Citation Nr: 1300766 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 09-01 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent for wedge osteotomy, 3rd metatarsal, right foot, with residual scars. 2. Entitlement to an evaluation in excess of 10 percent for status-post neuroma, left foot, with residual scars. 3. Entitlement to an initial compensable evaluation for degenerative arthritis of the right knee. 4. Entitlement to an initial compensable evaluation for degenerative arthritis of the left knee. 5. Entitlement to an initial compensable evaluation for degenerative disease of the lumbar spine. 6. Entitlement to an evaluation in excess of 30 percent for migraines. 7. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran, D.H., A.P., and J.B. ATTORNEY FOR THE BOARD H. Hoeft, Counsel INTRODUCTION The Veteran served on active duty from April 1988 to March 1994. This matter comes before the Board of Veterans' Appeals, hereinafter the Board, on appeal from rating decisions of February 2008 and March 2010, of the Nashville, Tennessee, Regional Office (RO), of the Department of Veterans Affairs. The Veteran testified before the undersigned Veterans Law Judge in September 2012. A transcript of that proceeding has been associated with the claims file. The issues of entitlement to service connection for an acquired psychiatric disorder as secondary to service-connected disabilities, entitlement to service connection for an elbow injury as secondary to service-connected disabilities, and whether new and material evidence has been submitted to reopen claims of entitlement to service connection for hearing loss and sleep apnea, have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). See Hearing Transcript, generally; see also June 2012 Statement from Veteran. Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issues of entitlement to an evaluation in excess of 10 percent for wedge osteotomy, 3rd metatarsal, right foot, with residual scars, and entitlement to an evaluation in excess of 10 percent for status-post neuroma, left foot, with residual scars, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout this claim and appeal, the Veteran's migraine headaches have been productive of very frequent, prolonged and completely prostrating attacks, resulting in severe economic inadaptability. 2. As none of the medical evidence of record sufficiently establishes the degree of disability in the lumbar spine prior to onset of aggravation from the service-connected foot disabilities, no deduction of pre-existing disability in the left knee will be made; i.e., the Veteran's lumbar spine disability will be considered as 0 percent disabling prior to the onset of aggravation from the bilateral foot disability and any current impairment in the lumbar spine will be considered as caused by the bilateral foot disabilities, and thus service-connected. 3. Throughout this claim and appeal, the Veteran's lumbar spine disability has been manifested by pain and mild limitation of motion (limited to 70 degrees of flexion, at most), with localized tenderness not resulting in abnormal gait or abnormal spinal contour; there is no evidence of forward flexion of the thoracolumbar spine to 60 degrees or less, or combined ranges of motion to 120 degrees or less, or incapacitating episodes of intervertebral disc syndrome. 4. As none of the medical evidence of record sufficiently establishes the degree of disability in the bilateral knees prior to onset of aggravation from the service-connected foot disabilities, no deduction of pre-existing disability in the left knee will be made; i.e., the Veteran's left and right knee disabilities will be considered as 0 percent disabling prior to the onset of aggravation from the bilateral foot disability and any current impairment in the right and left knees will be considered as caused by the bilateral foot disabilities, and thus service-connected. 5. The Veteran's degenerative arthritis of the right knee is manifested by motion of her right knee from 0 to 140 degrees (or full range of motion), with no additional loss of motion after repetition, but with objective evidence of tenderness, crepitus, and consistent and credible complaints of painful motion, fatigability, and weakness; there are no objective findings of instability. 6. The Veteran's traumatic arthritis of the left knee is manifested by motion of her left knee from 0 to 140 degrees (or full range of motion), with no additional loss of motion after repetition, but with objective evidence of tenderness, crepitus, and consistent and credible complaints of painful motion, fatigability, and weakness; there are no objective findings of instability. 7. Resolving reasonable doubt in the Veteran's favor, the evidence of record reflects that she is unable to obtain and/or maintain substantially gainful employment due to her service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a 50 percent rating, but no higher, for migraine headaches have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2012). 2. The criteria for an initial evaluation of 10 percent, but no higher, for a lumbar spine disability have been met throughout the entire appeals period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.55, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5235-5243 (2012); DeLuca v. Brown, 8 Vet. App. 202 (1995). 3. The criteria for an initial 10 percent rating, but no higher, for traumatic arthritis of the left knee with painful motion have been met throughout the entire appeals period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.22, 4.1, 4.2, 4.7, 4.22, 4.71a, DCs 5003, 5010, 5260, 5261 (2012). 4. The criteria for an initial 10 percent rating, but no higher, for traumatic arthritis of the right knee with painful motion have been met throughout the entire appeals period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.22, 4.1, 4.2, 4.7, 4.22, 4.71a, DCs 5003, 5010, 5260, 5261 (2012). 5. The criteria for assignment of a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.340, 4.3, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, 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 notice from VA 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). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The claims for higher initial ratings for left knee, right knee, and lumbar spine disorders arise from the Veteran's disagreement with the initial ratings assigned in connection with the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating or effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105 (West 2002). Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). With respect to the claim for a higher rating for migraine headaches, the Veteran received appropriate notification prior to the March 2010 adjudication by way of July 2009 and February 2009 letters from the RO. In sum, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of her claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir. 2004). Letters satisfying the notice requirements were sent to the Veteran in February 2009, July 2009, and September 2009. This notice was followed by readjudication of the claims subsequent supplemental statements of the case. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting her in the procurement of service treatment records and pertinent post-service treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has obtained service and VA treatment records, private treatment records, Social Security records, and Vocational Rehabilitation records. The Veteran was afforded multiple VA examinations to support her increased rating claims. She was also afforded a hearing before a Veterans Law Judge (VLJ) in September 2012, in which she presented oral argument. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). I. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). 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 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). 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. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). As many of the Veteran's claims involve arthritis, the Board will include the general rating criteria for arthritis here. Arthritis due to trauma is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2012). Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). However, when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 10 percent evaluation is assigned with x-ray evidence of involvement of two or more major joints; a 20 percent rating is assigned with x-ray evidence of involvement of two or more major joints with occasional incapacitating exacerbations. Id. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) a. Migraines The Veteran seeks a higher evaluation for her service-connected migraine disability. She reports that she experiences two to three prostrating migraine attacks per week, which are accompanied by vomiting and only relieved by resting in a dark room. See Hearing Transcript, pp. 4-5. The Veteran's claim for an increased disability rating was received in May 2009. She has been assigned a 30 percent disability rating for her migraine headaches. A noncompensable evaluation is warranted for migraine headaches with attacks less often than the frequency of attacks required for a 10 percent evaluation. 38 C.F.R. Part 4, Diagnostic Code 8100 (2012). A 10 percent evaluation requires characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent evaluation requires characteristic prostrating attacks occurring on an average of once a month over the last several months. A 50 percent evaluation requires very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. Part 4, Diagnostic Code 8100 (2012). In this case, VA treatment records dated throughout 2008 reflect ongoing complaints and treatment for migraine headaches. For example, a May 2008 treatment note indicates that the Veteran was experiencing one to two migraines per week. A 2009 VA treatment note shows that the migraines increased in frequency from one or two per week, to twice per week with nausea and light sensitivity. At the June 2009 QTC examination, the Veteran reported that she experienced migraines two to three times per week and that each episode lasted approximately 24 hours. She stated that she had to stay in bed and was unable to do anything during these episodes. Accompanying symptoms included nausea, vomiting, blurry vision, and light sensitivity. Treatment consisted of amitriptyline at night, hydrocodone/acetametaphine, and morphine for pain. She reported that the medication helped "some," but she still waited a full 24 hours for pain to resolve completely. The pertinent diagnosis was active migraines with associated vomiting, photophobia, and pain. The examiner further noted that the migraines affected the Veteran's ability to work, but only when headaches were present. At the August 2011 QTC examination, the Veteran described her migraines as severe and accompanied by light sensitivity, nausea, and vomiting. The migraines are only relieved by lying in a dark room; she is unable to do anything during these episodes. On the pain scale, the migraines are a level 9 out of 10. She reported migraines on average of 2 times per week, and lasting for 24 hours. During flare-ups/episodes, she is not able to perform regular activities/duties due to headache. Treatment included Amitriptilline. Numerous other treatment records from the remainder of 2008 and 2009 have been associated with the claims folder, in connection with the Veteran's claim that are consistent with the findings noted above and, at the very minimum, corroborate the Veteran's account of severity, frequency, and the need of treatment. Moreover, the Veteran's statements concerning the frequency of the headaches, the severity of the pain produced by the headaches, and the incapacity that she experiences are credible when compared to the medical evidence of record. The Board considers these statements credible and probative, and they are consistent and plausible with the other evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995); and Davidson v. Shinseki, 581 F.3d. 1313, 1315 (Fed. Cir. 2009). After considering the evidence of record, the Board finds that the criteria for a 50 percent evaluation under 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2012), are approximated. The evidence dated within the claim period shows that the Veteran reports having on average headaches two to three out of seven days each week. Because these headaches occur frequently, last for long periods of time (24 hours), are accompanied by severe pain, vomiting, and light sensitivity, and require her to lie down for extended periods of time, severe economic hardship has resulted. In other words, the headaches are productive of severe economic inadaptability. The QTC examiners have confirmed as much. Comparing these manifestations to the rating criteria, it is clear that the criteria for a 30 percent rating are greatly exceeded, because that rating requires characteristic prostrating attacks that occur only once a month. Throughout the appeal period, the Veteran's migraines have occurred much more frequently than once per month. Comparing the reported eight to twelve severe, prostrating headaches per month and resulting incapacity, it is clear that the criteria for a higher rating are more nearly approximated. Even if all elements specified in the rating criteria are not shown, they need not be. 38 C.F.R. § 4.21 (2012). The Board must resolve any remaining doubt in favor of the Veteran and find that the 50 percent criteria are more nearly approximated throughout the period of time covered by this claim. In this case, the evidence does not contain factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal. The assignment of staged ratings is therefore unnecessary. Hart, supra. The Veteran is thus entitled to a 50 percent disability rating for the entire period of time that is covered by her claim. After considering all the evidence of record, including the testimony, the Board finds that the evidence is at least in relative equipoise. The benefit of the doubt doctrine will therefore be applied. See 38 U.S.C.A. § 5107 (West 2002). A 50 percent schedular rating for migraine headaches is granted. Concerning the appeal for a schedular rating greater than 50 percent, Diagnostic Code 8100 does not offer a rating greater than 50 percent. 38 C.F.R. Part 4 (2012). b. Lumbar Spine The Veteran's service-connected lumbar spine disability has been assigned an initial noncompensable rating, effective July 10, 2009, under Diagnostic Code 5242. See March 2010 Rating Decision Granting Lumbar Spine Disability. She contends that she experiences low back pain with everyday activities, such as bending over getting in/out shower and doing laundry, and that her back stiffens up after sitting for long periods of time. See Hearing Transcript, 9-10. Initially, the Board observes the RO determined the Veteran had met the criteria for a 10 percent evaluation effective July 10, 2009, and reduced this disability evaluation by 10 percent based upon aggravation. See March 2010 Rating Decision. For the sake of clarity, prior to determining whether an increased evaluation is warranted based upon the schedular criteria, the Board will discuss whether reduction is warranted based upon aggravation of a nonservice-connected disability by a service-connected disability. In this regard, VA regulations governing aggravation (with consideration of aggravation in service) establish that in cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree of disability existing at the time of entrance into active service. It is necessary to deduct from the present evaluation the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule except that if the disability is total (100 percent) no deduction will be made. If the degree of disability at the time of entrance into service is not ascertainable in terms of the schedule no deduction will be made. 38 C.F.R. §§ 3.22, 4.22. Again, the Veteran's lumbar spine disability has been rated as noncompensable under Diagnostic Code 5242. Back disabilities are evaluated under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. Intervertebral disc disease can alternatively be rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Id. Under the general rating formula, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted if forward flexion of the thoracolumbar spine is 30 degrees or less; or, if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for ankylosis of the entire spine. Id. The Veteran underwent a QTC examination in January 2010. Subjectively, she reported that she experienced stiffness, decreased motion, numbness, and weakness of the spine, leg, and foot. She stated that her back pain was severe and exacerbated by physical activity. It was relieved by rest, Morphine, and Vicodin. During flare-ups, she reported that she experienced pain with standing, walking, and bending. She denied ever being hospitalized or having surgery for her lumbar spine condition. The examiner noted that she required a walker, but this was due to her feet and knee problems. Objectively, there was no evidence of radiating pain with movement; muscle spasms were absent; there was mild tenderness of all lumbar muscles; spinal contour was preserved (although tender); there was no guarding of movement and no weakness; muscle tone and musculature was normal; bilateral leg raises and Lasegue's sign were negative; and there was no atrophy or ankylosis present. Posture and gait were also normal. Range of motion findings revealed forward flexion to 70 degrees (with pain starting at 70 degrees); extension was to 30 degrees; right and left lateral flexion were to 30 degrees; and right and left rotation were to 30 degrees. Repetitive motion was possible and did not produce any additional degree of limitation. Joint function of the spine was not additionally limited by pain, fatigue, weakness, or lack of endurance or incoordination after repetitive use. The Veteran underwent an additional QTC examination in August 2011. Subjectively, she reported worsening low back pain, falls, limited walking, stiffness, fatigue, decreased motion, and paresthesias. She denied having any spasms or numbness relating to her spine condition. She also denied experiencing any bowel or bladder problems relating to her spine condition. She stated that the low back pain occurs 10 times per day and lasts for 24 hours. The pain travels to the upper and lower back and legs. She reported that the pain was severe and exacerbated by physical activity. She is able to function with the use of pain medication. During flare-ups, she described functional impairment consisting of pain and leg weakness. Pain is controlled with a TENS unit and Morphine/Vicodin. She stated that her condition had not resulted in any incapacitation over the last 12 months. Objectively, the Veteran's gait and posture were normal; she did not require any assistive aids for ambulation; there was no evidence of radiating pain on movement; there were no muscle spasms; tenderness of the lumbar region was present; spinal contour was preserved (but tender); there was no weakness; muscle tone was normal; musculature was normal; right and left leg raises were negative; Lasegue's sign was negative; and there was no atrophy or ankylosis present. Range of motion findings revealed full range of motion of the thoracolumbar spine; in other words, flexion was to 90 degrees; extension was to 30 degrees; right and left lateral flexion were to 30 degrees; and right and left rotation were to 30 degrees. Repetitive motion was possible and did not produce any additional degree of limitation. Joint function of the spine was not additionally limited by pain, fatigue, weakness, or lack of endurance or incoordination after repetitive use. Lumbar Spine - Analysis As an initial matter, based on the evidence of record outlined above, neither the January 2010 VA examiner nor the August 2011 VA examiner established the degree of baseline level of disability prior to the aggravation of the lumbar spine by the bilateral foot disability. As noted above, the regulations addressing aggravation of disabilities note that if the degree of disability at the time of entrance into service, or as in this case, prior to the onset of aggravation from the bilateral foot disability, is not ascertainable in terms of the schedule, no deduction will be made. See 38 C.F.R. §§ 3.22, 4.22. As neither examiner in January 2010 or August 2011, nor any of the other medical evidence of record, sufficiently establishes the degree of disability in the lumbar spine prior to onset of aggravation from the bilateral foot disability, no deduction of pre-existing disability in the lumbar spine disability will be made. In other words, the Veteran's lumbar spine disability will be considered as 0 percent disabling prior to the onset of aggravation from the bilateral foot disability and any current impairment in the lumbar spine will be considered as caused by the bilateral foot disability, and thus service-connected. The Board will now turn to what the appropriate disability rating is for the lumbar spine disability. In this case, the January 2010 VA examination reflects forward flexion of the thoracolumbar limited to 70 degrees, while the August 2011 VA examination reveals full range of motion of the thoracolumbar spine, but with localized tenderness in the lumbar region (without abnormal gait or abnormal spinal contour). Under the General Rating Formula, these findings warrant a 10 percent rating. See also Diagnostic Code 5242. Thus, examining the evidence summarized above, and giving due consideration to the provisions under 38 C.F.R. § 4.59, as well as due consideration to the provisions of 38 C.F.R. §§ 4.7, 4.10 and 4.40, the medical evidence of record shows that the Veteran's orthopedic spinal symptomatology approximates the schedular criteria for an evaluation of 10 percent for the lumbar spine disability and has done so throughout the appeal period. The Veteran's reported pain and functional limitations caused by the lumbar spine disorder are contemplated in the evaluation for the orthopedic symptomatology of the spinal segments that is represented by the 10 percent rating awarded herein. In order to warrant a higher rating, however, there must be the functional limitation of flexion to 60 degrees or less; a combined range of motion to 120 degrees or less; or muscle spasm or guarding resulting in abnormal gait or spinal contour. Here, neither the objective nor subjective evidence suggests that the Veteran is so impaired, even when considering functional loss due to limited or excess movement, pain, weakness, excess fatigability, or incoordination, to include during flare-ups and with repeated use. Again, flexion was limited to 70 degrees (even when considering pain) upon VA examination in January 2010; upon VA examination in August 2011, she demonstrated full range of motion of the thoracolumbar spine. Moreover, both VA examiners confirmed that repetitive motion was possible and did not produce any additional degree of limitation. In addition, joint function of the spine was not additionally limited by pain, fatigue, weakness, or lack of endurance or incoordination after repetitive use. See DeLuca v. Brown, 8 Vet. App. 202. Thus, as the Veteran's impairment does not approximate the functional equivalent of limitation of flexion to 60 degrees or less, combined range of motion to 120 degrees or less, or muscle spasm or guarding resulting in abnormal gait or spinal contour, an initial rating higher than 10 percent is not warranted for the Veteran's low back disability. The Board has considered the Veteran's statements about her lumbosacral spine. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469. In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to her through her senses. Layno, 6 Vet. App. at 470. She is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Such competent evidence concerning the nature and extent of the Veteran's low back disability has been provided by the medical personnel who have examined her during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which the low back disability is evaluated. Furthermore, the initial 10 percent evaluation assigned herein is based in part on the Veteran's statements about her low back disability. The Board also finds that separate ratings for other neurologic abnormalities are not warranted. There is no evidence of any neurological deficits related to the lumbar spine disability on either examination. See, e.g., March 2008 and September 2009 EMGs (normal studies);see also August 2011 VA Examination (indicating that there were no neurological deficits related to the lumbar spine). Thus, there is no showing that the Veteran objectively manifests neurologic symptoms as a consequence of her service-connected lumbar spine disability. Thus, a separate rating for neurological impairment is not warranted. Further, with respect to the Formula for Rating Intervertebral Disc Syndrome (IVDS), there is no evidence of incapacitating episodes with bed rest prescribed by a physician due to arthritis of the thoracolumbar spine. Thus, Diagnostic Code 5243 is not applicable. In sum, the findings set forth above most closely approximate those necessary for the 10 percent evaluation for the lumbosacral spine. The findings needed for the next higher evaluation are not currently demonstrated and have not been demonstrated at any point during the course of this appeal. Based upon the guidance of the Court in Fenderson, supra, the Board has considered whether a staged rating is appropriate. As reflected in the discussion above, the Board did not find variation in the Veteran's lumbosacral spine symptomatology or clinical findings that warrant the assignment of any staged ratings for the low back disability. c. Right and Left Knee The Veteran seeks entitlement to increased ratings for her service-connected left and right knee disabilities, arguing that they are worse than initially evaluated. The Veteran's service-connected right and left knee disabilities (diagnosed as degenerative arthritis as secondary to service-connected foot disabilities) have been assigned an initial noncompensable rating, effective July 10, 2009, under Diagnostic Code 5010. See March 2010 Rating Decision Granting Lumbar Spine Disability. She contends that she experiences constant, dull pain in her knees, as well as locking, swelling, and stiffness of the knee joints. See Hearing Transcript, 9-10. The Board notes that the RO initially determined the Veteran met the criteria for a 10 percent evaluation (based on arthritis with painful motion) effective July 10, 2009, and reduced this disability evaluation by 10 percent based upon aggravation. See March 2010 Rating Decision. For the sake of clarity, prior to determining whether increased evaluations are warranted based upon the schedular criteria, the Board will also discuss whether reduction is warranted based upon aggravation of a nonservice-connected disability by a service-connected disability. In this regard, VA regulations governing aggravation (with consideration of aggravation in service) establish that in cases involving aggravation by active service, the rating will reflect only the degree of disability over and above the degree of disability existing at the time of entrance into active service. It is necessary to deduct from the present evaluation the degree, if ascertainable, of the disability existing at the time of entrance into active service, in terms of the rating schedule except that if the disability is total (100 percent) no deduction will be made. If the degree of disability at the time of entrance into service is not ascertainable in terms of the schedule no deduction will be made. 38 C.F.R. §§ 3.22, 4.22. Again, the Veteran's bilateral knee disabilities have been evaluated under Diagnostic Code 5010 for arthritis. Arthritis, due to trauma, substantiated by X-ray findings will be rated as degenerative arthritis. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010, (2012). Diagnostic Code 5010 instructs to rate under Diagnostic Code 5003 [degenerative arthritis]. Under that diagnostic code, arthritis of a major joint is to be rated under the criteria for limitation of motion of the affected joint. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2012). For the purpose of rating disabilities due to arthritis, the knee is considered a major joint. See 38 C.F.R. § 4.45 (2012). Where limitation of motion of the joint is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012). Under Diagnostic Code 5260, limitation of flexion of the leg provides a noncompensable rating if flexion is limited to 60 degrees, a 10 percent rating where flexion is limited to 45 degrees, a 20 percent rating where flexion is limited to 30 degrees, and a maximum 30 percent rating if flexion is limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg provides a noncompensable rating if extension is limited to five degrees, a 10 percent rating if limited to 10 degrees, a 20 percent rating if limited to 15 degrees, a 30 percent rating if limited to 20 degrees, a 40 percent rating if limited to 30 degrees, and a 50 percent rating if limited to 45 degrees. A veteran may receive separate ratings for limitations in both flexion and extension under Diagnostic Codes 5260 and 5261. See VAOPGCPREC 9-2004. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II (2012). Turning to the pertinent medical evidence of record, a May 2009 VA orthopedic note shows normal alignment of the bilateral extremities; normal pulses; no joint line tenderness; negative McMurray's test; stable ligaments; no effusion; and positive medial and lateral facet tenderness and crepitation. The Veteran demonstrated full range of motion (from 0 to 140 degrees), bilaterally. X-rays revealed mild lateral joint space narrowing and early degenerative joint disease, bilaterally. A June 2009 orthopedic note again indicated full range of motion of the bilateral knees. In January 2010, the Veteran underwent a VA/QTC knee examination. She endorsed bilateral knee weakness, stiffness, giving way, locking, tenderness, and pain. She denied swelling, lack of endurance, fatigability, effusion, subluxation, or dislocation of the knees. She reported flare-ups as often as once per day, lasting for 12 hours, with a pain level of 10/10. She stated that she was unable to walk without her walker or stand longer than 15 minutes during flare-ups; she noted that she also used the walker for her extensive foot problems. Treatment included Morphine and Vicodin. The Veteran also reported that her knee impairment interferes with her ability to engage in activities that require standing or walking, as well as house cleaning and laundry. Objectively, the Veteran's gait was normal, although she did use a walker for ambulation due to feet and knee pain. She did not require the use of a brace, crutches, cane, corrective shoes, or a wheelchair. Neither the right nor left knee showed signs of edema; instability; abnormal movement; effusion; weakness; tenderness; redness; malalignment; or subluxation or guarding of movement. There was also no genu recurvatum or locking pain. Crepitus of the bilateral knees was present. There was no ankylosis. Upon examination, the Veteran demonstrated full range of motion (from 0 to 140 degrees) of both knees; the examiner noted that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use, bilaterally. The medial/lateral collateral stability tests and anterior/posterior cruciate ligament stability tests were all normal. The pertinent diagnosis was degenerative arthritis of both knee joints. The Veteran underwent a VA/QTC knee examination in August 2011. She reported worsening knee pain due to poor posture from multiple foot surgeries. She also endorsed weakness, stiffness, swelling, giving way, locking, fatigability, and pain. She denied experiencing lack of endurance, tenderness, effusion, subluxation, and dislocation. She reported flare-ups as frequently as 3 times per week, lasting for one day, and 7/10 on the pain scale. Pain is alleviated by Morphine and Vicodin. She stated that she has problems walking and standing due to knee pain. Objectively, the Veteran's gait was normal, although she used a walker for ambulation due to fee and knee pain. She did not require the use of a brace, crutches, cane, corrective shoes, or a wheelchair. Neither the right nor left knee showed signs of edema; instability; abnormal movement; effusion; weakness; redness; malalignment; or subluxation or guarding of movement. There was also no genu recurvatum, crepitus, or locking pain. Tenderness, bilaterally, was present. There was no ankylosis. Upon examination, the Veteran demonstrated full range of motion (from 0 to 140 degrees) of both knees; the examiner noted that joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use, bilaterally. The medial/lateral collateral stability tests and anterior/posterior cruciate ligament stability tests were all normal. The pertinent diagnosis was degenerative arthritis of both knee joints. The pertinent diagnosis was right and left knee degenerative arthritis with objective evidence of tenderness on knee joint (but no objective signs of instability). Analysis As an initial matter, based on the evidence of record outlined above, neither the January 2010 VA examiner nor the August 2011 VA examiner established the degree of baseline level of disability prior to the aggravation of the left and right knee disabilities by the bilateral foot disability. As noted above, the regulations addressing aggravation of disabilities note that if the degree of disability at the time of entrance into service, or as in this case, prior to the onset of aggravation from the bilateral foot disability, is not ascertainable in terms of the schedule, no deduction will be made. See 38 C.F.R. §§ 3.22, 4.22. As neither examiner in January 2010 or August 2011, nor any of the other medical evidence of record, sufficiently establishes the degree of disability in the left knee and right knee prior to onset of aggravation from the bilateral foot disability, no deduction of pre-existing disability in the left and right knee disabilities will be made. In other words, the Veteran's left knee and right knee disabilities will be considered as 0 percent disabling prior to the onset of aggravation from the bilateral foot disability and any current impairment in the left and right knees will be considered as caused by the bilateral foot disability, and thus service-connected. The Board will now turn to what the appropriate disability ratings are for the left and right knee disabilities. In this case, the January 2010 and August 2011 VA examinations, as well as the contemporaneous VA treatment records, reflect that the Veteran has consistently demonstrated full range of motion of both knees (i.e., from 0 to 140 degrees). Such findings do not warrant a compensable evaluation under Diagnostic Codes 5260 and/or 5261. However, as noted above, under Diagnostic Codes 5003-5010, when limitation of motion is noncompensable under the appropriate diagnostic codes (in this case, DCs 5260 and 5261), a 10 percent evaluation is warranted where there is evidence of degenerative arthritis with painful motion. As the Veteran has consistently and competently endorsed painful, limited bilateral knee motion, as well as weakness and fatigability of the knees, and as the objective evidence shows tenderness and crepitus of both knees, among other symptoms, the Board will resolve doubt in the Veteran's favor and assign initial 10 percent ratings throughout the claims period for degenerative arthritis of the bilateral knees with painful motion. In so finding, there is no evidence of additional limitation of motion due to functional factors that would approximate the criteria for higher initial ratings. The January 2010 and August 2011 examination reports reveals that ranges of knee motion were not additionally limited following repetitive motion. Furthermore, the ranges of knee motion were not additionally limited by pain or fatigue following repetitive use. Thus, even considering pain and other factors, the evidence does not support assignment of higher ratings under DCs 5260 or 5261 for limitation of flexion or extension, as the evidence does not reflect that the Veteran's pain or other functional factors are so disabling to actually or effectively result in flexion limited to 30 degrees or extension limited to 15 degrees-the requirements for the next higher percent ratings under DCs 5260 and 5261. Indeed, examiners have consistently found flexion to be limited to no less than 140 degrees even with consideration of functional factors. No limitation of extension has been found, even with consideration of functional factors. DCs 5260 and 5261. As the foregoing discussion should make clear, there is no evidence of limitation of flexion to, or approximating, 30 degrees. Hence a separate initial rating for limitation of knee flexion under DC 5261 is not warranted. Moreover, the Veteran has consistently been found to have full bilateral knee extension to 0 degrees. Hence a separate initial rating for limitation of knee extension under DC 5261 is not warranted. Therefore, 10 percent ratings are warranted under DC 5010 on the basis of noncompensable limitation of knee motion and higher initial ratings are not warranted. The Veteran has also reported instability (or, giving way) associated with her knees. Knee impairment with recurrent subluxation or lateral instability is rated as follows: a 10 percent rating is assigned if the condition is slight; a 20 percent rating is assigned if the condition is moderate; and a 30 percent rating is assigned if the condition is severe. 38 C.F.R. § 4.71a, DC 5257 (2012). The VA examination reports indicate that the Veteran reported occasional bilateral knee instability, or giving way. The Veteran is competent to report observable symptoms of her knee disabilities, such as instability. However, her reports must be weighed against the objective evidence and their credibility must be assessed. The January 2010 and August 2011 VA examination reports reveal that the medial/lateral collateral stability tests and anterior/posterior cruciate ligament stability tests were all normal. The objective evidence of a lack of knee instability outweighs the Veteran's statements to the contrary and in light of the clinical evidence, the Board concludes that the Veteran's reports of knee instability are not credible. Therefore, she is not entitled to separate initial compensable ratings for left or right knee instability under DC 5257. In addition, the Veteran is not entitled to a rating under DCs 5256, 5258, 5259 or 5262-5263 as there is no evidence of ankylosis, removal or dislocation of cartilage, tibia or fibula impairment, or genu recurvatum. Although there is evidence of knee pain, this is already compensated under the current ratings. Accordingly, the Board finds that initial ratings of 10 percent, but no higher, for degenerative arthritis of the knees with painful motion are warranted for the entire period on appeal. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DCs 5003, 5010, 5260, and 5261. II. Extraschedular Evaluation The Board has also considered whether the Veteran is entitled to an extraschedular evaluation for the disabilities discussed above. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected migraine headaches, lumbar spine disability, and bilateral knee disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disorders with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology; as discussed above. For example, the Veteran's symptoms which result in severe economic inadaptability have been considered in assigning the 50 percent evaluation for migraines under Diagnostic Code 8100. The Veteran's loss of flexion of the thoracolumbar spine and accompanying painful motion falls squarely within the 10 percent rating criteria assigned herein under Diagnostic Code 5254. Lastly, the Veteran's bilateral degenerative arthritis of the knees is fully contemplated by the initial 10 percent ratings assigned herein under Diagnostic Code 5003-5003, for painful motion. Accordingly, referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) (2012) is not warranted. III. TDIU The Veteran contends that she is unable secure or follow substantially gainful occupation as a result of her service-connected disabilities. Specifically, she asserts that her service-connected foot, knee, and back conditions severely limit her ability to walk, stand, bend, or lift, while her service-connected migraines are frequent and prostrating and require her to lie down for extensive periods of time. She reports that she was last gainfully employed in 1997. See Hearing Transcript, p. 12; see also August 2011 VA/QTC Examination and VA Form 21-8940, dated June 2011. VA will grant a TDIU when the evidence shows that the veteran is precluded, by reason of his service-connected disabilities, from obtaining or maintaining "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012); VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). Under the applicable criteria, a TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining whether TDIU is warranted, consideration may be given to a veteran's level of education, special training, and previous work experience. Marginal employment, which is defined as earned annual income that does not exceed the poverty threshold as determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran was originally denied a TDIU evaluation in a March 2010 rating decision. At that time, she did not meet the schedular requirements for TDIU. Given Board's action, herein, the Veteran now meets the minimum percentage requirements for a TDIU under 38 C.F.R. § 4.16(a). Her migraine disability is now evaluated as 50 percent disabling, and there are additional service-connected disabilities to bring the combined rating to 70 percent or more. The remaining question, then, is whether the Veteran's service-connected disabilities rendered her unemployable. The Board finds that the evidence of record is in relative equipoise on the question of whether the Veteran is precluded from obtaining or maintaining substantially gainful employment consistent with her education and occupational experience by reason of her service-connected disabilities. The record contains a medical statement from VA Vocational Rehabilitation & Employment weighing against the claim (see January 2009 Functional Ability Request Form - stating that the Veteran was able to work, but unable to drive due to medications), but also includes a later-dated finding from VA's own Vocational Rehabilitation program that the Veteran is unemployable, or that achievement of her vocational goal was "no longer feasible." See December 2009 Letter from Rehabilitation Counselor. In addition, a July 2009 Vocational Rehabilitation assessment indicated that the Veteran was not currently able to work due to her chronic pain; a January 2009 certification letter from her treating podiatrist indicated that she was permanently limited or impaired and "severely limited in ability to walk due to an arthritic, neurological, or orthopedic condition." And most recently, in July 2010, the Veteran submitted a certification letter from her treating podiatrist in which the physician stated that the Veteran's "chronic, intractable foot pain" prevented her from "working and earning money indefinitely in any capacity in any field of work." Limitations included standing and walking. See July 2010 Certification Letter from Dr. A.R., DPM. The Veteran has also submitted credible lay statements describing her various functional limitations and inability to retain various types of employment due to her service-connected conditions, and particularly, as a result of her feet disabilities. See January 2008 and January 2009 Statements from Husband and Friend, respectively. In such situations, the Veteran is given the benefit of the doubt. 38 C.F.R. § 3.102. See Ashley v. Brown, 6 Vet. App. 52, 59 (1993), citing 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (under the "benefit- of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue). Consequently, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran is unemployable due to her service-connected disabilities and the claim is granted. ORDER Entitlement to a 50 percent disability rating for migraine headaches is granted for the entire claim period, subject to the governing laws and regulations pertaining to the payment of monetary benefits. Entitlement to an initial 10 percent disability rating, but no higher, for the orthopedic manifestations of the service-connected lumbar spine disability is granted for the entire claim period, subject to the law and regulations governing the award of monetary benefits. Entitlement to an initial 10 percent disability rating, but no higher, for degenerative arthritis of the left knee, with painful motion is granted for the entire claim period, subject to the rules governing payment of monetary benefits. Entitlement to an initial 10 percent disability rating, but no higher, for degenerative arthritis of the right knee, with painful motion is granted for the entire claim period, subject to the rules governing payment of monetary benefits. TDIU is granted, subject to the rules governing payment of monetary benefits. REMAND Inasmuch as the Board regrets the additional delay of this appeal, a remand is required before the claims can be properly adjudicated. The Veteran contends that she is entitled to higher evaluations for her service-connected bilateral foot disabilities. She is currently service-connected for status-post neuroma, left foot, and wedge osteotomy, 3rd metatarsal, right foot. Both disabilities are currently evaluated as 10 percent disabling under Diagnostic Code 5279, for metatarsalgia (Morton's disease). The Veteran has testified, and the medical evidence reflects, that her bilateral foot disabilities are likely much worse than contemplated by the 10 percent ratings currently assigned. For example, she states that she is unable to walk due to foot pain and uses a walker for ambulation; she reports near-constant burning in her bilateral feet (again, there is no evidence of spine-related neurological deficits/neuropathy); and she reports that has no feeling in her feet and that her toes are completely "dead." In addition, the Veteran has testified that she has had nearly 15 surgeries on her feet. Most recently, in September 2012, she testified that her scars are red, painful, and tender. The Board recognizes that the Veteran was afforded a QTC examination of the feet in August 2011. However, given the Veteran's more recent testimony concerning the severity bilateral foot disability, and possible additional neurological and scarring manifestations, the Board finds that a new, comprehensive foot examination must be provided to the Veteran in order to better assess her current foot conditions. Indeed, contrary to the Veteran's testimony, the August 2011 VA examination did not reflect limitation of motion of the toes or ankles, neurological deficits, "floppy toes," intractable plantar keratosis, contracture of the metatarsal joints, toe deformities (as otherwise clinically noted throughout the record), or other severe symptoms complained of by the Veteran. See, e.g., July 2010 VA Podiatric Note. These findings, along with other medical evidence of record and the Veteran's competent statements, should be reconciled by the VA examiner upon remand. In sum, the Veteran is entitled to a new examination when there is evidence of a change in the condition since the last examination. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); Allday v. Brown, 7 Vet. App. 517, 526 (1995). Accordingly, the case is REMANDED for the following action: 1. Obtain VA records of treatment for foot disabilities since February 2011. If any requested records cannot be obtained, inform the Veteran of this fact, tell her what efforts were made to obtain the records, and what additional efforts will be made with regard to her claim 2. Afford the Veteran a VA examination to ascertain the nature and severity of her service-connected bilateral foot disabilities, to include residual surgical scars and neurological deficits of the feet due to the service-connected disabilities. The claims file, including any relevant records in Virtual VA, should be made available to and reviewed by the examiner. All indicated tests shall be performed and all findings reported. Ask the examiner to discuss all findings in terms of the diagnostic codes, particularly Diagnostic Code 5284. The pertinent rating criteria must be provided to the examiner. The findings reported must be sufficiently complete to allow for rating under all alternate criteria. All indicated tests and studies should be accomplished. All clinical findings should be reported in detail. Please advise if any other diagnostic code applicable to rating disabilities of the feet (Diagnostic Codes 5276-5284) more properly describes or addresses the Veteran's symptoms associated with the service-connected bilateral foot disabilities, to include any residual surgical scarring to the feet, and/or any neurological deficits related to the feet. To that end, the examiner should identify and describe any and all scars of the feet that are associated with the Veteran's numerous foot surgeries. 3. The agency of original jurisdiction should consider (a) whether the Veteran has manifestations of the service connected foot disabilities that are not contemplated by the rating schedule; and if so, (b) whether there is evidence of exceptional factors such as marked interference with employment or frequent hospitalization. .If there is a finding that there are manifestations not contemplated by the rating schedule, and exceptional factors; the claim should be referred to VA's Director of Compensation and Pension or Undersecretary for Benefits for adjudication of entitlement to an extraschedular rating under 38 C.F.R. § 3.321(b). 4. If the benefits sought on appeal remain denied, issue a supplemental statement of the case. Then return the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MARJORIE. A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs