Citation Nr: 1136136 Decision Date: 09/26/11 Archive Date: 10/03/11 DOCKET NO. 07-29 235 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a compensable disability rating for left shoulder impingement syndrome. 2. Entitlement to a compensable disability rating for right wrist tendinitis. 3. Entitlement to a compensable disability rating for gastroesophageal reflux disease (GERD). 4. Entitlement to a compensable disability rating for bilateral pes planus with plantar fasciitis. 5. Entitlement to a compensable disability rating for residuals scar, left great toe. 6. Entitlement to a higher initial rating for cholecystectomy with biliary dyskinesia, currently rated 10 percent disabling. 7. Entitlement to a compensable disability rating for thrombophlebitis, left leg. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. N. Moats, Counsel INTRODUCTION The Veteran served on active duty from September 1979 to September 2005. This matter comes to the Board of Veterans' Appeals (Board) from a December 2005 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing in April 2009. The Board remanded these issues for further development in July 2009. FINDINGS OF FACT 1. The Veteran's service-connected left shoulder impingement is manifested by pain and limitation of motion at shoulder level, but without objective findings of recurrent dislocation of the scapulohumeral joint, ankylosis or limitation to 25 degrees from side. 2. The Veteran's service-connected right wrist tendinitis has been manifested by subjective complaints of pain, but without objective findings of dorsiflexion limited to less than 15 degrees or palmar flexion limited in line with forearm. 3. The Veteran's service-connected GERD has been manifested by subjective complaints of heartburn, but without objective findings of two or more symptoms. 4. The Veteran's service-connected bilateral pes planus with plantar fasciitis is productive of moderate symptoms, but without objective findings of severe symptoms characteristic of marked deformity, indication of swelling on use or callosities. 5. The Veteran's service-connected residual scar, left great toe is manifested by tenderness and skin breakdown. 6. The Veteran's service-connected cholecystectomy with biliary dyskinesia is productive of mild symptoms, and does not more nearly approximate a disability picture consistent with severe symptoms. 7. The Veteran's service-connected thrombophlebitis is currently asymptomatic without objective findings of occasional complaints of swelling and objective findings of intermittent edema of the extremity or aching and fatigue in the leg after prolonged standing or walking, but without objective findings of persistent edema, incompletely relieved by elevation of the extremity. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability evaluation of 20 percent, but no higher, for left shoulder impingement have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.71(a), Diagnostic Code 5201 (2010). 2. The criteria for entitlement to an initial compensable disability evaluation for right wrist tendinitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.71(a), Diagnostic Code 5215 (2010). 3. The criteria for entitlement to an initial compensable disability evaluation for GERD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including 4.7, 4.114, Diagnostic Code 7346 (2010). 4. The criteria for entitlement to an initial disability evaluation of 10 percent, but no higher, for bilateral pes planus with plantar fasciitis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.71(a), Diagnostic Code 5276 (2010). 5. The criteria for entitlement to an initial disability evaluation of 10 percent, but no higher, for residual scar, left great toe, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.118, Diagnostic Code 7804 (in effect prior to October 23, 2008). 6. The criteria for entitlement to an initial disability evaluation in excess of 10 percent for cholecystectomy with biliary dyskinesia have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.1114, Diagnostic Code 7318 (2010). 7. The criteria for entitlement to an initial compensable evaluation for thrombophlebitis, left leg, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.104, Diagnostic Code 7121 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet.App. 183, 187 (2002). Duty to Notify The Board remanded this case in July 2009 because the Veteran had not received notice with respect to these issues pursuant to the VCAA. On remand, in a January 2010 VCAA letter, the appellant was informed of the information and evidence necessary to warrant entitlement to the benefits sought on appeal. The appellant was also advised of the types of evidence VA would assist her in obtaining as well as her own responsibilities with regard to identifying relevant evidence. See Quartuccio v. Principi, 16 Vet.App. 183 (2002); Charles v. Principi, 16 Vet.App. 370 (2002). The United States Court of Appeals for Veterans Claims' decision in Pelegrini v. Principi, 18 Vet.App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. The Board recognizes that the January 2010 VCAA notice was provided after the initial decision. However, the deficiency in the timing of this notice was remedied by readjudication of the issues on appeal in a subsequent supplemental statement of the case. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Further, 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). In the present, the January 2010 letter gave notice of the types of evidence necessary to establish a disability rating and effective date for the disabilities on appeal. At this point the Board acknowledges the decision of the United States Court of Appeals for Veterans Claims (Court) in Vazquez-Flores v. Peake, 22 Vet.App. 37 (2008) which noted that for an increased-compensation claim, 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. The Court further indicated, among other things, that 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), VA must provide at least general notice of that requirement to the claimant. However, the Board believes that the nature of the present appeal is somewhat different from the situation addressed in Vazquez-Flores because the present appeal involves the issues of higher initial ratings, not a claim for an increased rating. Regardless, the U.S. Court of Appeals for the Federal Circuit recently reversed the Court's holding in Vazquez-Flores, to the extent the Court imposed a requirement that VA notify a Veteran of alternative diagnostic codes or potential "daily life" evidence. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Reviewing the January 2010 correspondence in light of the Federal Circuit's decision, the Board finds that the Veteran has received 38 U.S.C.A. § 5103(a)-compliant notice as to his claim. Accordingly, the Board finds that the RO has complied with the July 2009 remand with respect to the VCAA notice requirements. See Stegall v. West, 11 Vet.App. 268 (1998); Dyment v. West, 13 Vet.App. 141 (1999); D'Aries v. Peake, 22 Vet. App. 97 (2008). In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes service treatment records, private treatment records and VA examination reports. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. Initially, the Veteran was afforded a VA examination in May 2005. However, in its remand, the Board directed the RO to schedule additional VA examinations. In accordance with the remand, the Veteran was afforded a VA examination in April 2010. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The examination reports obtained contain sufficient information to decide the issues on appeal. See Massey v. Brown, 7 Vet.App. 204 (1994). Thus, the Board finds that a further examination is not necessary. The Board determines that the RO had also complied with the Board remand with respect to its duty to assist. For all the foregoing reasons, the Board concludes that VA's duties to the claimant have been fulfilled with respect to the issues on appeal. Analysis Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). In the present case, it should also be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet.App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Left Shoulder Impingement The Veteran is seeking an initial compensable rating for her service-connected left shoulder impingement. The Veteran's service-connected left shoulder disability has been rated by the RO under the provisions of Diagnostic Code 5201, which provides the rating criteria for evaluation of limitation of motion of the arm, states that a 20 percent rating is warranted when motion is limited at shoulder level for both arms or midway between side and shoulder level for the minor arm; a 30 percent rating when motion is limited midway between side and shoulder level for major arm or to 25 degrees from side for minor arm; and a 40 percent when motion is limited to 25 degrees from side for major arm. 38 C.F.R. § 4.71(a), Diagnostic Code 5201. Normal forward flexion and abduction of the shoulder are from 0 degrees to 180 degrees with 90 degrees being at shoulder level and external and internal rotation if from zero to 90 degrees. 38 C.F.R. § 4.71, Plate I. Prior to her retirement, the Veteran was afforded a VA examination in May 2005. It appears that the claims file review was incomplete. The Veteran reported limited range of motion with adduction, posterior extension, as well as problems carrying a back pack and sleeping on her left side. There were no fixations, swelling or discoloration. It was noted that the Veteran was right-hand dominant. On physical examination, there was no asymmetric appearance, effusion, or crepitus. Range of motion was 180 degrees flexion, 140 degrees abduction, 70 degrees internal rotation and 90 degrees external rotation. The examiner diagnosed chronic left shoulder impingement, stage III, recurrent. The examiner observed that the condition would likely worsen due to it progressive nature. It would not affect the Veteran's activities of daily living in the short time. Unfortunately, the examiner did not consider additional functional loss pursuant to DeLuca. In her August 2006 notice of disagreement, the Veteran indicated that range of motion testing was not done during the VA examination. She provided that she was unable to raise her left arm above her head or do any overhead work. She asserted that her movement was limited to her left shoulder. In her September 2007 substantive appeal, the Veteran again asserted that the examination was inadequate as range of motion testing was not done. She asserted that her shoulder disability should be rated at a minimum of 20 percent because she was unable to do regular overhead work. Post service private treatment records have been associated with the claims file. May 2007 and November 2007 records showed that pain was elicited by motion of the shoulder. The November 2007 record showed that range of motion was 110 degrees flexion with pain at end range and abduction was 100 degrees. At the April 2009 Board hearing, the Veteran reported limitation of movement. She indicated that she could not sleep on her left shoulder or do any overhead work. She could not carry a purse or do any lifting. She reported that she was on numerous medications. She had begun to report that she could not lift her shoulder past a certain point, but she was cut off by her representative. In a subsequent February 2010 statement, she again asserted that she experienced pain. On remand, the Veteran was afforded another VA examination in April 2010. The claims file was reviewed. The Veteran reported shoulder pain leaving her unable to perform overhead activities or abduct properly. She again indicated that she was unable to sleep on the left shoulder. The Veteran stated that she experienced pain, stiffness, weakness and tenderness, but no deformity, giving way, instability, incoordination, decreased speed of joint motion, dislocation or subluxation, locking episodes or effusion. On physical examination, it was observed that there were no recurrent dislocations. The examiner found tenderness, weakness, abnormal motion and guarding of movement. There was objective evidence of pain with active motion. Range of motion was 100 degrees flexion, 70 degrees abduction, 60 degrees internal rotation and 70 degrees external rotation. The examiner also indicated that there was objective evidence of pain following repetitive motion, but there were no additional limitations after three repetitions. There was no joint ankylosis. An x-ray of the shoulder was normal. It was noted that the Veteran was employed full-time as a clinical administrator. She had lost four weeks of work during the last 12 month period. The diagnosis was rotator cuff tendinitis. It was noted to have significant effects on her occupation in that she had problems lifting and carrying and experienced decreased strength and pain. There was a mild effect on chores, shopping, recreation, traveling and dressing and a moderate effect on exercise and sports. However, no other effects on daily activities of living were found. Given that the claims file was reviewed by the examiner and the examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination to be sufficient for rating purposes. The Board also observes that the Veteran was afforded a VA examination for her service-connected fibromyalgia in January 2011. The examiner observed that she had signs and symptoms of left shoulder tendonitis, which was separate from the tender points of her fibromyalgia. After reviewing the totality of the evidence and when resolving the benefit of the doubt in favor of the Veteran, the Board finds that a 20 percent disability rating is warranted under Diagnostic Code 5201. The most recent VA examination clearly indicated that abduction was below shoulder level, which is one of the criteria for a 20 percent rating. Further, the Veteran has consistently reported pain on motion throughout the appeal period and indicated that she could not lift her arm above shoulder level. Private treatment records also showed painful motion. Given the insufficiency of the May 2005 VA examination in that DeLuca was not addressed and based on the Veteran's assertions, the Board finds that the Veteran's disability picture has been consistent throughout the entire appeal period. In turn, a 20 percent rating is warranted from the date after the Veteran's retirement from service. See Fenderson. Nevertheless, the Board finds that a rating in excess of 20 percent is not warranted. There is no objective finding that limitation of motion of the arm has been limited to 25 degrees from the side for a higher rating under Diagnostic Code 5201 for the minor arm. Again, the most recent examination documented range of motion at much higher than 25 degrees. Importantly, the Veteran herself has never asserted that she could not move her left arm higher than 25 degrees. Further, the remaining Diagnostic Codes applicable to the shoulder and arm are not for application. Diagnostic Code 5203 does not provide for a rating in excess of 20 percent. Further, Diagnostic Code 5200 is not applicable because there has been no competent medical evidence showing that the Veteran has ankylosis of his left shoulder. Moreover, Diagnostic Code 5202 is also not for application because there has been no objective finding of recurrent dislocation of the scapulohumeral joint. The most recent VA examination clearly found no ankylosis or recurrent dislocations. The Board acknowledges that the Veteran has chronic shoulder pain and thus, recognizes the application of 38 C.F.R. §§ 4.40 and 4.45, and DeLuca, supra. However, a higher compensation is not warranted under these provisions because the Veteran does not have additional functional loss due to pain, weakness, fatigue, or incoordination, which would limit motion to such a degree so as to warrant a rating in excess of the 20 percent disability rating assigned in this decision. Importantly, the April 2010 VA examiner found no additional limitations after three repetitions. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of her left shoulder disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. Medical evidence is generally required to address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this case, however, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In conclusion, the Board concludes that a 20 percent disability rating, but no higher, is warranted for the Veteran's service-connected left shoulder impingement. Right Wrist Tendinitis The Veteran is also seeking a compensable rating for her service-connected right wrist tendinitis. The Veteran's right wrist disability has been rated by the RO under Diagnostic Code 5215, which provides that the maximum rating allowed for disability resulting from limitation of motion of the wrist is 10 percent. This rating is applicable when there is limitation of motion of the wrist with dorsiflexion less than 15 degrees or with palmar flexion limited in line with the forearm. Higher ratings are available under Diagnostic Code 5214 when there are objective findings of ankylosis of the wrist. 38 C.F.R. § 4.71(a), Diagnostic Codes 5214-5215. Normal range of motion of the wrist is as follows: wrist dorsiflexion (extension ) 0 to 70 degrees; wrist palmar flexion 0 to 80 degrees; wrist ulnar deviation 0 to 45 degrees; and wrist radial deviation 0 to 20 degrees. 38 C.F.R. § 4.71, Plate I. At the May 2005 VA examination, the Veteran reported pain with gripping and holding solid objects. It was noted that the Veteran was right hand dominant. Physical examination showed no asymmetric appearance. The Veteran exhibited a good grip bilaterally and sensation was intact. Radial/ulnar deviation was 20/45 and dorso/palmar flexion was 50/60 bilaterally. The diagnosis was bilateral wrist tendinitis. The examiner opined that future exacerbations were likely to occur, but would not affect the Veteran's activities of daily living. Again, no opinion pursuant to DeLuca was provided. In her notice of disagreement, the Veteran asserted that she experienced limited motion due to pain. She was unable to carry items that caused her to flex her wrist. She again asserted that range of motion testing was not done at the examination. In her substantive appeal, she asserted that her disability rating should be at least 20 percent because she was unable to have full range of motion and she was not examined at the examination. Post service private treatment records in May and November 2007 indicated that the wrists showed no abnormalities. At the Board hearing, the Veteran reported that she could not lift her three year old grandchild, open jars or put stockings on. She indicated that she also had to wear slip on shoes. She also reported that a doctor was recommending a nerve conduction study because her hands were going numb. She reported that her wrist was real painful and sore; and the pain radiated into her thumb. At the April 2010 VA examination, the Veteran denied having carpal tunnel syndrome, but did not know the diagnosis. She had problems lifting objects and bending the wrist caused pain and discomfort. The pain had been noticed to radiate into her thumb. While there was pain, there was no deformity, giving way, instability, stiffness, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking episodes or effusion. There were no flare-ups reported and the disability did not affect the motion of the joint. On physical examination, pain at rest was observed. There was no objective evidence of pain with active motion. Range of motion was 70 degrees dorsiflexion, 80 degrees palmar flexion, 20 degrees radial deviation, and 45 degrees ulnar deviation. There was no objective evidence of pain following repetitive motion. Further, there were no additional limitations after three repetitions. There was no joint ankylosis. An x-ray of the right wrist was normal. Again, it was noted that the Veteran was employed. The diagnosis was right wrist, chronic tendinitis. The impact on occupational activities was difficulty with lifting and carrying as well as pain. There were no effects on usual daily activities. Again, given that the claims file was reviewed by the examiner and the examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination to be sufficient for rating purposes. The Board also observes that the Veteran was afforded a VA examination for her service-connected fibromyalgia in January 2011. The examiner observed that she had signs and symptoms of right wrist tendonitis, which was separate from the tender points of her fibromyalgia. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the grant of a compensable rating for the Veteran's service-connected right wrist tendinitis. Although some limited motion was noted at the May 2005 VA examination, motion was clearly not limited to less than 15 degrees dorsiflexion and palmar flexion was not found to be limited in line with forearm. Importantly, follow up private treatment records observed no wrist abnormalities and the most recent VA examination found normal range of motion of the right wrist, with no objective findings of pain on motion. The examination also found no effects on the Veteran's activities of daily living. Based on a review of the evidence of record, the Board concludes that the criteria for a compensable evaluation for under Diagnostic Code 5215 have not been met. Moreover, as there has been no objective evidence of ankylosis, the award of a compensable rating under Diagnostic Code 5214 is also not appropriate. The Board has specifically considered the guidance of DeLuca (discussing 38 C.F.R. §§ 4.40, 4.45); however, the analysis in DeLuca does not assist the Veteran, as there is no medical evidence to support a finding that the Veteran's disorder is manifested by limitation of motion, loss of function, or weakness to warrant a compensable evaluation. The April 2010 VA examiner found no objective evidence of pain following repetition and there were no additional limitation after three repetitions. Again, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of her right wrist disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. With respect to this issue, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In summary, for the reasons and bases expressed above, the Board has concluded that a preponderance of the evidence is against the Veteran's claim for a compensable rating for right wrist tendinitis. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). GERD The Veteran is also seeking an initial compensable rating for her service-connected GERD, which has been rated by the RO under the provisions of Diagnostic Code 7346 for hiatal hernia. Under this provision, symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health warrant a 60 percent disability rating. Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health warrants a 30 percent disability rating. Two or more of the symptoms for the 30 percent evaluation of less severity warrant a 10 percent disability rating. 38 C.F.R. § 4.114, Diagnostic Code 7346. At the May 2005 VA examination, the Veteran reported that her GERD was controlled with daily medication use. No other objective findings were given. GERD was diagnosed. In her notice of disagreement, the Veteran reported that she experienced constant reflux, even when taking medications. She reported that she was taking medications twice a day without adequate relief. In her substantive appeal, she asserted that her GERD should be rated at a minimum of 30 percent because her symptoms were not relieved even after taking medication twice a day. An April 2007 VA treatment record indicated that the Veteran reported having GERD and wanted Prilosec, which had worked for her. Post service private treatment records showed heartburn, but no dysphagia, nausea, vomiting or abdominal pain. A November 2007 private record indicated that the heartburn was controlled with Prilosec. At the Board hearing, the Veteran testified that she experienced regurgitation daily as well as problems swallowing. She indicated that her pain medications aggravated her GERD. A follow up February 2010 statement indicated that her prescribed medications only alleviated some of the symptoms, not all. At the April 2010 VA examination, the Veteran reported that she was now on Nexium with mixed results. She avoided acid laden foods, but otherwise her condition was relatively controlled. The Veteran indicated that there was no vomiting, dysphagia, hematemesis, melena or regurgitation. However, she did report heartburn or pyrosis several times a week. On physical examination, there were no signs of anemia. Again, it was noted that the Veteran was employed, but had missed four weeks of work during the last 12-month period. The diagnosis was GERD. There were no significant effects on occupation or daily activities. Given that the claims file was reviewed by the examiner and the examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination to be sufficient for rating purposes. Based on the medical evidence of record, the Board must conclude that a compensable rating for GERD is not warranted. There is simply no objective findings of two or more symptoms outlined under the 30 percent criteria to warrant a 10 percent evaluation or higher. Treatment records and VA examinations continually showed that the only consistent symptom experienced by the Veteran experienced was heartburn. Although the Veteran reported dysphagia or regurgitation at times, the medical evidence of record specifically found no objective evidence of these symptoms. Moreover, the medical evidence also showed that this condition was relatively controlled with medication. Importantly, the most recent VA examiner again found no effects on the Veteran's activities of daily living. Further, 38 C.F.R. § 4.114 provides that ratings under codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. In the instant case, the Veteran has been rated separate under Diagnostic Code 7318 for cholecystectomy, which as discussed in more detail below reflects the predominant disability picture. Accordingly a compensable rating under Diagnostic Code 7346 is also not allowed pursuant to 38 C.F.R. § 4.114. Again, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of her GERD. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. With respect to this issue, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In conclusion, for the reasons and bases expressed above, the Board has concluded that the preponderance of the evidence is against the Veteran's claim for a compensable rating for GERD. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. Bilateral Pes Planus with Plantar Fasciitis The present appeal also includes the issue of entitlement to a compensable rating for the Veteran's service-connected bilateral pes planus with plantar fasciitis. The RO has rated the Veteran's bilateral foot disability as noncompensable under Diagnostic Code 5276. Under Diagnostic Code 5276 for flatfoot, a 10 percent rating, regardless of whether the condition is unilateral or bilateral, indicates it is moderate with the weight-bearing line over or medial to the great toe, inward bowing of the tendon Achilles, and pain on manipulation and use of the feet. A 20 percent rating for unilateral pes planus or a 30 percent rating for bilateral pes planus requires a severe condition with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indications of swelling on use, and characteristic callosities. A 30 percent rating for unilateral pes planus or a 50 percent rating for bilateral pes planus requires a pronounced condition manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendon Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The Board must also determine whether a higher rating is warranted under other diagnostic codes applicable to the foot. Disabilities of the foot are rated under Diagnostic Codes 5276 to 5284. 38 C.F.R. § 4.71a. However, the Board notes that Diagnostic Codes 5277, 5278, 5279, 5280, 5281, 5282 and 5283 are not for application in the instant case because there has been no objective findings of weak foot (Diagnostic Code 5277), claw foot (Diagnostic Code 5278), metatarsalgia (Diagnostic Code 5279), hallux rigidus (Diagnostic Code 5281), hammer toe (Diagnostic Code 5282) or malunion or nonunion of tarsal or metatarsal bones (Diagnostic Code 5283). Turning to applicable diagnostic codes, Diagnostic Code 5280 provides for a 10 percent disability rating for unilateral hallux valgus with resection of the metatarsal head, or severe enough to be equivalent of amputation of the great toe. Diagnostic Code 5284 provides criteria for rating other foot injuries. A moderate foot injury warrants a 10 percent disability evaluation. A moderately severe foot injury warrants a 20 percent disability evaluation and a severe foot injury is assigned a 30 percent disability evaluation. A note to Diagnostic Code 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Codes 5280, 5284. At the May 2005 VA examination, the Veteran reported having to wear shoe inserts and experiencing pain four to five times a year. Examination of the feet revealed moderate pes planus. There was no asymmetric appearance. The extremities were warm and sensation was intact. There was no tenderness to palpation at plantar surface of feet. Eversion and inversion range of motion was normal. Plantar flexion was 35 degrees and dorsoflexion was 20 degrees. The diagnoses were bilateral pes planus and bilateral plantar fasciitis. It was observed that the Veteran's pes planus was likely a contributing factor to plantar fasciitis. Condition would not likely interfere with Veteran's activities of daily living. In her notice of disagreement, the Veteran reported constant arch pain. She indicated that the pain was not relieved by corrective foot wear. She also provided that she does not have corrective foot wear, but rather wore inserts, which could only be used with certain foot wear. The inserts had been corrected several times due to continuing pain. In her substantive appeal, the Veteran reported that she had developed calluses on her left foot and was unable to walk properly. The Veteran indicated that she believed she should receive a 30 percent disability rating because she continued to have constant pain and she was not examined during the examination. Post service private treatment records also showed complaints of bilateral foot pain. Further, a January 2008 private x-ray showed that the Veteran reported pain in the left toe and multiple hammertoes. Alignment was anatomic and there were no fractures. Bony mineralization was within normal limits and joint spaces appeared preserved throughout. Soft tissues were unremarkable. However, borderline hallux valgus and plantar calcaneal spurs were noted bilaterally. In sum, the impression was borderline hallux valgus bilaterally and small calcaneal spurs. An August 2007 VA treatment record also showed a past medical history of flat feet. In a June 2008 statement, the Veteran reported that her bilateral foot condition was causing her severe pain and a secondary condition of heel spurs. She indicated that her most recent x-ray showed additional degenerative changes. She reported constant pain while ambulating with no relief even with new inserts. In August 2008, the Veteran was afforded another VA examination pertaining to her feet. The claims file was reviewed. The Veteran reported pain. She indicated that she was unable to stand for more than a few minutes and unable to walk more than a few yards. She wore orthotic inserts with minimal relief. On physical examination, there was no evidence of painful motion, swelling, weakness, or abnormal weight bearing. There was evidence of tenderness on the left at the scar. Angulation and dorsiflexion at the 1st MTP was normal with no stiffness. There was no evidence of hammertoes, clawfoot, malunion or nonunion of the tarsal or metatarsal bones, malalignment, pronation, pain on manipulation, muscle atrophy or other foot deformity. The examiner noted that the gait was antalgic due to right knee condition. An x-ray showed normal feet with no signs of fracture dislocation or arthritic changes. The diagnosis was bilateral plantar fasciitis. This disability did not affect occupational activities. There was a mild affect on shopping, a moderate affect on exercise and sports, and it prevented recreation. However, no other affects on activities of daily living were observed. There was no evidence of bilateral pes planus on examination or x-ray. Nevertheless, the examiner found that this condition had a mild affect on chores, shopping and exercise, and a moderate affect on sports, recreation and traveling. At the Board hearing, the Veteran again reiterated that she experienced pain and that inserts did not work. She reported that she walked pigeon-toed with her feet pronated inward. She also indicated that she had heel spurs on both feet. The April 2010 VA examination showed that the Veteran continued to report pain on the bottom of her feet. The pain was present while standing, walking and at rest along the arch and heel. However, there was no swelling, heat, redness, stiffness, fatigability, weakness, lack of endurance or other symptoms. The Veteran indicated that she could stand up to one hour and was able to walk 1/4 of a mile. She used orthotic inserts, which did not help. On physical examination, there was no evidence of swelling, instability, weakness or abnormal weight bearing. There was evidence of painful motion and tenderness. On passive range of motion, there was pain on arch. There was no hammertoes, pes cavus, malunion or nonunion of the tarsal or metatarsal bones, muscle atrophy or other foot deformity. There was no malalignment or foot pronation. Weightbearing and gait were normal. However, there was pain on manipulation. X-rays showed abductus angles of the distal phalanges in relation to the proximal phalanges of the fifth digit bilaterally and diffuse osteopenia. The diagnosis was pes planus with plantar fasciitis bilaterally. The effects on occupation were decreased mobility and pain. The Veteran's bilateral foot disability had a mild effect on chores, shopping, recreation and traveling and a moderate effect on exercise and sports. However, it did not have any effect on any other activities of daily living. Given that the claims file was reviewed by the examiner and the examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination to be sufficient for rating purposes. The Board also observes that the Veteran was afforded a VA examination for her service-connected fibromyalgia in January 2011. The examiner observed that she had signs and symptoms of bilateral plantar fasciitis, which were separate from the tender points of her fibromyalgia. Based on the evidence of record, the Board finds that an initial 10 percent disability rating is warranted for the Veteran's service connected bilateral pes planus with plantar fasciitis under Diagnostic Code 5276 for flatfoot. Importantly, the May 2005 VA examination characterized the Veteran's bilateral foot disability as moderate, which is the description for a 10 percent rating under this code. Moreover, the most recent VA examination showed that the Veteran's symptoms were not relieved by special shoes or orthotics and there was pain on manipulation of both feet, which is one of the criteria for a 10 percent rating. Thus, when resolving the benefit of the doubt in favor of the Veteran, a 10 percent rating for moderate symptoms is warranted under this code. Moreover, given that the May 2005 VA examination described the Veteran's condition as moderate, the Board finds that the Veteran's disability picture has been consistent throughout the entire appeal period. In turn, a 10 percent rating is warranted from the date after the Veteran's retirement from service. See Fenderson. However, the Board finds that a disability rating in excess of 10 percent is not warranted under this code. Although the Veteran has asserted that she walked with inward pronation and had calluses, there has been no objective finding of marked deformity, pain on manipulations and use accentuated or indication of swelling on use or characteristic callosities that could be characterized as severe to warrant a higher rating. The most recent VA examiner found that pronation was normal. There were no other foot deformities. It was clearly indicated that there was no swelling. The Board notes that the rating criteria under this code is conjunctive as it uses the word "and," which means that all the criteria must be met to award a higher rating. See Melson v. Derwinski, 1 Vet.App. 334 (June 1991) [use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met]; compare Johnson v. Brown, 7 Vet.App. 95 (1994) [only one disjunctive "or" requirement must be met in order for an increased rating to be assigned]. In sum, the objective evidence does not support a finding that the bilateral pes planus with plantar fasciitis meets all of the objective criteria of severe. The Veteran's bilateral pes planus with plantar fasciitis appears to be equivalent to the criteria for moderate flatfoot disability which warrants a 10 percent rating, but no higher. Again, Diagnostic Codes 5277, 5278, 5279, 5281, 5282 and 5283 are not applicable to this analysis. Moreover, although there has been x-ray evidence of borderline hallux valgus, a separate rating for hallux valgus under Diagnostic Code 5280 is not warranted because the Veteran has not undergone surgery and although limitation of motion of the great toe has been documented, there has been no objective finding that her hallux valgus is severe enough to be equivalent to amputation of the great toe. The residual scar of the left toe will be addressed in a separate analysis below. The medical evidence of record also does not show that the Veteran has moderately severe foot injuries or greater to warrant a higher evaluation under Diagnostic Code 5284. Again, the Veteran's symptoms were described as moderate at the May 2005 VA examination and the most recent VA examination only found at most a moderate effect on certain activities of daily living. In sum, the symptoms of the Veteran's feet disabilities are adequately contemplated in the current 10 percent rating. Again, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of her bilateral foot disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. With respect to this issue, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In conclusion, the Board finds that an initial rating of 10 percent, but no higher, for bilateral pes planus with plantar fasciitis is warranted. Residual Scar, Left Great Toe The Veteran is also seeking a compensable evaluation for the residual scar of the left great toe. Initially, the Board observes that the RO has rated this disability under Diagnostic Code 5283 for malunion or nonunion of the tarsal or metatarsal bones. In Butts v. Brown, 5 Vet.App. 532 (1993), the Court held that the selection of the proper diagnostic code is not a question of law subject to the de novo standard of review. Accordingly, the Court held in Butts that as VA and the Board possess specialized expertise in determining the application of a particular diagnostic code to a particular condition, their determination is due greater deference. Indeed, the Court has also held that, although the reason for the change must be explained, the VA and the Board may change the diagnostic codes under which a disability or disabilities are evaluated. Pernorio v. Derwinski, 2 Vet.App. 625 (1992). As noted in the prior analysis, the Veteran does not currently have malunion or nonunion of the tarsal and metatarsal bones. Based on the medical evidence discussed in more detail below, it appears that the Veteran's primary disability is a residual scar. Moreover, in the most recent supplemental statement of the case, the RO also primarily addressed whether a higher rating was warranted under the rating criteria for scars. Accordingly, the Board finds that the it would be more appropriate to address whether a higher rating is warranted under diagnostic codes applicable to scars under 38 C.F.R. § 4.118. Under regulations pertaining to scars, Diagnostic Code 7801 provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Note (1) to Diagnostic Code 7801 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to Diagnostic Code 7802 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7803 provides a 10 percent rating for superficial unstable scars. Note (1) to Diagnostic Code 7803 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that a superficial scar is one not associated with underlying soft tissue damage. Diagnostic Code 7804 provides a 10 percent evaluation for scars that are superficial and painful on examination. Note (1) to Diagnostic Code 7804 provides that a superficial scar is one not associated with underlying soft tissue damage. Note (2) provides that a 10 percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. (See 38 C.F.R. § 4.68 of this part on the amputation rule.) Diagnostic Code 7805 provides that other scars are to be rated on limitation of function of affected part. 38 C.F.R. § 4.118. The Board notes that effective October 23, 2008, VA amended criteria for rating the skin so that it more clearly reflects VA's policies concerning the evaluation of scars. Specifically, these amendments concern 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. This amendment applies to all applications for benefits received by VA on or after October 23, 2008. See Notice, 73 Fed. Reg. 54,708 (September 23, 2008). However, as the Veteran's claim was received prior to the effective date of these amendments, they are not applicable to this appeal. The Veteran has not requested that the new criteria be considered in his case, and her arguments are based, correctly, on the application of the older criteria. At the May 2005 VA examination, it was noted that he Veteran fractured her left great toe and she underwent surgery to remove an un-united fracture at the base of the left hallux valgus proximal phalange. The Veteran indicated that she could not bend her toe. She was able to ambulate as long as she wore soft shoes. On physical examination, it was noted that the Veteran had a well-healed scar on the left great toe. A diagnosis of hallux valgus, left great toe secondary to fracture was given. The examiner opined that the condition should not affect the Veteran's activities of daily living. In her notice of disagreement, the Veteran reported that this condition impaired her ability to walk straight. She indicated that she had developed a callous on the outside of left foot because she was unable to put pressure on weight on my left toe. In her September 2007, substantive appeal, she reiterated that she was unable to walk properly. She indicated that she was developing a bunion at the surgery site and the scar constantly peels. She again indicated that she was developing calluses outside of her left foot. Post service private treatment records showed toe pain. Again, a January 2008 x-ray showed borderline hallux valgus bilaterally. In a June 2008 statement, the Veteran provided that the scar continued to grow outward and that she was recently diagnosed with the initial stages of bunions. The condition caused excruciating pain while doing normal activities. At the August 2008 examination, it was observed that the residual scar was minimal of the left hallux. The Veteran reported pain and redness on the left foot over the surgical scar. On physical examination, there was a mild healed scar of the left 1st MTP, status post surgery for the fracture of the left hallux. The scar measured approximately 1.5 x 2.0 cm and was flat. There was no keloid or hypersensitivity, including hypertrophic changes, inflammation or underlying tissue loss. The examiner did note objective findings of tenderness over the scar. Again, x-rays of the feet were normal. The diagnosis was residual scar. It was observed that the Veteran had to wear wide shoes with little support to avoid direct pressure on the scar tissue. At the Board hearing, the Veteran reported that the scar had never healed properly and the skin still peeled away. The scar was a little over an inch long and a quarter-inch wide. The Veteran also indicated that there was no movement and constant pain. She reported that it looked like a bunion because it was raised, but it was not really a bunion. She also indicated that she walked more to the side because she could not put pressure on her toe. At the April 2010 VA examination, the Veteran reported that the skin over the scar broke down every two to four weeks. She also indicated that she had restrictive movement at the PIP of the hallux. Although the Veteran had previously reported pain, the examination report indicated that she did not have pain. On physical examination, the scar was .25 inches width by 1 inch length. The scar was not painful and was considered superficial, but had signs of skin breakdown. It was had no inflammation, edema, keloid formation or other disabling effects. The diagnosis was residual scar status post surgical correction to left hallux with minimal skin breakdown. The examiner found no significant effects on the Veteran's occupation or usual daily activities. Initially, the Board observes that it is faced with conflicting evidence as to whether the scar is tender or painful on examination. The May 2005 VA examination was silent with respect to these findings. However, the August 2008 VA examination did observe tenderness over the scar, but the most VA examination indicated that the scar was not painful on examination. Nevertheless, with the exception of the most recent VA examination, the Veteran has consistently reported pain over the scar throughout the appeal period. The Board is thus presented with conflicting evidence that is essentially in a state of equipoise as to the medical conclusions to be drawn. In such situations, a decision favorable to the appellant is mandated by 38 U.S.C.A. § 5107(b). Accordingly, the Board finds that a 10 percent rating is warranted for painful scar of the left great toe under Diagnostic Code 7804, effective the day after retirement. See Fenderson. However, a preponderance of the evidence is against a rating in excess of 10 percent for residual scar of the left great toe. The Veteran has been awarded the maximum rating available under Diagnostic Code 7804. Further, a higher rating under Diagnostic Code 7801 is not for application because the medical evidence or record does not show that the Veteran's scar exceeds an area of 12 square inches in order to warrant a 20 percent rating. Diagnostic Codes 7802 and 7803 also only allow for a maximum disability rating of 10 percent. Thus, a higher rating is not available under these codes. Moreover, Diagnostic Code 7805 is not applicable because there are no diagnostic codes that allow for a rating in excess of 10 percent for limitation of the great toe. Again, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of her left great toe disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. With respect to this issue, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In conclusion, the Board finds that an initial rating of 10 percent, but no higher, for residual scar, left great toe is warranted. Cholecystectomy with Biliary Dyskinesia The Veteran is also seeking a rating in excess of 10 percent for her service-connected cholecystectomy with biliary dyskinesia. This disability has been rated under Diagnostic Code 7318, which provides ratings for removal of the gallbladder. Gallbladder removal with mild symptoms is rated 10 percent disabling and removal with severe symptoms is rated 30 percent disabling. 38 C.F.R. § 4.114. At the May 2005 VA examination, it was noted that the Veteran had 95 percent inflammation of the common bile duct with slow gastric emptying secondary to slow gastric motility disorder. On examination, a well-healed cholecystectomy scar was noted and no other objective findings were observed. The examiner diagnosed biliary dyskinesia. It was observed that future exacerbations with biliary inflammation would be likely. The condition was also complicated by coexisting chronic colitis. In her notice of disagreement, the Veteran asserted that she experienced constant pain, accompanied with nausea and a slow digestive symptoms, which she considered severe. She asserted that the examination was deficient because her abdomen was not examined. In her substantive appeal, the Veteran requested a 30 percent rating and reiterated that she was in constant pain that was debilitating at times. She provided that she was unable to eat due to an inflamed bile duct. However, a May 2007 private treatment record showed no dysphagia, nausea, vomiting, or abdominal pain. In fact the report specifically noted that there was no chronic, frequent recurring abdominal pain. There was no change in stool, diarrhea and there was no constipation. A November 2007 record noted the same findings, except now intermittent changes in stool, diarrhea and constipation were noted. Another March 2008 record indicated that there were no gastrointestinal symptoms; however mild tenderness in the epigastric area was observed. At the Board hearing, the Veteran reported experiencing pain, nausea and vomiting at times. She indicated that more surgery was recommended but given that one of the complications was pancreatitis, she had chosen to just live with the pain. She took medication everyday to keep bile at a minimum. When she got a bad attack, she went without eating for a couple of days until it got better. She explained that these attacks were sometimes twice a week. In a subsequent February 2010 statement, she again indicated that she experienced several pain attacks per month. At the April 2010 VA examination, the Veteran reported having sharp pain in the right upper quadrant for which she was taking Reglan, which had moderate results. She was re-scanned, which showed bile duct inflammation. When she had exacerbations, she restricted herself to a liquid diet with Reglan and symptoms abated. The examiner observed that weekly moderate abdominal pain was reported, but no distension, nausea, vomiting or jaundice. On physical examination, there was no evidence of anemia, malnutrition or portal hypertension. Liver size was normal and there was no sign of liver disease. Right upper quadrant tenderness was observed. Pain was noted to effect occupational activities. While a mild effect on feeding was noted, there were no other effects on activities of daily living. Given that the claims file was reviewed by the examiner and the examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination to be sufficient for rating purposes. The Board finds that a higher rating is not warranted because based on the evidence of record, the Board must determine that the Veteran's symptoms cannot be characterized as severe. Although right upper quadrant tenderness has been observed on examination, there have been no objective findings of any other symptoms. Importantly, private treatment records observed no gastrointestinal symptoms. Moreover, the April 2010 VA examiner found no evidence of anemia or malnutrition. The examiner only observed a "mild" affect on feeding and no other affect on activities of daily living. In sum, the evidence of record does not reflect that the Veteran experiences "severe" symptoms. Rather, the objective findings documented in the record tend to align with the finding that her symptoms are no worse than mild. Further, again under 38 C.F.R. § 4.114, a single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. However, even though the Veteran's cholecystectomy is considered the predominant disability, the overall severity of the Veteran's gastrointestinal symptoms does not warrant elevation to the next higher rating. As discussed above, the Veteran's symptoms for her GERD are not considered severe enough to warrant a compensable rating. Following the same analysis, the severity of the Veteran's GERD would also not warrant elevation to the next higher rating under Diagnostic Code 7318. The Board observes that the May 2005 VA examiner appeared to indicate that the Veteran's residuals of her cholecystectomy may be intertwined with her colitis. However, the Veteran has been assigned a separate noncompensable rating for her colitis and this issue is currently not before the Board. Moreover, given that the Veteran's scar has been observed to be well-healed and there have been no complaints of tenderness, a separate compensable rating is also not warranted for her residual scar. Again, the Board has carefully reviewed and considered the Veteran's statements regarding the severity of her disability. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. With respect to this issue, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In summary, the Board concludes that a preponderance of the evidence is against assigning a rating in excess of 10 percent for cholecystectomy with biliary dyskinesia and, in turn, the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. Thrombophlebitis, Left Leg Lastly, the Veteran is seeking a compensable disability rating for her service-connected thrombophlebitis of the left leg. This disability is rated under Diagnostic Code 7121 for post-phlebitic syndrome. Under this code, a 10 percent rating is warranted for intermittent edema of an extremity or aching and fatigue in the leg after prolonged standing or walking, with symptoms relieved by elevation of the extremity or compression hosiery. A 20 percent rating is warranted for persistent edema, incompletely relieved by elevation of the extremity, with or without beginning stasis pigmentation or eczema. A 40 percent rating is warranted for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent rating is warranted for persistent edema or subcutaneous indurations, stasis pigmentation or eczema, and persistent ulceration. The maximum 100 percent rating is warranted for massive board-like edema with constant pain at rest. 38 C.F.R. § 4.104, Diagnostic Code 7121. At the May 2005 VA examination, the Veteran reported that thrombosis occurred intermittently (three to four times per year) and resolved with warm packs. No clear objective findings were observed. The examiner diagnosed left leg thrombophlebitis, recurrent. The examiner opined that while the Veteran may experience future recurrences, symptomatic treatment continued to be successful and no additional treatment was needed. In her notice of disagreement, the Veteran indicated that she experienced pain and swelling. She stated that she was unable to stand for very long and had to elevate her feet. She again asserted that the examiner did not examine her leg. In her substantive appeal, the Veteran argued that his disability should be rated at least 20 percent disabling because she experienced constant swelling and pain and the only remedy was surgery. Post service treatment records do not provide any objective findings pertaining to the left leg for rating purposes. Importantly, a February 2008 private treatment record indicated a diagnosis history of no thromboembolic disease. At the Board hearing, the Veteran reported constant symptoms including swelling. She again reported that she could not stand for a long time and the only other remedy would be surgery. She treated the disability with ice, heat and inflammatories. At the April 2010 VA examination, the Veteran reported continued pain near the popliteal fossa, especially if she stood for a prolonged period of time. The Veteran also developed varicose veins and had injections done in July 2009 to remove them at a private facility. The Veteran reported that no edema was present, but there was skin discoloration and pain present. Aching and throbbing occurred after prolonged walking or standing. The symptoms were relieved by elevation or compression hosiery. An ulceration was not present. On physical examination, there was no edema, stasis pigmentation, eczema or ulceration present. There was a visible and palpable vein on medial aspect of popliteal fossa and nearby veins status post attempted sclerosis. The diagnosis was varicose vein, left popliteal fossa. The effect on occupational activities was decreased mobility and pain. There was a mild effect on chores, shopping, exercise and sports, but no other effects on activities of daily living. The examiner determined that there was no clinical evidence that the varicosities were explicitly caused by thrombophlebitis. There were no reported recurrences of thrombophlebitis currently, and the current issue of a superficial varicosity and a suboptimal outcome from attempted intervention was unlikely related to thrombophlebitis. The Board observes that the July 2009 private treatment records pertaining to the varicose vein removal have not been associated with the claims file. However, as the examiner clearly indicated that the Veteran's varicose veins were not caused by the service-connected thrombophlebitis, these records are not pertinent to this issue. Moreover, given that the claims file was reviewed by the examiner and the examination report sets forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations, the Board finds the examination to be sufficient for rating purposes. After a careful review of the record, the Board finds that the evidence of record does not support a compensable rating. In order to receive a higher rating under Diagnostic Code 7121, the evidence must show intermittent edema of the extremity with symptoms relieved by elevation of the extremity or compression hosiery. Even though, the May 2005 VA examiner indicated that the Veteran's thrombophlebitis was recurrent, there is no objective evidence throughout the course of the appeal showing treatment for thrombophlebitis. Importantly, the most recent VA examiner found no evidence of edema. In fact, the examiner found no reported recurrences of thrombophlebitis. It appears that the Veteran's complaints were primarily associated with her varicosities, which the examiner explicitly found were not related to the service-connected thrombophlebitis. Therefore, as there is no evidence of intermittent edema or any objective residuals attributed to thrombophlebitis of the left leg, a higher disability rating for this condition is not warranted. The Board has carefully reviewed and considered the Veteran's statements regarding the severity of thrombophlebitis of the left leg. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severe than the assigned disability rating reflects. In this case, however, it appears that the symptoms described by the Veteran pertain to her nonservice-connected varicose veins rather than her thrombophlebitis. Further, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. In sum, the Board finds that the preponderance of the evidence indicates that the Veteran's disability picture more nearly approximates the criteria required for the currently assigned noncompensable rating, and that an increased rating is therefore not warranted. Extraschedular In general, the schedular 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. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1)). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet.App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet.App. 218, 227 (1995). In Thun v. Peake, 22 Vet.App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the symptoms described by the Veteran fit squarely within the criteria found in the relevant Diagnostic Codes for the disabilities at issue. In short, the rating criteria contemplate not only her symptoms but the severity of her disabilities. For these reasons, referral for extraschedular consideration is not warranted. TDIU The United States Court of Appeals for Veterans Claims (Court) has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim, or, if the disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet.App. 447, 453-54 (2009). However, in the instant case, the evidence of record shows that the Veteran is currently employed full time as a clinical administrator. Accordingly, no further discussion of this matter is necessary. ORDER An initial 20 percent rating, but no higher, is warranted for left shoulder impingement. Further, initial 10 percent ratings, but no higher, are also warranted for bilateral pes planus with plantar fasciitis and residual scar, left great toe. To that extent, the appeal is granted, subject to the law and regulations governing the payment of monetary benefits. Compensable ratings for right wrist tendinitis, GERD and left leg thrombophlebitis are not warranted. Further, a rating in excess of 10 percent for cholecystectomy with biliary dyskinesia is not warranted. To that extent, the appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs