Citation Nr: 1136583 Decision Date: 09/28/11 Archive Date: 10/11/11 DOCKET NO. 07-03 191 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for a back disorder as secondary to service-connected left foot disorder with mild circulatory impairment. 2. Entitlement to service connection for a left leg disorder as secondary to service-connected left foot disorder with mild circulatory impairment. 3. Entitlement to a disability rating in excess of 10 percent for service-connected left foot disorder with mild circulatory impairment prior to August 24, 2010. 4. Entitlement to a disability rating in excess of 20 percent for service-connected left foot disorder with mild circulatory impairment as of August 24, 2010. 5. Entitlement to a total disability rating based on individual employability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Ann L. Kreske, Associate Counsel INTRODUCTION The Veteran served on active military duty from November 1954 to November 1957. This appeal comes to the Board of Veterans' Appeals (Board) from two rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas: a February 2006 rating decision, which, inter alia, denied the Veteran's claim for a disability rating in excess of 10 percent for a service-connected left foot disorder with mild circulatory impairment; and a January 2007 rating decision, which found that no new and material evidence had been received to reopen a previously denied claim for service connection for a low back disorder and denied service connection for a left leg disorder as secondary to service-connected left foot disorder. In the February 2006 rating decision, the RO also adjudicated an issue of whether new and material evidence had been received to reopen a previously denied claim for service connection for a left hip disorder. However, the Veteran did not perfect an appeal of that claim by filing a notice of disagreement (NOD) and substantive appeal (e.g., VA Form 9 or equivalent statement). See 38 U.S.C.A. § 7105(a) (West 2002); 38 C.F.R. § 20.200 (2010). Therefore, it is not before the Board. In a June 2011 rating decision, the RO increased the disability rating for the Veteran's left foot disorder to 20 percent, effective August 24, 2010. Inasmuch as a higher evaluation is potentially available and as the rating was already in appellate status, the Board will consider entitlement to an increased rating for a left foot disorder for the entire appeal period. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In June 2009, the Veteran provided testimony at a hearing before the undersigned Veterans Law Judge at the RO (Travel Board hearing). The transcript of the hearing has been associated with the claims file and has been reviewed. This matter was previously before the Board in August 2009, at which time it found that new and material evidence had been received to reopen a previously denied claim for service connection for a back disorder, and remanded the claims for service connection for a low back disorder and for a left leg disorder for further evidentiary development. The case has returned to the Board and is again ready for appellate action. The Board notes that the issue of TDIU is also under consideration by the Board. In this regard, the U.S. Court of Appeals for Veterans Claims (Court) has held that a request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. In this case, in a statement dated in May 2008, the Veteran appeared to raise a claim for entitlement to TDIU. Furthermore, it appears that this issue has undergone preliminary development, as the RO sent to the Veteran a duty to assist letter concerning his claim for entitlement to TDIU in July 2009. However, a review of the claims file shows no subsequent development of this issue. Therefore, the Board finds the Veteran has raised the issue of entitlement to a TDIU as an element of the increased rating claim on appeal. Since entitlement to a TDIU is part of the Veteran's increased rating claim, the proper remedy here is for the Board to remand, rather than refer, the TDIU issue to the AOJ for further development and adjudication. Rice, supra. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to a TDIU is REMANDED to the agency of original jurisdiction (AOJ) via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. There is probative evidence that the Veteran's back disorder, diagnosed as complex regional pain syndrome with degenerative joint disease, is secondary to the left foot injury he sustained and the sympathetic block he received during service. 2. There is probative evidence that the Veteran's left leg disorder, diagnosed as complex regional pain syndrome, is secondary to the left foot injury he sustained and the sympathetic block he received during service. 3. Prior to August 24, 2010, the Veteran's service-connected left foot disorder with mild circulatory impairment was manifested by pain on weight bearing and tenderness under the fourth and fifth metatarsal heads, but painless motion. 4. As of August 24, 2010, the Veteran's service-connected left foot disorder with mild circulatory impairment has been manifested by pain, numbness, weakness, and fixed dorsiflexion of toes 2-5, but not painful motion, swelling, tenderness, or abnormal weight-bearing. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, a back disorder is proximately due to, the result of, or chronically aggravated by, service-connected left foot disorder with mild circulatory impairment. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310(a) (2010). 2. Resolving all reasonable doubt in favor of the Veteran, a left leg disorder is proximately due to, the result of, or chronically aggravated by, service-connected left foot disorder with mild circulatory impairment. 38 U.S.C.A. §§ 1110, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310(a) (2010). 3. The criteria for a disability rating in excess of 10 percent for a left foot disability are not met prior to August 24, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp.2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71, Plate II, § 4.71a, Diagnostic Code 5278 (2010). 4. The criteria for a disability rating in excess of 20 percent for a left foot disability are not met on and after August 24, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp.2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71, Plate II, § 4.71a, Diagnostic Code 5278 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Duties to Notify and Assist Review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The duty to notify was accomplished by way of VCAA letters from the RO to the Veteran dated in October 2005 and September 2006. These letters effectively satisfied the notification requirements of the VCAA consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) by (1) informing the Veteran about the information and evidence not of record that was necessary to substantiate his claims, (2) informing the Veteran about the information and evidence the VA would seek to provide, and (3) informing the Veteran about the information and evidence he was expected to provide. See also Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Thus, the Board finds that the RO has provided all notice required by the VCAA as to the three elements of notice. 38 U.S.C.A. § 5103(a). See Pelegrini II, Quartuccio, supra. Additionally, the September 2006 VCAA letter from the RO further advised the Veteran that a disability rating and an effective date will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Thus, he has received all required notice in this case, such that there is no error in content. The RO also correctly issued the September 2006 VCAA notice letter prior to the January 2007 adverse determination on appeal. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini II, 18 Vet. App. at 120. Thus, there is no timing error with regard to the VCAA notice. With regard to the additional notice requirements for increased rating claims, as is the case here with respect to the issues pertaining to the Veteran's service-connected left foot disorder, a VCAA letter dated in May 2008 was compliant with the decision of the Court's decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Specifically, this letter advised the Veteran of the evidentiary and legal criteria necessary to substantiate higher ratings for his left foot disorder. In any event, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court) has vacated the Court's previous decision in Vasquez-Flores, concluding that generic notice in response to a claim for an increased rating is all that is required. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). Nevertheless, overall, the Board is satisfied that the RO provided both generic and specific VCAA notice as to the increased rating claim when considering all of the VCAA letters provided. With respect to the duty to assist, the RO has obtained the Veteran's service treatment records (STRs) and VA treatment records. Further, the Veteran and his representative have submitted numerous statements, including from family members, friends, and private physicians, in support of his claim. The Veteran also was afforded opportunities to provide testimony before RO personnel and a Veterans Law Judge. Thus, there is no indication that any additional evidence remains outstanding, and the duty to assist has been met. 38 U.S.C.A. § 5103A. Finally, a remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). In this regard, the Board is satisfied as to compliance with the instructions from its August 2009 remand. Specifically, in the remand, the RO was instructed to obtain relevant VA treatment records dated from January 2007 to the present; request that the Veteran identify and authorize the release of any private treatment records, and obtain such identified records; request from the Social Security Administration (SSA) any records associated with the Veteran's disability claim; arrange for the Veteran to undergo VA examinations of his low back and left leg to determine the nature and etiology of any existing low back and left leg disorders, including whether they were at least as likely as not related to his service-connected left foot disorder or treatment with a sympathetic block in April 1955 while in service, and arrange for the Veteran to undergo a VA examination of his service-connected left foot to determine the current nature and severity of the disorder. The Board finds that the RO has complied with its remand directives to the extent possible. The RO has obtained the Veteran's VA treatment records dated from January 2007 to the present and associated them with the claims file. The Veteran also has identified and authorized the release of relevant private treatment records, which also have been obtained and associated with the claims file. The RO also requested the Veteran's SSA medical records, but was met with a negative response that the Veteran's SSA records had been destroyed. Furthermore, the Veteran was provided VA examinations of his low back, left leg, and left foot in August 2010. The Board finds these August 2010 VA examination reports to substantially comply with the Board's August 2009 remand directives as the VA examiner responded to the questions posed in the remand. Stegall v. West, 11 Vet. App. 268 (1998). Analysis - Secondary Service Connection A disability that is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Generally, when a Veteran contends that a service-connected disability has caused a new disorder, there must be competent medical evidence that the secondary disorder was caused or chronically worsened by the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310 (2011). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen v. Brown, 7 Vet. App. 439 (1995), it was made clear in the comments to the regulation that the changes were intended to place a burden on the Veteran to establish a pre-aggravation baseline level of disability for the nonservice-connected disability before an award of service connection may be made. Given what appear to be substantive changes, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which clearly favors the claimant. A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status generally do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). In this regard, the Court emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). A review of the evidence of record reveals that, in March 1955, the Veteran was building a bridge when a 300-pound truss fell on his left foot. He was unable to stand on that foot. Examination revealed abrasion, swelling, and tenderness. An X-ray of the left foot revealed no fractures. He was placed on a temporary profile. Throughout the months of March 1955 and April 1955, he continued to complain of pain, swelling, and redness in the left foot. In April 1955, he received a sympathetic block at the L2-3 level to treat his chronically swollen left foot. Following the sympathetic block, the Veteran alleges that his back, left hip, and left leg began hurting and feeling numb, symptoms that have persisted since. See, e.g., the Veteran's statements dated in January 1989, the Veteran's claim dated in August 2006, and Travel Board hearing transcript dated in June 2009. In this regard, the Veteran is competent to provide reports pertaining to his in-service injuries and continuity of symptomatology. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). A December 1987 VA examination report notes complaints of low back pain for many years and numbness in the left lower extremity. The Veteran was diagnosed with degenerative disc disease in the lumbar spine. A VA nerve conduction study dated in February 1988 showed minimal evidence of a left S1 radiculopathy. A July 1988 VA treatment record noted additional complaints concerning the low back and left leg. A May 2009 statement from a private physician, E. L. Dyck, M.D., indicated that the Veteran injured his left foot in 1955 during service, after which he experienced persistent pain. He was given a sympathetic block in his left hip, after which he was unable to bear weight on his left leg and the left leg became numb. Since that time, the Veteran has had problems with the left leg, which have worsened over the years. At the time of the statement, he had pain radiating into his leg and required a cane to walk. Recent evaluation revealed lumbosacral spinal stenosis, peripheral artery disease, and degenerative joint disease in the hip. The physician indicated that the Veteran's history was compatible with a chronic painful mononeuropathy secondary to the injection he received in service. An evaluation report from C. N. Bash, M.D., dated in June 2009, suggested a diagnosis of reflex sympathetic dystrophy (RSD) (also known as complex regional pain syndrome (CRPS)), given the Veteran's history and symptomatology. Specifically, this physician stated that trauma is a well-known cause of RSD/CRPS, and that the Veteran had left hip pain after receiving the sympathetic block, which is consistent with RSD. The Veteran's symptoms were consistent with RSD. The physician also emphasized that the Veteran's spine degeneration was advanced beyond normal aging, likely due to a combination of his long-standing RSD and the abnormal functioning of his left leg. A recent VA examination dated in August 2010 also provided the diagnoses of CRPS with degenerative joint disease between L1 and L2 in the spine and CRPS in the left leg. The August 2010 VA examiner opined that the Veteran's low back pain with pain, numbness, and weakness of the left leg are due to, or a result of, his left foot trauma and spinal injection during service. The rationale provided was that the Veteran's spine and left leg disabilities are most likely caused by CRPS, which occurred after his foot trauma and was made worse by the in-service sympathetic block. The VA examiner pointed out that his opinion was consistent with the opinions of E. L. Dyck, M.D., and C. N. Bash, M.D., both of whom also implicated CRPS. Based on the evidence of record showing the Veteran sustained an in-service injury to his left foot, after which he received a sympathetic block that caused pain and numbness in his spine and left leg, his consistent reports that he has experienced pain and numbness in his low back and left leg since his sympathetic block, and the private physicians' and VA physician's diagnosis of CRPS and favorable nexus opinions dated in May 2009, June 2009, and August 2010, the Board finds that service connection for the Veteran's low back and left leg disorders as secondary to his service-connected left foot disorder with mild circulatory impairment is warranted. In this case, there is competent and credible evidence that the secondary disorders were caused or chronically worsened by the service-connected disability. Wallin, supra. Thus, giving the Veteran the benefit of the doubt, the Board finds that the evidence is in favor of his claim. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 53-56. Analysis - Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but findings sufficiently characteristic to identify the disease and the resulting disability, and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of her disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Where an increase in an existing disability rating based on established entitlement to compensation is at issue, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Court has held that VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. See Hart v. Mansfield, 21 Vet. App. 505 (2007). That is, the Board must consider whether there have been times when the Veteran's disability has been more severe than at others. If so, the Board may "stage" the rating. The relevant temporal focus for adjudicating the level of disability of an increased-rating claim is from one year before the claim was filed (here, July 2004) until VA makes a final decision on the claim. See Hart, supra. See also 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). While older evidence is not necessarily irrelevant, it is generally not needed to determine the effective date of an increased rating. See Francisco, supra. The Veteran's service-connected left foot disorder with mild circulatory impairment is rated as 10 percent prior to August 24, 2010. As of August 24, 2010, it is rated as 20 percent disabling. The Veteran's service-connected left foot disorder with mild circulatory impairment is rated under Diagnostic Code 5278, claw foot, acquired (pes cavus). Under Diagnostic Code 5278, acquired claw foot with the great toe dorsiflexed, some limitation of dorsiflexion at the ankle, and definite tenderness under the metatarsal heads is rated as 10 percent disabling. Acquired claw foot with all toes tending to dorsiflexion, limitation of dorsiflexion at the ankle to right angle, shortened plantar fascia, and marked tenderness under the metatarsal heads, is rated as 20 percent disabling for unilateral involvement. Acquired claw foot with marked contraction of plantar fascia with dropped forefoot, all toes hammer toes, very painful callosities, marked varus deformity, is rated 30 percent disabling for unilateral involvement. 38 C.F.R. § 4.71a. 10 Percent Rating Prior to August 24, 2010 A review of the evidence of record dated since July 2004, one year prior to the Veteran's claim for entitlement to an increased rating, reveals no complaints or treatment pertaining to the Veteran's service-connected left foot disability in 2004. VA treatment records dated from March 2005 to May 2005 show treatment for unrelated thick and painful toenails. In October 2005, the Veteran was provided a VA examination, during which it was noted that the Veteran had never been treated or evaluated for any pain or problems with the left foot. The Veteran indicated intermittent pain in the left foot over the years. He had weight-bearing pain in the left foot. He reported probably being able to walk 1/2 mile, if he had no other limiting condition, before his left foot would become too painful for him to walk. He had no pain at rest or while sitting, and little pain on standing. He stated he had a bad injury to his left ankle in 1957. Examination revealed an antalgic gait due to hip and knee pain. Inspection of the left foot revealed pitting edema. The ankle had a range of motion of 10 degrees in dorsiflexion and 30 degrees without pain. Both feet were normal in appearance, with no deformities, hammertoes, high arch, or claw foot, and normal arches. Skin was intact, with small, superficial spider varicosities on both ankles. There was no painful motion, breakdown, or unusual shoe wear. There was tenderness over the top of the foot. Dorsalis pedis and posterior tibial pulses were intact per Doppler. The Veteran had back pain on standing. His posture was normal. He was unable to squat. He was able to rise on his toes. No calluses were found. The range of motion of the toes was equal in the right and the left. However, due to the condition of his spine, hips, and knees, the Veteran was incapable of repeated activity. While walking and at rest, no caval (talipes) varus of clubbing was noted in the left foot. X-rays of the left foot revealed normal results, with small calcaneal spurs noted. The diagnosis was status post distant history of contusion of the left foot. Minimal residuals due to this injury were found. Subsequent VA treatment records reveal no treatment for the left foot until December 2006, when the Veteran was hospitalized for pneumonia. Examination revealed no edema, cyanosis, or clubbing in the extremities. Neurologic examination revealed decreased sensation in both feet and 4/5 strength in both lower extremities. Another VA examination dated in April 2008 revealed complaints of constant, achy pain in the left foot rated at the severity of 7/10. The Veteran also complained of weakness and occasional swelling and numbness, but no stiffness. He also reported a lack of endurance. At rest, there was a constant, dull ache that became more intense with standing and walking. The Veteran reported periods of flare-ups that were rated as 7/10 and that generally occurred one to two times a week, lasting from 12 to 24 hours. Precipitating factor was weather changes. Alleviating factors were elevation, pain medication, and rest. The Veteran denied additional limitation of motion during a flare-up, indicating that there was just more pain. He had difficulty walking and with prolonged standing. He used a cane for ambulation to steady himself. He could not walk for more than 1/4 mile and could not stand for more than 5 minutes. There was no history of hospitalization or surgeries. Examination revealed feet that were reasonably aligned. There was tenderness to palpation over the fourth and fifth metatarsal heads. There was no evidence of painful motion, instability, or weakness. The Veteran had difficulty getting in and out of a chair, but appeared to distribute his weight equally between the right and left feet once ambulating. He used a cane. No calluses or breakdown was found. There was no unusual shoe wear pattern. There were varicosities in both feet. The arches appeared normal, and there was normal weight-bearing and nonweight-bearing alignment of the Achilles tendons. The forefoot and midfoot appeared to have good alignment. The Veteran was able to flex and extend at the metatarsophalangeal joint of the great toe. He also was able to flex and extend the remainder of the digits. X-rays of the left foot revealed stable mild degenerative arthritis of the first metatarsal phalangeal joint. The diagnoses were contusion of the left foot during military service and degenerative joint disease of the left metatarsophalangeal joint of the great toe. No evidence of residuals from the in-service left foot injury was found. In this case, the Board finds that a disability rating in excess of 10 percent is not warranted for the period prior to August 24, 2010. The record does not show that the Veteran's left toes tended to dorsiflexion, limitation of dorsiflexion at the ankle to right ankle, shortened plantar fascia, or marked tenderness under the metatarsal heads. Treatment records dated from 2004 to 2009 show no complaints of, or treatment for, left foot symptomatology. VA examinations have revealed a normal-appearing left foot, with some limitation of dorsiflexion, no abnormalities, and some tenderness over the top of the foot and over the fourth and fifth metatarsal heads. While the Veteran complained of pain, instability, weakness, and lack of endurance, there was no objective evidence of painful motion, instability, or weakness. Weight distribution between the two feet appeared to be equal. The Veteran was able to flex and extend at the metatarsophalangeal joint of the great toe, and was able to flex and extend all other toes. In this regard, the symptoms exhibited by the Veteran, as described above, do not warrant a disability rating of 20 percent, which, as discussed earlier, requires acquired claw foot with all toes tending to dorsiflexion, limitation of dorsiflexion at the ankle to right angle, shortened plantar fascia, and marked tenderness under the metatarsal heads, symptoms that have not been found. Thus, the Board finds that a disability rating greater than 10 percent for the Veteran's left foot disorder with mild circulatory impairment for the period prior to August 24, 2010, is not warranted. 38 C.F.R. § 4.7. 20 Percent Rating as of August 24, 2010 A review of the evidence of record from this time period reveals an August 2010 VA examination. At this examination, the Veteran reported symptoms of pain and numbness, both of which occurred while standing, walking, and at rest. He indicated being unable to stand for more than one minute and being unable to walk more than a few yards. He reported no flare-ups. He used no assistive device. Examination of the left foot revealed no evidence of painful motion, swelling, tenderness, instability, or abnormal weight-bearing. There was evidence of weakness manifested as generalized muscle atrophy and weakness for dorsiflexion and plantar flexion of all toes. Examination also revealed fixed dorsiflexion of toes 2 to 5. X-ray of the left foot revealed an old, incompletely united fracture of the distal fibular shaft; calcaneal enthesopathy; calcaneal spur; hammertoe deformities of toes 2 through 5; and minimal osteoarthritis. The Board finds that the record, pertaining to the left foot disorder with mild circulatory impairment, as of August 24, 2010, documents symptoms of dorsiflexion of the toes, weakness, muscular atrophy, and weakness for dorsiflexion and plantar flexion of the toes. However, there was no evidence of painful motion, swelling, tenderness, instability, or abnormal weight-bearing. The VA examination found no evidence of hallux valgus or rigidus, pes cavus, malunion or nonunion of the tarsal or metatarsal bones, flat foot, or other deformity of the foot. Thus, the Board finds that a disability rating in excess of 20 percent is not warranted for the period as of August 24, 2010. The record does not show that the Veteran exhibited symptoms such as marked contraction of plantar fascia with dropped forefoot, all toes hammertoes, very painful callosities, or marked varus deformity. The symptoms exhibited by the Veteran, as described above, do not meet the criteria required for a 30-percent disability rating. Thus, the Board finds that a disability rating greater than 20 percent for the Veteran's left foot disorder with mild circulatory impairment for the period as of August 24, 2010, is not warranted. 38 C.F.R. § 4.7. Finally, the Board adds that the disability ratings for the Veteran's left foot disorder with mild circulatory impairment are effective within the time periods previously established by the RO and currently established by the Board. As there have been no occasions within the effective dates mentioned when the Veteran's disability has been more severe than its assigned ratings, there is no basis to further "stage" his ratings for the disability on appeal. Hart, supra. Further, although it is possible to assign an extra-schedular evaluation, the Board finds no reason to refer the case to the Compensation and Pension Service to consider whether it is warranted. In this case, there is no evidence of any hospitalization associated with the disability in question. In addition, although the Board acknowledges the Veteran's disability has some impact on his employment, it finds no evidence that the Veteran's left foot disorder with mild circulatory impairment markedly interferes with his ability to work above and beyond that contemplated by his separate schedular ratings. See 38 C.F.R. § 4.1 (indicating that generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability). ORDER Service connection for a back disorder is granted. Service connection for a left leg disorder is granted. Prior to August 24, 2010, a disability rating in excess of 10 percent for left foot disorder with mild circulatory impairment is denied. As of August 24, 2010, a disability rating in excess of 20 percent for left foot disorder with mild circulatory impairment is denied. REMAND Before addressing the merits of the claim for entitlement to TDIU, the Board finds that additional development of the evidence is required. First, in the present decision, the Board has granted service connection for a back disorder and a left leg disorder. As a result, the case must be returned to the AOJ for the assignment of disability ratings for a back disorder and a left leg disorder. Subsequently, the AOJ must then consider the TDIU issue, which is inextricably intertwined with assignment of percentage rating for the service connection grant. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The Board notes that the RO has already sent the Veteran a VCAA notice letter for his TDIU claim. Next, the AOJ should provide a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to the Veteran. See M21-1MR, IV.ii.2.F.25.i. Finally, a remand is required for a VA examination and opinion to assess whether the Veteran's service-connected disabilities prevent him from securing or following a substantially gainful occupation, without consideration of nonservice-connected disorders and advancing age. Currently, the evidence of record is unclear in demonstrating entitlement to a TDIU. While the Veteran and lay statements submitted by the Veteran contend that he can no longer perform his job as a mechanic due to his service-connected disabilities, there is no evidence that the Veteran is unemployable in other fields as well. In light of this inconclusive evidence, a VA examination and opinion are required in order to ascertain whether the Veteran's service-connected left foot, left leg, and back disorders, by themselves, would prevent him from securing gainful work. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. Send the Veteran a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, for him to fill out. See M21-1MR, IV.ii.2.F.25.i. The claims file should include documentation that VA has complied with VA's duties to notify and assist a claimant. 2. After the above development has been completed and all outstanding treatment records have been associated with the claims file, the Veteran should be afforded an examination with an appropriate medical professional to obtain an opinion regarding the effect(s) of his service-connected disabilities, including his left foot, left leg, and back disorders, have on his employability. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. The examiner should be requested to render an opinion as to whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of both the lay and medical evidence of record. 3. After completion of the above, and any additional notice or development deemed necessary, then adjudicate the TDIU claim at issue. If any determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental statement of the case and be afforded an opportunity to respond before the case is returned to the Board for further review. No action by the Veteran is required until he receives further notice; however, the Veteran is advised that failure to cooperate by reporting for examination without good cause may have adverse consequences on his claims. 38 C.F.R. § 3.655 (2010). The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs