decision, the Veteran filed a notice of disagreement with the assigned ratings in October 2007. The RO readjudicated the claims continuing the ratings assigned in a July 2008 statement of the case and December 2009 supplemental statement of the case. In October 2009, the RO again provided the Veteran with a letter including the criteria for assigning disability ratings and effective dates. The notification substantially complied with the specificity requirements of Dingess v. Nicholson, 19 Vet. App. 473 (2006) identifying the five elements of a service connection claim; and Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence. The Veteran was not provided with notice on how to substantiate an increased rating claim. However, the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice has served its purpose. Dingess, 19 Vet. App. at 490; see also Goodwin v. Peake, 22 Vet. App. 128 (holding that "where a claim has been substantiated after the enactment of the VCAA, [the veteran] bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements."). As the Veteran was granted service connection and assigned an evaluation and effective date, the Secretary had no obligation to provide further notice under the statute. Dingess, 19 Vet. App. at 490. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and has not been prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). See also Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). Furthermore, the Board finds that there has been substantial compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, VA treatment records, hearing testimony, and VA examination reports. The Veteran was given the opportunity to notify VA or provide any additional treatment records but did not do so. There is no indication in the record of any outstanding evidence. The Veteran was afforded VA examinations in May 2007 and October 2009. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). As discussed below, these examination were adequate because they were based on consideration of the Veteran's prior medical history described the disabilities in sufficient detail to allow a fully informed evaluation by the Board. See Stefl v. Nicholson, 21 Vet.App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet.App. 405, 407 (1994)). Therefore, a further examination is not necessary. II. Analysis The RO granted service connection for left shoulder sprain, left foot plantar fasciitis, and rectal hemorrhoids in September 2007, assigning disability ratings effective July 1, 2007, the day after the Veteran's discharge from military service. The Veteran seeks entitlement to higher initial ratings for his service-connected disabilities. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a reasonable doubt as to the degree of disability, such doubt shall be resolved in favor of the claimant, and where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 3.102, 4.3, 4.7. In addition, the Board will consider the potential application of the various other provisions of 38 C.F.R., Parts 3 and 4, whether or not they were raised by the veteran, as well as the entire history of the veteran's disorder in reaching its decision, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran's claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Once the evidence is assembled, the Secretary is responsible for determining whether the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. Id. Left shoulder The Veteran's left (major) shoulder disability is evaluated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5010- 5203 for impairment of the clavicle or scapula due to arthritis. Under Diagnostic Code 5203, malunion of the clavicle or scapula on the minor or major side, or nonunion of the clavicle or scapula without loose movement on the minor or major side warrants a 10 percent rating. Nonunion of the clavicle or scapula with loose movement on the minor or major side, or dislocation of the clavicle or scapula on the minor or major side warrants a 20 percent rating. Alternatively, the shoulder is to be rated based on impairment of function of contiguous joint. Diagnostic Code 5010 provides that arthritis due to trauma substantiated by x-ray findings are to be rated as degenerative arthritis. Under Diagnostic Code 5003, 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 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. Normal range of motion in the shoulder is forward elevation (flexion) from 0 to 180 degrees, abduction from 0 to 180 degrees, external rotation from 0 to 90 degrees, and internal rotation from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. A May 2007 VA examination report shows the Veteran reported that in April 1998, he was in a motor vehicle accident and had shoulder pain as a result. X-rays were normal and did not confirm any pathology. He stated that he had pain and stiffness in the shoulder with repetitive use and that if he threw a ball or did any heavy lifting on the left side including overhead lifting, the day after his pain level would increase from a 1-2 out of 10 to an 8-9 out of 10. The shoulder also was sensitive to cold, damp weather, which caused his pain level to be at a 7-8 out of 10 and described as a sharp to dull, achy type pain lasting all day. He took non-steroidal anti-inflammatory drugs for minimal relief. He denied weakness, swelling, heat, redness, instability, giving way, "locking," fatigability, or lack of endurance. He currently worked from his home as a guidance counselor and denied any functional limitations at work due to his shoulder. However, he stated that he avoided picking up any boxes, as he was left hand dominant and more aware of items not to lift because of his left shoulder injury. In his activities of daily living, he avoided any overhead movements and no longer played baseball or bowled as a form of recreation. He also did not do pushups as a form of exercise. On physical examination of the shoulder, there was tenderness to palpation at the left distal clavicle. There were no constitutional signs of bone disease or objective evidence of deformity, angulation, false motion, shortening, or intra- articular involvement. There also was no malunion, nonunion, loose motion, false joint, tenderness, drainage, edema, painful motion, weakness, redness, or heat. Range of motion showed that forward flexion and abduction were from 0 to 170 degrees with pain at the endpoint. Shoulder external and internal rotation was from 0 to 90 degrees. The joint was painful on motion but the range of motion or joint function was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use. X-rays showed minimal productive changes of the distal clavicle and no evidence of fracture or dislocation. The x-ray impression was unremarkable left shoulder. The diagnosis was left shoulder sprain, as likely as not related to the initial motor vehicle accident, with mild degenerative joint disease on imaging and mild functional limitations with flare-ups. An October 2009 VA examination report shows the Veteran reported pain with performing yard work, such as mowing the lawn or raking the yard. He stated that with strenuous work the shoulder would bother him for three to four days. He reported that he used to be able to play volleyball for three to four hours and recently had only been able to play two games about half an hour. He last played about a month ago, which had caused an increase in his usual level of discomfort and pain. His shoulder hurt daily with reaching or lifting his arm, which had only been present since the re-injury. He had not gone to anyone for re-evaluation or done anything for the pain. He reported that his current pain is at a 6 out of 10, which interfered with his ability to sleep. He is left hand dominant and reports that at work he has pain with reaching across his desk to place papers into the copy machine. With repetitive motions he has to take a lot of breaks. This was not present prior to one month ago. He was able to perform his job but his shoulder reportedly slowed him down. He denied any surgery or dislocation or recurrent subluxation. On physical examination, no left shoulder ankylosis was shown. There was facial grimacing and guarding as objective evidence of painful motion. There was no edema, effusion, instability, weakness, tenderness, redness, heat, or abnormal movement. Shoulder forward flexion was from 0 to 130 degrees with pain to 180 degrees; abduction was 0 to 100 degrees with pain to 160 degrees; external rotation was from 0 to 90 degrees with pain at end range of motion; and internal rotation was from 0 to 45 degrees with pain and inability to progress further because of pain. He had pain including pain on repeated use and a recent flare-up following re-injury playing volleyball. He reported no fatigue, weakness, lack of endurance, or incoordination with repetition. X-ray examination showed no fracture, dislocation, or bone lesion. There were mild degenerative changes in the acromioclavicular joint with small osteophyte formation. There was no significant degeneration in the glenohumeral joint. The diagnosis was left shoulder impingement syndrome with recent (one month ago) re-injury following volleyball game. Currently there was mild functional impairment. Mild degenerative change in the acromioclavicular joint was as likely as not related to the service-connected condition. The record shows that the next higher 20 percent evaluation is not warranted for the left shoulder disability. The left shoulder disability is manifested by pain and stiffness in the shoulder after repetitive or strenuous use, mild functional impairment after a flare-up, limitation of motion most severely limited to 130 degrees of flexion, 100 degrees of abduction, 90 degrees of external rotation, and 45 degrees of internal rotation, and x-ray findings of mild degenerative changes in the acromioclavicular joint with small osteophyte formation. The medical evidence shows that there is no nonunion or dislocation of the clavicle and scapula, which is required for a 20 percent rating under Diagnostic Code 5203. The Veteran denied any surgery or dislocation or recurrent subluxation. X-rays showed no evidence of fracture or dislocation. There also was no objective evidence of deformity, angulation, false motion, shortening, intra-articular involvement, malunion, nonunion, loose motion, or false joint. Moreover, there is no indication of any functional impairment on a contiguous joint. A rating higher than 10 percent is not warranted under any of the other diagnostic codes pertaining to the shoulder. The medical evidence shows that there is no malunion or nonunion of the humerus; thus a rating under Diagnostic Code 5202 does not apply. Motion in the arm is not limited to shoulder level, i.e., 90 degrees of flexion or abduction. The most severe limitation was to 100 degrees of abduction with painful motion to 160 degrees, and he reported no fatigue, weakness, lack of endurance, or incoordination with repetition. Thus, a higher rating is not warranted under Diagnostic Code 5201. Last, a rating higher than 10 percent does not apply under Diagnostic Code 5200 for ankylosis of the scapulohumeral articulation. Ankylosis was not found on physical examination. In evaluating the Veteran's left shoulder claim, the application of a higher disability evaluation based on functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59 has been considered. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The May 2007 VA examination report indicated that while the left shoulder joint was painful on motion, the range of motion or joint function was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use. In the diagnosis section, the examiner indicated that there were mild functional limitations with flare ups. The October 2009 VA examination report indicated that there was no reported fatigue, weakness, lack of endurance, or incoordination with repetition, and these factors did not additionally limit the joint. The diagnosis indicated generally that there was mild functional impairment currently. In his Board hearing testimony, the Veteran indicated that, while he probably could life his left arm over his shoulder, the more he uses it, the weaker it becomes and the less range of motion that he has. Hearing transcript, p. 8. Thus, neither the lay nor medical evidence specifically indicates that, to the extent that there has been additional functional impairment due to pain or any of the other DeLuca factors, this functional limitation has actually or effectively limited motion of the arm to the shoulder level warranting a 20 percent rating under DC 5201. For the foregoing reasons, entitlement to an initial rating higher than 10 percent for left shoulder strain is not warranted. Left foot plantar fasciitis The Veteran's left foot plantar fasciitis is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Codes 5020-5276 for synovitis, which is to be rated based on limitation of motion as degenerative arthritis, and acquired flatfoot. Under Diagnostic Code 5276, a 10 percent evaluation is warranted for unilateral or bilateral moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo Achilles, pain on manipulation and use of the feet. A 20 percent evaluation is warranted for severe unilateral flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A 30 percent rating is assigned for the same findings for severe flatfoot if the disability is bilateral. A 30 percent evaluation also is warranted for pronounced unilateral flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances. A 50 percent evaluation is warranted for the same findings for pronounced flatfoot if the disability is bilateral. Under Diagnostic Code 5003, 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.). In the absence of limitation of motion rate as 10 percent disabling with x-ray evidence involvement of 2 or more major joints or 2 or more minor joint groups; and 20 percent disabling with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. A May 2007 VA examination report shows the Veteran reported that he recently developed left foot pain six to seven months ago and was seen in the emergency room and diagnosed with plantar fasciitis of the left heel. He was advised to stretch his left foot, use Motrin as needed, and avoid prolonged weight-bearing. He purchased orthotics on his own, which did not relieve the pain. X-rays of the foot were normal and did not show any bone spurs or other causes for his pain. He stated that with weight- bearing he had pain, fatigability, and lack of endurance, but no redness, heat, stiffness, or incoordination. At rest, the pain level was at a 1 to 2 out of 10 and with standing or walking at a 9 to 10 out of 10. He had flare-ups with walking and prolonged standing and also sometimes in bed he had sharp heel pain. Motrin provided minimal relief and sitting down also relieved the pain. Regarding any effect on employment, the Veteran had to do a lot of walking on his daily commute and had increased pain until he arrived at the office. He was presently looking for local jobs that did not require weight-bearing or prolonged walking. On physical examination, there was tenderness to palpation at the insertion of the fascia into the calcaneous. The gait was normal and there were no callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight-bearing. There were no skin or vascular changes and the Veteran's posture on standing, squatting, supination, pronation, and rising on toes was normal. There was no other deformity including hammertoes, high arch, clawfoot, or hallux valgus. There was normal weight- bearing and non-weight bearing alignment of the Achilles. The diagnosis was left foot plantar fasciitis likely having occurred during active duty with mild to moderate functional limitations with flare-ups. An October 2009 VA examination report shows the Veteran reported that the left foot plantar fasciitis started about four months prior to his discharge around the same time he was required to wear boots. At that time, he reported pain in the heel of his foot with running and would have to stop and walk. He had been able to do this for 30 years prior without a problem. His foot continued to get worse and he was not able to pass his physical therapy test; so he decided to retire. At his retirement physical he was given a diagnosis of plantar fasciitis. Since retirement, he developed pain with walking about 10 blocks to work that could last for several days. He tried to buy shoes that were comfortable. On a monthly basis, he reported that his feet bothered him about three to four times a month on the left. He bought arch supports that he used in certain shoes; with other shoes there was good support and no need for the arch supports. There was no weakness, stiffness, swelling, heat, or redness. There was fatigability and lack of endurance with prolonged walking. At rest, his foot felt okay; after standing for one to one and a half hours his foot would start to bother him. He was able to walk about one to one and a half miles before his foot started to bother him. He stated that he was offered a position as a postal carrier after he retired and reported that he turned it down due to the foot pain. He reported that he worked in an office position with no particular impact from his foot. He no longer ran due to his left foot and his private life was impacted in his ability to play with his grandchildren. On physical examination, he had a brisk gait with no limping, or limitation on walking or standing. There was no objective evidence of painful motion, edema, instability, weakness, or tenderness. There also were no callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight- bearing. There were no skin or vascular changes, or pain reported at the insertion of the plantar tendon to calcaneous to firm palpation. The Veteran's posture was erect on standing, squatting, and rising on toes and heels. He was able to perform supination and pronation. There were no hammertoes, high arch, or clawfoot noted. The Veteran had a normal arch of the left foot and no hallux valgus was noted. X-ray examination showed no fracture, dislocation, bone lesion, or significant degenerative changes; there also was no significant pes planus deformity or midfoot vulgus. The diagnosis was left foot plantar fasciitis, and intermittent and mild functional impairment as subjectively reported. The Veteran testified during the Board hearing that he experienced excruciating pain due to his left foot disability. Hearing Transcript, p. 5. He indicated that he had calluses on his heel but did not know if it could be attributed to his left foot plantar fasciitis. The record shows that the next higher 20 percent evaluation is not warranted for the Veteran's left plantar fasciitis under DC 5276. The lay and medical evidence shows that the plantar fasciitis is manifested by pain, fatigability, and lack of endurance with prolonged weight-bearing or walking, and some tenderness to palpation at the insertion of the fascia into the calcaneous. However, the mostly normal findings on the May 2007 VA examinations show that there was no objective evidence of marked defomrity, accentuated pain on manipulation and use, swelling on use, or callosities. The Veteran did testify that he had calluses on his heel. However, the Board finds that the specific May 2007 and October 2009 VA examinaiton findings by trained professionals outweigh the Veteran's general testimony, and that the weight of the evidence thus reflects that there were no characteristic callosities. Thus, a rating higher than 10 percent is not warranted under Diagnostic Code 5276 because the symptoms do not more nearly approximate those in the criteria for a 20 percent rating under DC 5276. A higher rating also is not warranted under any other diagnostic codes pertaining to the foot including Diagnostic Code 5278 for clawfoot, Diagnostic Code 5283 for malunion or nonunion of the tarsal or metatarsal bones, or Diagnostic Code 5284 for other foot injuries (20 percent rating warranted for moderately severe foot injury). The Veteran's posture on standing, squatting, supination, pronation, and rising on toes was normal; and there was no other deformity including hammertoes, high arch, clawfoot, or hallux valgus. There was normal weight-bearing and non-weight bearing alignment of the Achilles. He was able to perform supination and pronation. X-ray examination showed no fracture, dislocation, bone lesion, or significant degenerative changes; there also was no significant pes planus deformity or midfoot vulgus. A rating higher than 10 percent also does not apply under Diagnostic Code 5003 for degenerative arthritis, as x-ray examination was normal with no significant degenerative changes shown. To the extent that the left foot plantar fasciitis is at least partly rated on the basis of limitation of motion, a higher disability evaluation based on functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59 has been considered. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran has foot pain causing functional impairment with prolonged standing and walking. This functional impairment, however, is considered by the 10 percent rating assigned under DC 5276, and there is no indication that it causes symptoms equivalent to those in the criteria for a higher rating under any potentially applicable diagnostic code. For the above reasons, the evidence reflects that entitlement to an initial rating higher than 10 percent is not warranted for the Veteran's plantar fasciitis. Hemorrhoids The Veteran's hemorrhoids are rated as noncompensable (0 percent) under 38 C.F.R. § 4.114, Diagnostic Code 7336. Under Diagnostic Code 7336, mild or moderate external or internal hemorrhoids are rated noncompensably (0 percent) disabling. A 10 percent rating is assigned if the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is assigned for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. In Tatum v. Shinseki, 23 Vet. App. 152 (2009), the Court indicated that except where a diagnostic code uses "successive rating criteria," if there is a question as to which disability rating most accurately reflects a claimant's disability picture, the Board must discuss whether the effects of the claimant's disability warrants a higher rating under 38 C.F.R. § 4.7, irrespective of formal rules of construction. Id. at 155-156. DC 7336 does not employ successive rating criteria; instead it is possible to have all of the criteria for a 20 percent rating without any of the requirements for a 10 percent rating. Id. at 156. A May 2007 VA examination report shows that the Veteran had had chronic pain and bleeding intermittently since entering the Army and was advised to change his diet, eat more fiber, and avoid constipation. He had a colonoscopy confirming internal and external hemorrhoids and a banding procedure done in 2005; however the procedure reportedly failed, as he had bleeding rectally four to five times per week. Current symptoms included anal itching, diarrhea, pain, tenesmus, swelling, and perianal discharge, in addition to intermittent rectal bleeding. Current treatment consisted of taking Metamucil pills, stool softeners, and sitz baths, but these provided little relief. With respect to any effect on occupational functioning, he had intermittent bleeding and rectal itch and had become aware that he had to use the bathroom more frequently to be sure he was not spotting his trousers, due to the embarrassment he would face at work. He avoided prolonged sitting that would increase his hemorrhoids, and was told by his doctor that he needed to stand up every 15 to 20 minutes at work to take the pressure off his rectum. He denied any functional limitations in his activities of daily living. On physical examination, there was one small external hemorrhoid visible. There was no melena but there was subjective discomfort and tenderness in the anal sphincter due to the visible palpable hemorrhoid. The diagnosis was rectal hemorrhoids that were likely exacerbated in the service as a result of prolonged sitting in his occupation as a recruiter and dietary indiscretion, with mild functional limitations. His complete blood count was normal and there was no evidence of anemia due to subjective episodes of intermittent hematochezia. An October 2009 VA examination report shows that the claims file documented internal hemorrhoids in 1995 for which the Veteran underwent a sigmoidoscopy with notation of internal hemorrhoids only. There only conservative treatment. At present, the Veteran reported that he first started to have problems with hemorrhoids about 15 years ago, which started as mild blood on the toilet paper. Over time he got them banded and following this, he reported minimal symptoms. Over the past two years, he reported itching and some bleeding but not much pain. He had constipation with some difficulty moving his bowels and some pain. He treated the hemorrhoids with cream once a month when the hemorrhoids got swollen. He indicated that the bleeding varied; once it started it would bleed lightly for several weeks, then stop. He had not had any re-evaluation. His current symptoms included intermittent anal itching, diarrhea, pain, tenesmus, swelling, and perianal discharge. There was no fecal incontinence reported. The hemorrhoids caused intermittent bleeding but no thrombosis. On physical examination, the Veteran appeared to sit comfortably. There was no colostomy or evidence of fecal leakage. He had a normal size anal/rectal lumen. There were no signs of anemia, fissures, or frank hemorrhoids. There also was no evidence of redundant tissue, thrombosed hemorrhoids, bleeding, or rectal prolapse. There was good sphincter tone to digital rectal examination. The diagnosis was internal hemorrhoids with no functional impairment and subjective reports of external hemorrhoids. During the Board hearing, the Veteran testified, "I've always had a bit of bleeding, excessive I would say," in addition to itching and an increase in size of the hemorrhoids. Board Hearing Transcript, p. 6. Thus, the evidence reflects that the Veteran's hemorrhoids are manifested by anal itching, pain, constipation and tenesmus, swelling, and perianal discharge, in addition to intermittent rectal bleeding. There were no findings of hemorrhoids that were large or thrombotic, irreducible, with excessive redundant tissue, fissures, or anemia. While the VA examination reports indicated either intermittent or no bleeding, the Veteran testified that he always had bleeding, and that he perceived his hemorrhoids as getting larger. The Veteran is competent to testify to his perception of bleeding and the size of his hemorrhoids. Even assuming frequent bleeding, the absence of any other symptoms in criteria for a 10 or 20 percent rating warrants a finding that the symptoms more nearly approximate those in the criteria for a noncompensable rating. To the extent that the Veteran perceived his hemorrhoids getting larger, the findings of trained physicians that there were "one small external hemorrhoid" and no "frank hemorrhoids" are more probative than the general statement of the Veteran as to whether or not the hemorrhoids are large. A higher rating also is not warranted under Diagnostic Codes 7332 for impairment of sphincter control in the rectum and anus, Diagnostic Code 7333 for stricture of the rectum and anus, Diagnostic Code 7334 for prolapse of the rectum, or Diagnostic Code 7335 for fistula in ano. There were no signs of fecal leakage, fissures, or rectal prolapse, and sphincter tone was good on digital rectal examination. The anal/rectal lumen also was normal size. Thus, the Veteran is not entitled to an initial compensable rating for his hemorrhoids. Summary The above evidence reflects that the level of impairment involved with the left shoulder, left foot, and hemorrhoids has been relatively stable throughout the appeals period, or at least has never been worse than what is warranted for the ratings assigned. Therefore, staged ratings (i.e., different percentage ratings for different periods of time) are inapplicable. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration has also been given regarding whether the schedular evaluation is inadequate, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. If so, the appeal must be referred for consideration of the assignment of an extraschedular rating, otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The discussion above reflects that the impairment associated with the left shoulder, left foot, and hemorrhoids disabilities is adequately considered by the applicable diagnostic codes and the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disabilities. Moreover, the Veteran has not required frequent periods of hospitalization due to the service-connected disabilities, and marked interference with employment has not been shown. The Veteran reported that he has to avoid jobs requiring overhead lifting, prolonged standing, and walking due to his shoulder and foot disabilities and that his hemorrhoids require him to avoid sitting for too long and to frequently visit the bathroom. However, the record does not show, nor has the Veteran asserted that he has had to miss any work because of his service-connected disabilities. The Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. An inferred claim for a total disability rating for individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) also has been considered. The record shows that the Veteran continues to be employed full-time. While he reports suffering pain during his commute to work with respect to the feet, functional limitations in reaching overhead with respect to his shoulder, and having to avoid prolonged sitting with respect to the hemorrhoids, the issue of unemployability has not been raised by the record. Therefore, any inferred TDIU claim is inapplicable in this case. As the preponderance of the evidence is against the initial rating claims for the left shoulder, left foot, and hemorrhoids, there is no doubt to be resolved, these claims must therefore be denied. Gilbert v. Derwinski, 1 Vet. App. at 57-58. ORDER Entitlement to an initial evaluation higher than 10 percent for left (major) shoulder sprain is denied. Entitlement to an initial evaluation higher than 10 percent for left foot plantar fasciitis is denied. Entitlement to an initial compensable evaluation for hemorrhoids is denied. ____________________________________________ J. HAGER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs