Citation Nr: 1145253 Decision Date: 12/12/11 Archive Date: 01/30/12 DOCKET NO. 03-15 998 ) DATE DEC 12 2011 ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a disability claimed as stroke and TIAs. 2. Entitlement to an initial rating in excess of 10 percent for left foot plantar fasciitis. 3. Entitlement to an initial rating in excess of 10 percent for gastroesophageal reflux disease (GERD). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and her spouse ATTORNEY FOR THE BOARD D. Bredehorst INTRODUCTION The Veteran served on active duty from March 1977 to March 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions in February 2001 and August 2003. In March 2006, the Veteran testified during a video conference hearing before the undersigned; a transcript of this hearing is associated with the claims file. In May 2006, November 2006, and August 2008, these matters were remanded for additional development. In April 2011, an advisory medical opinion from the Veterans Health Administration (VHA) was obtained with regard to the claim for service connection. FINDINGS OF FACT 1. The Veteran's TIA's and CVA are shown to not be related to the Veteran's service. 2. Throughout the appeal, the service-connected left plantar fasciitis is shown to be productive of severe impairment with manifestations of symptoms resistant to treatment to include pain that significantly limits ambulation and precludes prolonged standing; loss of use of the left foot is not shown or approximated. 3. Throughout the appeal, the service-connected dyspepsia and GERD is manifested by continuous moderate impairment with manifestations of continuous epigastric distress and dyspepsia with occasional nausea, vomiting, anorexia, and reflux. CONCLUSIONS OF LAW 1. The Veteran's TIA's and CVA were not caused or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.303 (2011). 2. The criteria for the assignment of an initial 30 percent evaluation, but no higher, for the service-connected left foot plantar fasciitis have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159 , 4.7, 4.71a, including Code 5284 (2011). 3. The criteria for the assignment of an initial 20 percent evaluation, but no higher, for the service-connected dyspepsia and GERD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.20, 4.113, 4.114 including Diagnostic Codes (Codes) 7305 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, 3.326(a) (2011). VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) ; 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (including as amended effective May 30, 2008, 73 Fed. Reg. 23353 (Apr. 30, 2008)). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that the notice requirements of VCAA applied to all 5 elements of a service connection claim (i.e., to include the rating assigned and the effective date of award). Since the August 2006 rating decision on appeal granted service connection for dyspepsia with GERD and left foot plantar fasciitis and assigned disability ratings and effective date for the awards, the statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The question of whether a further VCAA letter for such "downstream" issues is required was also addressed by the VA Office of General Counsel in VAOPGCPREC 8-2003 (Dec. 22, 2003). In this opinion, the General Counsel held that, in such circumstances, a Statement of the Case (SOC) was required in cases involving a "downstream" issue, but 38 U.S.C.A. § 5103(a) did not require separate notice of the information and evidence necessary to substantiate the newly raised issue. Id. In this case, the necessary SOC was issued in April 2003. The claimant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to either of these "downstream elements." See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008); see also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). A June 2005 letter provided the Veteran with notice of VA's duties to notify and assist her in the development of her claim for service connection consistent with the laws and regulations outlined above. In this regard, the letter informed her of the evidence and information necessary to substantiate her claim, the information required of her to enable VA to obtain evidence in support of her claim, and the assistance that VA would provide to obtain information and evidence in support of her claim. Although she was not provided notice regarding disability ratings and effective dates of awards, such notice is only critical if service connection when granted. Thus, the omission of such notice in this instance is not prejudicial. The Board also finds that VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A (West 2002). The Veteran's service treatment records are associated with his claims file, and VA has obtained all pertinent/identified records that could be obtained. The RO arranged for VA examinations and the Board obtained a VHA opinion. Additional development requested in the Board prior remands has been completed and the Veteran indicated that she had no additional evidence to submit. In sum, there is no evidence of any VA defect in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Service Connection Legal Criteria Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability which is service- connected; and (3) competent evidence of a nexus between the two. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Analysis The Veteran contends that her claimed disability involving stroke and TIA's is related to estrogen treatment, hypothyroidism, and high cholesterol, which were shown in service. The Veteran's service treatment records do not contain any complaints, findings, or diagnosis associated with TIA's or a CVA, but she was shown to have had a long history of cholesterol treatment. (See treatment record dated in October 1977, August 1988, and March 1994). She underwent a hysterectomy in 1996 for which she was later given estrogen treatment and hypothyroidism was also diagnosed in service. Consequently, hypothyroidism and hysterectomy disabilities have been service-connected. Postservice VA medical records show the Veteran was receiving estrogen treatment in relation to her prior hysterectomy (see March 2001 and June 2004 records). Symptoms possibly associated with a TIA or CVA were first documented in VA treatment records in July 2004 when the Veteran complained of left upper extremity numbness and tingling from the elbow to wrist and fingers that lasted from 30 to 60 seconds. This occurred intermittently all day and the tingling went up to the shoulder to the left side of the mouth, lips, and tongue. There was occasional right arm tingling and, at times, weakness. At one point the left arm, leg, and face tingled at one and then the arm became dead weight; she felt dazed at this time. She was evaluated by neurology to rule out CVA and TIA, and the impression was that the most possible diagnosis was anxiety considering the episodic event and history of anxiety and perioral numbness. However, migraine and demylinating disorders needed to be ruled out although these were considered to be less likely causes. Due to her complaints of subacute left-sided numbness, an MRI study of the brain was performed in August 2004, which revealed five small foci of high T2 signal in the white matter that was very nonspecific. Differential considerations included demyelinating process, small vessel disease, infection such as Lyme disease, or other etiology. November 2004 records from a private hospital show that the Veteran complained of left-sided weakness and that she had been followed for a year for these symptoms. Neurologically, there was minimal subjective sensation of weakness on the left side and the physician was unable to elicit any clear-cut weakness. The impression was possible transient ischemic attack; rule out other etiology. A November 2004 note from Dr. P. T, a private physician, stated that the Veteran has had multiple strokes. A January 2005 VA neurology record indicates the Veteran had residual weakness over her left side, decreased memory, and tiredness, and she felt emotionally drained. It was noted that her records showed that her symptoms had become more prominent and that she had TIA vs. lacunar stroke in November 2004 and that she had been admitted to a private hospital. Two VA physicians reviewed the Veteran's MRI and MRA brain images and found no signs of lacunar or large vessel stroke; however, there was noticeable moderate to severe R ICA stenosis in the cavernose sinus portion right before ICA syphone. This finding could explain the intermittent focal neuro-deficit episodes as a result of probable TIAs, but there was no explanation for permanent neuro-deficit without signs of white or gray matter damage on an MRI. The impression was that the R ICA stenosis may predispose the Veteran to TIAs and that anxiety and depression were still contributing factors. An addendum by one of the physician's stated that he and another physician could not exclude the possibility that the high R (intracranial) ICA stenosis is an incidental finding. It was also considered strange that the Veteran had no risk factors for atherosclerosis. A February 2005 MRI of the brain revealed that there was no significant change since the December 2004 study. No evidence of acute infarction was observed. Non-enhancing mild T2 hyperintensities were scattered within the deep and subcortical white matter bilaterally and were nonspecific, although most suggestive of chronic microvascular ischemic disease. A February 2005 MRA of the brain revealed a tiny 2 to 3 mm aneurysm at the left middle cerebral artery without significant change since the December 2004 study. A May 2005 VA treatment record indicates the Veteran's neurologist informed her that her blood pressure was too high and that high blood pressure can cause another stroke. A June 2005 letter from Dr. S. G indicates that he has treated the Veteran since February 2005 for hypercholesterolemia and subsequent stenosis of her internal carotid artery. He stated that this caused a transient loss of function in the Veteran's left lower extremity consisting of a sensory deficit and weakness that resolved completely. She was found to have hypercholesterolemia and hypertension. The right grade stenosis of the carotid artery was due to atherosclerotic narrowing of the carotid artery due to her atheroscherlotic condition. In July 2005, the Veteran was admitted to a private hospital due to left-sided weakness. It was noted that she had a history of TIA. A CT scan of her brain revealed no abnormalities; however, her symptoms continued. An echocardiogram was also normal and a carotid duplex ultrasound showed thickening of the right internal carotid artery. In August 2005, the Veteran presented to a VA facility as follow-up to the prior episode of numbness and tingling in July 2005 for which she had been hospitalized. She had been told after multiple work ups that she may have had a seizure or mini stroke. The current assessment was that the Veteran had a history of intermittent episodes of left-sided numbness and subjective feeling of left-sided weakness. From her prescription and hyperventilation test, an anxiety attack was considered. The episodes were not like seizures and the EEG was normal. A September 2005 letter from Dr. N. M to Dr R. J indicates the Veteran had severe right internal carotid artery stenosis that resulted in a stroke in November 2004 and a brief TIA in July 2005. An MRI showed very little evidence of any ischemic injury in the cerebral hemisphere. The record shows that the Veteran received state disability benefits from November 2005 to April 2006. An October 2005 private evaluation associated with the Veteran's disability claim notes her personal, professional, military, and medical history. The Veteran reported that she first experienced symptoms in June 2004 and that the symptoms became progressively more frequent at work. The report indicated that she believed her stroke was due to stressors of her job. In March 2006, the Veteran testified that she was hospitalized twice for ischemic attack. The first time was when she had a stroke and the second time she was admitted for observation and tests. Her representative stated that they believed the estrogen the Veteran took caused a blood clot that eventually led to her stroke. The Veteran stated that a VA physician acknowledge that estrogen caused blood clots and that there was a very strong possibility that this caused her TIA. She recalled that this conversation took place in April 2005. Dr. B. also had the same opinion. In May 2006, a VA treatment record indicates the Veteran expressed concern over strokes. Her records were reviewed and the physician's assessment was that the Veteran had evidence of intracranial vascular disease and stroke. While it was not certain that anything is due to the Veteran taking CEE (conjugated equine estrogen), it is known that oral estrogens increase the risk of thromboses. Therefore, it would be prudent to stop taking that which can increase the risk in someone who has already had cerebral infarctions. On February 2007 VA examination, the physician noted that the Veteran had a very complex medical history. He noted that following a hysterectomy in 1996 the Veteran had been taking estrogen, which was discontinued in 2006. The Veteran had concerns over whether the estrogen was a precipitating factor in her stroke or cardiac disease. Based on his review of the claims file, the physician commented that the events of neurological significance did not have a clear quality of transient ischemia. The overwhelming components of her purported events were anxiety and hyperventilation experiences. It is possible that a stroke could occur or a transient ischemic attack become evidence with subsequent production of anxiety. This seemed less likely in view of the precipitating effect of stress in the origination of the condition. In the physician's view, the broad pattern of medical conditions, including the history of fibromyalgia, reflects behavioral phenomena that is not likely to be explained on a medical basis. The white matter changes in the MRI scan are normal for her age. There is an 80 to 90 percent narrowing of the right cavernous carotid and hypoplasia of the MCA vasculature. It is likely that these are developmental rather than degenerative atherosclerotic. If they are acquired changes it would still be difficult to attribute these features as a cause of the left-sided sensory changes. The physician also noted that a foundational issue relates to the use of estrogen and the absence of reasonable connection between estrogen use and a central neurological abnormality. There is more likely than not an absence of connection between the use of estrogen and the development of neurological conditions or phenomena. He also explained that that there is no neurological foundation currently for disability. There may be a foundation found in the psychological realm. A key factor for future examinations would be objective rather than simple recordation of behavior and experiences of the Veteran, this particularly applies to the issue of fibromyalgia. The physician offered diagnoses of chronic intermittent hyperventilation syndrome and panic/stress reactions. Primary neurological abnormality of any type was doubted as there was no reasonable connection between the suspected neurological abnormalities and the use of estrogen. This particularly applied to the cavernous arotid stenosis, which was likely asymptomatic. In October 2010, an abstract from a medical website was submitted that related to acute ischemic stroke and hypothyroidism. The conclusion was that hypothyroidism is common in patients with AIS and TIA. Elevated homocysteine levels associated with hypothyroidism suggest that hypothyroidism may represent a modifiable stroke risk factor. Prospective studies were needed to verify this association. In July 2011, a VHA opinion was obtained based on the specialist's review of the Veteran's claims file. He noted the Veteran's various medical problems and the history of the claimed disability. In a brief summary he noted that her chart showed she initially developed left-sided tingling of the face in August 2004, which was evaluated in September 2004 and resulted in a diagnosis of anxiety. An MRI study revealed 5 small foci bilaterally with differential including demyelinating process, small vessel disease and/or infection. She was then admitted to a private hospital in November 2004 to rule out a TIA versus other etiology. Tests were performed, which revealed no acute infarction, and EEG and carotid ultrasound were negative. She was readmitted to the hospital for recurrent left-sided weakness in July 2005 and a CT scan was negative. In September 2005, she was seen by a neurosurgeon for evaluation of carotid stenosis. A CTA revealed approximately 50 percent stenosis, transcradial Dopplar did not show any evidence of embolization with collateralization. She was recommended for medical management only. In response to questions posed by the Board, the physician stated that there is sufficient evidence of previous CVA in the record as the Veteran was admitted to an outside hospital for work up of TIA symptoms and CVA twice. The Veteran was noted to have persistent weakness in the second admission that was noted in subsequent outpatient visits. A June 2005 MRI described bilateral small lacunar infarcts in subcortical while matter; there is however debate in regard to this interpretation. Dr. B. stated in a May 2005 addendum that there was no clear evidence of stroke after reviewing four MRI's from August 2004 to June 2005. The VHA specialist noted that while this was one interpretation, one could not discount the two admissions for TIA's and CVA and documented residual symptoms. The Veteran appeared to have had a good functional recovery with minimal sequelae of the reported stroke. The VHA specialist opined that the Veteran's CVA's or TIA's were not at least as likely as not related to her service. Although elevated cholesterol and hormones are independent risk factors for CVA and TIA's, there was no overwhelming evidence that these risk factors were caused by the Veteran's service. The causes of development of hypercholesterolemia were multifactorial with a significant genetic component and there was evidence that VA was actively treating theses condition. Although there was no clear association of increased risk of CVA with increased cholesterol there appeared to be a benefit with treatment with statins. The Veteran had been monitored and treated with statins during this time period. The Veteran underwent TAH-BSO for indicated reasons. There did not appear to be a connection of those indications related to her service. The HRT was associated with a TAH/BSO which was considered the standard of care. It was associated with increased rates of CVA but also has benefits in regard to treatment of post-menopausal symptoms. It is documented on November 2005 that the Veteran initially refused to terminate the medication even after being informed about the increased risk of stroke as she wanted to avoid hot flashes. The Veteran subsequently discontinued the medication. The VHA specialist also opined that the Veteran's hyperthyroidism is not at least as likely as not related to have aggravated the TIA's and CVA's. The abstract provided by the Veteran was an observational study that cannot be used as a basis of declaring that hypothyroidism is an independent risk factor for TIA's and CVA's. The abstract itself stated that although the data suggests a potential link, further study would be required to declare hypothyroidism as independent risk factor for stroke. In response to the fourth question posed, the physician opinioned that the Veteran did not have a disability secondary to TIA's or stroke that is related to her service per the medical record. Her evaluation by Dr. M. revealed no obvious sequelae from the events. He concurred with the neurology examination that there was question of the quality of the symptoms associated with the TIA's and CVA and that the MRI/CTA results did not obviously concur with her symptom complex. The decision not to intervene on the noted lesion was consistent with standard of care. The differential diagnosis for the above symptoms was extensive and could be explained by hyperventilation and anxiety disorder. The physician concluded by stating that in review of the record he could not discount the possibility of the Veteran having TIA's or a mild CVA; therefore, this was accepted as the diagnosis. It appeared that the Veteran has recovered and has no sequelae of the events. Although the Veteran had risk factors for TIA and CVA's, he could not establish a causal relationship between her service and the development of those risk factors. Given the substantial medical treatment records surrounding the claimed disability, the Board finds that there is ample evidence of TIA's and CVA. Now the Board must address whether the evidence establishes a nexus between the claimed disability and the Veteran's service or service-connected disability. On this record, the Board finds that the preponderance of the evidence is against the claim. The Veteran's service treatment record contain no complaints, findings, or diagnosis relative to a TIA or stroke. Furthermore, the Veteran reported on several occasions that she did not have any associated symptoms until 2004, which was 7 years after she separated from service. The passage of many years between separation from active service and the objective documentation of a claimed disability is a factor that weighs against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Significantly, the VHA examiner also opined against an etiology relating the claimed disability to the Veteran's service and provided a rationale to support this view. To the extent that the Veteran believes that her claimed disability is related to her high cholesterol that was first noted and treated with medication in service and continued thereafter, the VHA physician essentially opined against this theory and provided a rationale in support of his opinion. Notably, the Veteran has not presented nor does the record contain any competent evidence in support of her claim that is more persuasive or probative than the VHA opinion. As noted previously, the Veteran also asserts that the claimed disability is related to hypothyroidism or hysterectomy, both of which are service-connected disabilities. In support of her claim, an abstract of a medical study was submitted that explored the relationship between hyperthyroidism and stroke. As noted by the VHA examiner, who opined against this theory, this abstract offered no conclusive evidence and specifically stated that additional studies were needed to verify the association. Consequently, this evidence is far less probative and persuasive than the VHA opinion. As for the association between the Veteran's estrogen treatment after her hysterectomy, physicians acknowledged that hormone replacement therapy poses an increased risk of stroke; however, none of the physicians indicated that this scenario applies in the Veteran's case. In particular, a May 2006 record notes that it was not certain that anything was caused by the Veteran's estrogen treatment. The VA examiner also found no relationship between the Veteran's neurological manifestations and estrogen. Moreover, the VHA physician did not indicate there was an association between the Veteran's estrogen treatment and her TIA's and stroke. The Board considered the Veteran's contentions as to the etiology of her TIA's and CVA and her belief that they are related to her service. Determining the etiology of a disability of this nature is a complex matter and not subject to lay observation. Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Since the Veteran does not have the medical training or knowledge to determine the etiology of her disability, her statements are not competent to establish a nexus between the TIA's and CVA and her service. The Board also observes that the record shows the Veteran also applied for and received disability pay from her state in relation to the disability for which she now seeks service connection. With respect to that claim, she asserted that the disability was caused by the stress associated with her job. In the absence of probative and persuasive evidence in support of the claim based on service connection on a direct or secondary basis, a preponderance of the evidence is against the claim. Therefore, the benefit-of-the-doubt doctrine does not apply and the claim must be denied. Increased Rating Legal Criteria Disability ratings are based on average impairment in earning capacity resulting from a particular disability, and are determined by comparing symptoms shown with criteria in VA's Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations, which are potentially applicable, based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Veteran's statements describing her symptoms are competent evidence to the extent that she can describe what she experiences. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, these statements must be viewed in conjunction with the objective medical evidence and the pertinent rating criteria. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2011). In every instance where the Rating Schedule does not provide a no percent rating for a diagnostic code, a no percent rating shall be assigned when the requirement for a compensable rating are not met. 8 C.F.R. § 4.31 (2011). When a question arises as to which of two ratings under a particular Code applies, the higher evaluation is assigned if the disability picture more closely approximates the criteria for the higher rating; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2011). With an initial rating assigned following a grant of service connection, as here, separate ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). This practice is known as "staged" ratings. In the present case, the RO did not assign staged ratings for the service-connected left foot and GERD disabilities. Analysis A. Left Foot On July and August 1998 VA examinations, the Veteran complained of constant foot pain that was previously treated with cortisone injections, braces, special shoes, and arch supports with no relief. The examination revealed no evidence of arch abnormality, limitation of ankle or metatarsal phalangeal motion, atrophy, or other deformity of the foot. There was pain on light palpation of her plantar fasciitis on wind-up of the great toe and smaller toes, but there was no pain over the origin of her plantar fascia at the calcaneus. X-rays of the left foot revealed no abnormality. The examiner noted that conservative treatment had failed and that her ability to engage in prolonged standing activities was affected. A September 1998 VA treatment record indicates the Veteran had progressive heel and arch pain that was rated 5 on a scale from 1 to 10. Various forms of treatment in the past had failed. No new left foot complaints were noted in 1999. In February 2000, the Veteran testified that she was told that unless she had surgery there was no other treatment for her left foot disorder. She reported having constant foot pain that fluctuated. It began in the morning as 4/10 and some days it was 5/10, 6/10, or even 10/10. She also had swelling at times depending on her activity level. In term of distances, she could walk from one end of the mall to the other and back but her feet would hurt. She was given a disability placard from her physician so she would not have to walk long distances. Her husband testified that it has become increasingly difficult for the Veteran to perform certain tasks like preparing a meal. On January 2003 VA examination, the Veteran complained of foot pain in the bottom of the heel that radiated toward the forefoot especially when she was on her feet for any length of time. There was no footwear that helped relieve her pain except slippers. There reportedly was no history of swelling or erythema and she was not taking any analgesics or anti-inflammatory medications. She currently had a job that was sedentary. An examination revealed ankle dorsiflexion of 10 degrees, plantar flexion of 45 degrees, eversion of 20 degrees, and inversion of 30 degrees. There was tenderness on the inferior aspect of the left heel at the attachment of the plantar aponeurosis on the os calsus. On June 2005 VA examination, the Veteran reported that flare-ups consisted of pain but not weakness, fatigability, lack of endurance, or lack of coordination. She could walk approximately 1 block and the distance was limited by foot pain. There were no episodes of incapacitation due to her foot disability. Accommodations had been made for her before she retired. The examination revealed no obvious abnormality to include flat foot. The hind foot was well aligned and there was no varus or valgus deformity. There was tenderness to palpation of the plantar surface in the longitudinal arch, and range of ankle motion was 20 degrees of dorsiflexion, 4 degrees of plantar flexion with 5 degrees of varus and valgus motion of the hind foot. There was no limitation in range of motion due to pain, weakness, fatigability, lack of endurance, or lack of coordination. The strength in dorsiflexion and plantar flexion of the ankle was 5/5 and the sensation in the left foot was normal. The diagnosis was severe plantar fasciitis, which has resisted orthotics, stretching, cortisone injections, and nonsteroidal anti-inflammatories. The disability significantly impacted her mobility. On February 2007 VA examination, there were no changes reported in the range of foot pain, but she did report having flare-ups approximately twice a week that were 10/10 in severity. She denied having antecedent exacerbating factors and that she reported most of her pain flare-ups occurred while she was asleep, which awoke her. The only other causative factor to increased pain was increased ambulation. She reported that she could walk 1/4 of a mile before her foot pain increased to 10/10. When this occurred the pain lasted into the next day and it precluded any significant standing or walking. She did not use any assistive devices and she did not have any incapacitating episodes. The Veteran was able to stand in place for approximately 1/2 hour before she had to sit due to the severity of the foot pain. An examination of the left foot revealed no visible abnormalities. There was no point tenderness to palpation over any boney prominence other than some tenderness at the inferior aspect at the origin of the plantar facia, over which there was exquisite point tenderness to palpation. The range of left ankle motion was 10 degrees of dorsiflexion, 40 degrees of plantar flexion, 30 degrees of inversion, and 10 degrees of eversion. These movements were performed without limitation by pain, weakness, fatigue, or lack of endurance on repetitive use. There was also no pain with forcible dorsiflexion of the great toe of the left foot. Her gait was steady and without evidence of favoring of the left lower extremity. There was normal valgus alignment of the heel, which showed slight varus posture with heel rise. There was no evidence of flat foot or toe abnormality on weight bearing. The assessment was that the Veteran had chronic left foot plantar fasciitis with significant functional limitation approximately twice a week during flare-ups when her pain was 10/10 in severity and precluded standing or walking. Her baseline limitation was 1/2 hour of standing and 1/4 mile of walking. Where a Veteran has been diagnosed as having a specific condition and the diagnosed condition is not listed in the Ratings Schedule, the diagnosed condition will be evaluated by analogy to closely related diseases or injuries in which not only the functions affected, but the anatomical localizations and symptomatology, are closely analogous. 38 C.F.R. § 4.20. In this case, the service-connected plantar fasciitis of the left foot is currently rated by analogy under Code 5284 and is assigned a 10 percent rating. Since there is no evidence of symptomatology analogous to flat foot, claw foot, or malunion or non union of the tarsal or metatarsal bones, Codes 5276, 5278, or 5283 are not applicable. Thus, the Board will consider whether a rating in excess of 10 percent is warranted at any time during the appeal under Code 5284. Foot injuries that are moderate warrant a 10 percent disability rating. If moderately severe, a 20 percent disability rating is appropriate. If the foot injury is severe, a maximum 30 percent disability rating is warranted. A 40 percent rating is assigned with actual loss of use of the foot. 38 C.F.R. § 4.71a , Diagnostic Code 5284. The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10 , 4.40, 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Throughout the appeal, the disability picture associated with the service-connected left foot disability more closely resembles severe impairment. The record not only shows that the disability has been characterized as being severe by the 2007 VA examiner, but throughout the appeal all forms of treatment have failed, she was significantly limited in her ability to stand or walk for prolonged periods, and she had flare-ups every week that severely limited her mobility. A higher rating of 40 percent is not warranted as the disability does not resemble loss of her left foot. Although she is significantly limited in ambulation at times, she still has use of her foot and she is not precluded from walking or standing most of the time. Furthermore, she does not require the use of a cane or other assistive device. The rating schedule represents as far as is practicable the average impairment of earning capacity. Ratings will generally be based on average impairment. 38 C.F.R. § 3.321(a), (b) (2011). However, to afford justice in exceptional situations, an extraschedular rating can be provided. 38 C.F.R. § 3.321(b). The Board may determine, in the first instance, that a veteran has not presented evidence warranting referral for extraschedular consideration, provided that it articulates the reasons or bases for that determination. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). This determination follows a three-step inquiry. See Thun v. Peake, 22 Vet.App. 111, 115 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, the level of severity and symptomatology of the veteran's service-connected disability must be compared with the established criteria found in the rating schedule for that disability. Id. If the rating criteria reasonably describe the veteran's disability level and symptomatology, the veteran's picture is contemplated by the rating schedule. Therefore, the assigned schedular evaluation is adequate and no referral is required. Id. If the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, and is found inadequate, the second step of the inquiry requires the Board to determine whether the veteran's exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-16. If analysis of the first two steps shows that the rating schedule is inadequate to evaluate a veteran's disability picture and that picture shows the related factors discussed hereinabove, the final step requires that the case be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether the veteran's disability picture requires the assignment of an extraschedular rating. Id. Here, the Board has considered, under the Thun three-step analysis, whether referral for extraschedular consideration is appropriate. However, the applicable rating criteria reasonably describe the Veteran's disability level and symptomatology. The evaluation of the disability takes into account whatever manifestations that may be present as well as other factors such as the severity and level of impairment that may be considered the basis for an increase. Thus, the findings of pain and limitation in walking and standing are factors contemplated by the criteria. Therefore, the Board is not required to remand the Veteran's claim for consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). See Bagwell, supra. at 338-9; Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). B. GERD On July 1998 VA examination, it was noted that the Veteran was on medication for heartburn and that there was no evidence of active ulcer or gastritis demonstrated. She was recently taking more medication to control her symptoms better. She denied having any difficulty in swallowing. The examination revealed there was no tenderness to deep palpation of the abdomen and the bowel sounds were active. It appeared that the Veteran's dyspepsia had no disabling impact on her present employment. The Veteran was seen in October 1998 and complained of epigastrium pain and reflux. There was tenderness and guarding on examination. Complaints of a week long history of nausea, diarrhea and cramping were diagnosed as gastroenteritis. An upper GI and abdominal ultrasound were negative. January 1999 VA treatment records note the Veteran had a 5 day history of abdominal cramps and diarrhea that was diagnosed as acute gastroenteritis; the symptoms resolved that same month. In October 1999, the Veteran had a follow-up visit and she complained of dyspepsia and abdominal pain with occasional nausea and vomiting. In February 2000, the Veteran testified that she was told that she had all the indications of an ulcer without having an ulcer. For approximately 3 out of every 4 weeks in the month she had stomach pain, nausea, and cramping. She rated her stomach pain as 7 on a scale of 1 to 10. She had difficulty sleeping since she woke up with vomiting or at times diarrhea. She has spasms with either her diarrhea or constipation. She had limitations in her diet due to her disability and she had symptoms when she ate the restricted foods. She continued to have gastric reflex and had an episode the previous night. In April 2000, the Veteran had an esophagogastroduodenoscopy at a private hospital due to symptoms of abdominal pain, nausea, anorexia, and dysphagia that was not responding to medical treatment. The impressions were hiatal hernia mild esophagitis, and erosive gastritis. There was no evidence of stricture, mass lesions, or other anomalies. A December 2000 VA treatment record indicates the Veteran reported that she had no complaints of heartburn with her medication. A July 2001 upper GI revealed mild gastroesophageal reflux; no demonstrable ulcer crater or additional abnormality was shown. In August 2001, an esophagogastroduodenoscopy was performed due to abdominal pain, nausea, and anorexia. The diagnoses were gastric polyps, small hiatal hernia, and antral gastritis; there was no evidence of esophagitis or strictures. A February 2002 endoscopy revealed hiatal hernia with esophagitis and esophageal stricture, and an antral gastritis and antral nodule. In August 2002, an esophagogastroduodenoscopy revealed gastric antrum. On January 2003 VA examination, the Veteran reported having continuous feelings of nausea with some days worse than others. The mid-epigastric pain was constant and worsened with some foods. She denied vomiting, there was no difficulty in swallowing, and her weight was noted to be stable. Her bowel habits alternated between constipation and diarrhea. The examination revealed tenderness with deep palpation of the mid-epigastric and right upper quadrant. There was no rebound, hepatosplenomegaly, or mass. The examiner noted that the Veteran's first endoscopy was in 2000 when she had abdominal pain, nausea, anorexia, and dysphasia, and she was not responding well to medical treatment. The diagnosis was hiatal hernia and mild esophagitis and antral gastritis. The gastric biopsies showed mild chronic gastritis, but it was otherwise negative. She underwent a second endoscopy in August 2001 due to similar symptoms. This study showed a small gastric polyp and hiatal hernia with gastritis. There was no esophagitis or stricture reported. Due to the same symptoms, she had an upper GI and small bowel follow through in 2001 that revealed a marked degree of gastroesophageal reflux. Symptoms of abdominal pain, dysphasia, and anorexia in 2002 led to an endoscopy that revealed gastric nodules, antral gastritis, and hiatal hernia. There was no esophageal stricture. The examiner noted that her chronic reflux symptoms may have improved to some extent by the induction of PPI into her medical regiment, but she continued to feel nauseated, burped, brought up food, and had free reflux. Her overall symptoms were suggestive of irritable bowel syndrome (IBS) with prominence of dyspepsia and reflux. An EGD was performed that revealed a gastric polyp and did not suggest Barrett's. She had non-ulcer dyspepsia and predominant IBS. An April 2003 colonoscopy revealed mild colitis; no polyps, mass lesions, or other anomalies were seen. On June 2005 VA examination, the Veteran complained of having a stomach ache on a continuous basis as well as cramping with bowel movements; these symptoms have not changed over the years. She indicated that she would have significant reflux if she went off her medication. If she did not chew her food properly then she had mild dysphagia at times even when she was on her medication. The Veteran was told in the past that her symptoms were suggestive of ulcer disease even though an ulcer had not been documented. She denied weight loss, vomiting of blood or blood in the stools, and anorexia. There was no documentation of esophageal strictures and she never had an upper gastrointestinal bleed documented. There were no other esophageal symptoms related to GERD. The examination of the abdomen revealed tenderness all over. The examiner noted that based on the date and examination that the Veteran had some form of gastroesophageal reflux that responded well to medication. Some of the Veteran's complaints bordered on irritable bowel syndrome, especially abdominal soreness and cramping with bowel movements. In the examiner's opinion she had not demonstrated any of the chronic sequelae of severe GERD such as stricture, erosions, ulcer, and upper GI bleeding. In March 2006, the Veteran testified that she had a lot of acid reflex even with her medication. An April 2006 VA treatment record notes the Veteran's history of longstanding heartburn that was moderately controlled on bid PPI. She had occasional upper dysphagia with solids, 2 solid bowel movements a day, and diffuse abdominal pain before moving bowels. She did not have weight loss or blood in her stools. In August 2008, the Veteran complained of having diarrhea 2 to 3 times a month. This was thought to be related to a recent change in medication. There was no change in her diet but she was not eating much and under a lot of stress. On February 2007 VA examination, it was noted that the Veteran's last upper endoscopy was in October 2006 and it showed marked villiform transformation and mild, chronic inflammation of the stomach that were thought to be secondary to chemical gastropathy. Biopsies were performed that revealed benign duodenal mucosa. She continued to have symptoms of abdominal distress, crampy pain in the abdomen during bowel movements, alternating constipation and diarrhea, and difficulty swallowing food unless she chewed well and swallowed with water. She reported that food got "stuck" if she drank normally and sometimes caused her to cough and gasp; therefore, she had to drink water with a straw. She had nighttime cramps and nausea, and she denied having weight loss. The examination indicated that she had no weight change during the past year and that she still had diffuse tenderness over the entire abdomen. The Veteran had been on antibiotics for bacterial overgrowth, which was suspected because of a change in her bowel habits from predominantly constipation to more of diarrhea recently. Overall, she only had 3 bowel movements the previous day and 2 the day before that; all of these bowel movements were well formed. The examiner commented that the Veteran had continuous symptoms of dyspepsia and GERD. More concerning was a diagnosis of Barrett esophagitis in 2003, which was related to her reflux disease. It was at least as likely as not that some of her lower GI symptoms of constipation and then alternating constipation and diarrhea were related to a separate entity of irritable bowel syndrome. Every other symptom the Veteran had of a GI nature was related to GERD and its sequelae. A September 2008 VA treatment record notes the Veteran did not have PUD, melena, hematochezia, hematesis, constipation, or diarrhea. A July 2009 colonoscopy was normal except for hemorrhoids. General rating considerations for diseases of the digestive system are contained in 38 C.F.R. §§ 4.110-4.113 (2011). Ratings under diagnostic 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 (2011). The service-connected dyspepsia with GERD is rated by analogy under Code 7307 and is currently assigned 10 percent rating. Under Code 7307, a 10 percent rating is assigned for chronic disability with small nodular lesions and symptoms. A 30 percent rating is assigned for chronic disability with multiple small eroded or ulcer areas and symptoms. A 60 percent rating is assigned for chronic disability with severe hemorrhages or large ulcerated or eroded areas. 38 C.F.R. § 4.114. Other diagnostic codes that address disability pictures similar to GERD and provide for ratings in excess of 10 percent are Codes 7203 (for esophagus stricture), 7304 (gastric ulcers) (rating under Code 7305 criteria), 7319 (irritable colon syndrome), 7323 (colitis), and 7346 (for hiatal hernia). Under Code 7203, a 30 percent rating requires moderate esophageal stricture; a 50 percent rating requires severe stricture, permitting liquids only; and an 80 percent rating requires passage of liquids only, with marked impairment of general health. 38 C.F.R. § 4.114. Under Code 7304 (Code 7305 criteria), a 10 percent rating is assigned for symptoms that are mild, with recurring symptoms once or twice yearly. A 20 percent rating is assigned for moderate symptoms; recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 40 percent rating is assigned for symptoms that are moderately severe; less than severe but with impairment of health manifested by anemia and with weight loss; or for recurrent incapacitating episodes averaging 10 days or more in duration at least four times per year. A rating of 60 percent is assigned for severe symptoms with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114. Under Diagnostic Code 7319, a 10 percent rating is assigned for moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress; a 30 percent rating is warranted for severe irritable colon syndrome manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114. Under Code 7323, a 10 percent rating is assigned for moderate disability with infrequent exacerbations. A 30 percent rating is assigned for moderately severe disability with frequent exacerbations. A 60 percent rating is assigned for severe disability; with numerous attacks a year and malnutrition, the health only fair during remissions. A 100 percent rating is assigned for pronounced disability resulting in marked malnutrition, anemia, and general debility, or with serious complications as liver abscess. 38 C.F.R. § 4.114. Under Code 7346, 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 rating. Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health warrant a 30 percent rating. Two or more of the symptoms for the 30 percent evaluation of less severity warrants a 10 percent rating. 38 C.F.R. § 4.114. The Board notes that terms such as "severe," "considerable," and "of lesser severity" are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2011). The Board has considered the various diagnostic codes to determine whether a higher initial rating is warranted and finds that no change is warranted under Codes 7203, 7319, 7323, or 7246. Regarding Code 7203, the record contains no evidence of moderate or severe stricture. Since the 2007 VA examiner stated that the symptoms of diarrhea and constipation are not related to the service-connected gastrointestinal disability, Code 7319 is not appropriate for rating the disability. Although colitis was suspected and noted on one record, there is no evidence of moderately severe symptoms with frequent exacerbations to warrant a higher rating under Code 7323. Lastly, the Veteran is shown to have persistently recurrent epigastric distress with dysphagia and regurgitation, but there is no associated substernal, arm, or shoulder pain nor is the disability productive of considerable impairment of health to warrant a higher rating under Code 7346. Given that the Veteran indicated that she was told her symptoms were suggestive of an ulcer yet was not productive of an ulcer, the Board finds that Code 7305 is the most appropriate diagnostic code for rating the disability. Under this code, the Board finds that a rating of 20 percent most accurately depicts the level of disability presented by the service-connected dyspepsia with GERD. Throughout the appeal the Veteran was shown to have dyspepsia and epigastric distress with occasional occurrences of nausea, vomiting, and anorexia. These symptoms are most compatible with continuous moderate impairment. A higher rating is not warranted since many of the Veteran's symptoms are fairly well controlled by medication and since a VA physician stated that she did not have severe sequelae stemming from GERD. Furthermore, she was not shown to have anemia, weight loss, or incapacitating episodes associated with the service-connected disability. Thus, resolving all reasonable doubt in the Veteran's favor, a rating of 20 percent is warranted for the entire period of the appeal. The Board considered whether referral for extraschedular consideration is warranted but finds that the threshold factors are not met. See 38 C.F.R. § 3.321, Thun v. Peake, 22 Vet.App. 111, 115 (2008). The Veteran's manifestations and the severity of the service-connected disability are compatible with the established rating criteria. There is nothing unusual or exceptional presented in her disability as all of her symptoms are adequately represented in the schedular criteria. Since the applicable rating criteria reasonably describe the Veteran's disability level and symptomatology, the Board is not required to remand the Veteran's claim for consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). See Bagwell, supra.; Floyd, supra; Shipwash, supra. ORDER Service connection for TIA's and CVA is denied. An initial 30 percent evaluation for the service-connected left foot plantar fasciitis is granted, subject to the regulations controlling disbursement of VA monetary benefits. An initial 20 percent evaluation for the service-connected dyspepsia and GERD is granted, subject to the regulations controlling disbursement of VA monetary benefits. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs