Citation Nr: 1302146 Decision Date: 01/18/13 Archive Date: 01/23/13 DOCKET NO. 07-05 344 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial compensable rating prior to May 2, 2007, and an evaluation in excess of 10 percent thereafter, for left knee status post meniscectomy (left knee disability). 2. Entitlement to an increased evaluation in excess of 10 percent for bilateral pes planus with plantar fasciitis (bilateral foot disability) from May 2, 2007, forward. 3. Entitlement to a higher initial evaluation on an extraschedular basis for bilateral pes planus with plantar fasciitis (bilateral foot disability). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from May 1988 to February 1992, and from December 2003 to December 2005. This matter comes before the Board of Veterans' Appeals (BVA or Board) from September 2006 and December 2007 rating decisions by the above Department of Veterans Affairs (VA) Regional Office (RO). In a January 2010 decision, the Board denied the Veteran's claim for a higher rating for his left knee disability and remanded the claim for a higher rating for his bilateral foot disability for extraschedular consideration. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In an August 2010 Order, the Court partially vacated and remanded the claim (as to the left knee and bilateral foot disabilities) to the Board pursuant to the terms of a July 2010 Joint Motion for Remand (Joint Motion). Subsequently, the Board rendered a decision in July 2011 that denied a higher rating for the bilateral foot disability (schedular only) and a higher rating for the left knee disability (on both a schedular and extraschedular basis), and remanded the issue of entitlement to an increased rating on an extraschedular basis for the bilateral foot disability to the RO for referral to the Director, Compensation and Pension Service. The Veteran again appealed the Board's decision to the Court, and, in April 2012, the Court granted a Joint Motion that vacated and remanded the portion of the Board's July 2011 decision that denied an initial rating in excess of 10 percent for bilateral pes planus from May 2, 2007, an initial compensable rating for left knee status post meniscectomy prior to May 2, 2007, and an initial rating in excess of 10 percent for left knee status post meniscectomy from May 2, 2007. The Board's remand of the issue of an increased rating for a bilateral foot disability on an extraschedular basis was left intact, as the Court lacked jurisdiction over that issue. In addition, it appears that the Board's denial of an initial compensable evaluation for bilateral pes planus prior to May 2, 2007 was left intact by the Court's Order. Thus, the issues on appeal have been characterized as they appear on the title page of this decision. On his VA Form 9, the Veteran requested a hearing before the Board. The hearing was scheduled for September 1, 2009, at the Waco RO; however, the Veteran did not report for the hearing, and no request for postponement was received and granted prior to the hearing date. Under 38 C.F.R. § 20.704(d) (2012), when a veteran fails to appear for a scheduled hearing and no request for postponement is received, the claim is processed as though the request for hearing had been withdrawn. Therefore, this case will be processed as though the request for a hearing was withdrawn, and the Board can now proceed to appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The issue of entitlement to a higher initial evaluation on an extraschedular basis for a bilateral foot disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Throughout the initial rating period on appeal prior to May 2, 2007, the Veteran's service-connected left knee disability was manifested by flexion to no worse than 115 degrees, extension to no worse than zero degrees, no additional loss of motion after repetitive use, complaints of daily pain, X-ray findings of degenerative changes, and symptomatic removal of the meniscus. 2. Throughout the rating period on appeal from May 2, 2007, forward, the Veteran's service-connected left knee disability was manifested by flexion to no worse than 95 degrees, extension to no worse than zero degrees, objective evidence of pain on range of motion testing, no additional loss of motion after repetitive use, complaints of daily pain with weekly flare-ups, X-ray findings of degenerative changes, and symptomatic removal of the meniscus. 3. Throughout the rating period on appeal from May 2, 2007, forward, the Veteran's service-connected bilateral foot disability has been manifested by pes planus, plantar fasciitis, and tarsal tunnel syndrome, with pain on walking, standing, and at rest, with no deformity, accentuated pain on manipulation and use, indication of swelling on use, or characteristic callosities. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, for the initial rating period on appeal prior to May 2, 2007, the criteria for a 10 percent evaluation for left knee arthritis have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5003 (2012). 2. For the rating period from May 2, 2007, forward, the criteria for an evaluation in excess of 10 percent for the left knee disability have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2012). 3. Resolving reasonable doubt in the Veteran's favor, for the entire initial rating period on appeal, both prior to and from May 2, 2007, forward, the criteria for a separate 10 percent rating for symptomatic removal of semilunar cartilage of the left knee have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5259 (2012). 4. For the entire rating period from May 2, 2007, forward, the criteria for an evaluation in excess of 10 percent for the bilateral foot disability have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5276 (2012). 5. Resolving reasonable doubt in the Veteran's favor, for the entire rating period on appeal from May 2, 2007, forward, the criteria for separate 10 percent ratings for each foot (pes planus with plantar fasciitis and tarsal tunnel syndrome) have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability Rating Criteria Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). As is the case with the bilateral foot disability claim, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Diagnostic Codes relevant to the knee disability are 5003, 5010, and 5257-5261. The VA General Counsel has interpreted that a veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. See VAOPGCPREC 23-97. Likewise, the VA General Counsel has also interpreted that, when X-ray findings of arthritis are present and a veteran's knee disability is evaluated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable evaluation under Diagnostic Code 5003 if the arthritis results in limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Furthermore, to warrant a separate rating for arthritis based on X-ray findings and limited motion under Diagnostic Codes 5260 or 5261, the limited motion need not be compensable but must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. Diagnostic Code 5010 is for arthritis due to trauma, substantiated by X-ray findings and provides for rating as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (Diagnostic Code 5200, etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range-of-motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to the affected joints. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. 38 C.F.R. § 4.59. The Veteran's bilateral foot disability has been evaluated under Diagnostic Code 5276, found in 38 C.F.R. § 4.71a. Under Diagnostic Code 5276, which addresses acquired flatfoot, a noncompensable, or zero percent, evaluation is assigned when the condition is mild, and symptoms are relieved by built-up shoe or arch support; a 10 percent evaluation is assigned when the conditions is moderate in severity, the weight-bearing line is over or medial to the great toe, there is inward bowing of the tendo achillis, and pain on manipulation and use of the feet, bilateral or unilateral; 20 and 30 percent evaluations are assigned when the condition is severe, unilaterally or bilaterally, respectively, and there is objective evidence of marked deformity (pronation, abduction, etc.), accentuated pain on manipulation and use, indication of swelling on use, and characteristic callosities; 30 and 50 percent evaluations are assigned when the condition is pronounced, unilaterally or bilaterally, respectively, and there is marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, and no improvement with orthopedic shoes or appliances. 38 C.F.R. § 4.71a. 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. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility 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 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. 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 a veteran 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 claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Left Knee Disability Rating Analysis The Veteran was granted service connection for a left knee injury status post meniscectomy in the September 2006 rating decision that is the subject of this appeal. An initial noncompensable, or 0 percent, evaluation was assigned, effective from December 22, 2005, the day after the Veteran's separation from active service. During the course of this appeal, in a December 2007 rating decision, the RO granted an increased rating of 10 percent, effective from May 2, 2007, the date the medical evidence demonstrated a worsening of the Veteran's knee disability. The left knee disability has been evaluated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5260, which addresses limitation of flexion of the leg. The Veteran contends that his left knee disability warrants a higher, compensable, initial rating, and an evaluation in excess of 10 percent from May 2, 2007, forward. Specifically, he avers that he has had injections to his knee to address pain and lack of mobility, that he cannot walk for long periods, and cannot run at all. Left Knee Disability Rating Prior to May 2, 2007 The Board will begin by reviewing the evidence most pertinent to the rating period on appeal prior to May 2, 2007. Historically, in June 2004, while still in active service, the Veteran underwent a left knee arthroscopic surgery that consisted of a partial lateral meniscectomy and picking of the medial tibial plateau with chondroplasty. The post-operative diagnoses were a left knee lateral meniscus tear and a small area of chondromalacia at the medial tibial plateau. The Veteran was afforded a VA examination in June 2006. The Veteran reported the onset of left knee problems in April 2003 while performing physical training, when he stepped in a hole and hypertextended the knee. Currently, he reported pain with walking and that he was unable to run. On physical examination, the left knee had full extension to zero degrees and flexion from zero to 115 degrees. The VA examiner did not note any pain with range of motion, and stated that there was no additional loss of motion on repetitive use of the joint due to pain, weakness, or lack of endurance. X-ray studies revealed questionable minimally or non-displaced medial tibial plateau fracture, joint effusion, and linear lucency through lateral tibial plateau probably representing a "vascular" groove. A prior MRI study from 2004 revealed an abnormal signal probably due to contusion involving the tibial plateau and distal medial femoral condyle anteriorly, intact cruciate and collateral ligaments, a lateral meniscal tear, and joint effusion. The VA examiner assessed a left knee injury with a lateral meniscus tear, status post meniscectomy. A July 2006 VA treatment note indicates the Veteran reported chronic pain in his knee, but said that is was well-controlled with Tylenol when he needed it. A September 2006 private treatment note indicates the Veteran reported moderate knee pain, characterized as a dull aching. Moreover, he stated it was progressively worsening and causing him daily pain. Physical examination showed no swelling or edema, no tenderness to palpation, no warmth, normal deep tendon reflexes, normal coordination, normal strength, normal range of motion, normal sensation, no instability, subluxation, or laxity, and no known fractures or deformities. There was coarse crepitus, however. An October 2006 private treatment note indicates that physical examination of the knee revealed tenderness to palpation and coarse crepitus. In January 2007, the Veteran reported constant knee pain that increased in severity with walking. He also reported morning stiffness of the knee lasting for two hours. Physical examination showed full range of motion. An X-ray study showed asymmetric narrowing of the interarticular space, where narrowing was more pronounced in the lateral compartment and was moderate. The private physician, Dr. R., assessed left knee pain secondary to osteoarthritis, which was moderate, and administered a steroid injection. On the question of whether the Veteran is entitled to a compensable initial rating for his left knee disability prior to May 2, 2007, the Board notes that arthritis and limitation of motion, including motion limited by pain and other orthopedic factors indicated at 38 C.F.R. §§ 4.40, 4.45, 4.59, and DeLuca are to be rated as part of one disability. See 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5003. Instability of the knee, which does not include painful limitation of the knee as part of the rating criteria, is a distinct disability. See VAOPGCPREC 23-97 and 9-98. The Board will first address the question of whether the left knee disability warrants an initial compensable rating based on arthritis and limitation of motion. The left knee disability has been evaluated under Diagnostic Code 5260, which contemplates impairment of the knee manifested by limitation of flexion. Where flexion is limited to 60, 45, 30, and 15 degrees, disability ratings of 0, 10, 20, and 30 percent, respectively, are assigned. 38 C.F.R. § 4.71a. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. In this case, the evidence shows that the Veteran had flexion to no worse than 115 degrees throughout the rating period on appeal prior to May 2, 2007, taking additional limitation due to pain into account. Although the Veteran reported pain with walking at the June 2006 VA examination, the VA examiner found no objective evidence of pain or additional limitations after repetition. Thus, even if pain is taken into account, there is no credible evidence of record demonstrating flexion limited to 60 degrees or less (the minimum criterion for a noncompensable evaluation under Diagnostic Code 5260). As the criteria for even a noncompensable disability rating under Diagnostic Code 5260 (limitation of flexion to 60 degrees) have not been met or more nearly approximated, the lay and medical evidence, which includes limitation of motion due to painful motion and other orthopedic factors, does not support an initial compensable rating under Diagnostic Code 5260 for the left knee disability for any period prior to May 2, 2007. 38 C.F.R. § 4.71a. The Board has also considered whether any other diagnostic code would allow for an initial compensable rating for the Veteran's left knee disability, manifested by limitation of motion, pain, or other orthopedic factors such as weakness or fatigability. Diagnostic Code 5261 contemplates impairment of the knee manifested by limitation of extension. Where extension is limited to 5, 10, 15, 20, 30 and 45 degrees, disability ratings of 0, 10, 20, 30, 40, and 50 percent, respectively, are assigned. 38 C.F.R. § 4.71a. In this case, the evidence shows that the Veteran had extension to no worse than 0 degrees throughout the rating period on appeal prior to May 2, 2007, taking additional limitation due to pain after repetition into account. As the criteria for even a noncompensable disability rating under Diagnostic Code 5261 (limitation of extension to 5 degrees) have not been met or more nearly approximated, the lay and medical evidence, which includes limitation of motion due to painful motion and other orthopedic factors, does not support an initial compensable rating under Diagnostic Code 5261 for the left knee disability for any period prior to May 2, 2007. 38 C.F.R. § 4.71a. In considering whether an initial compensable rating is warranted based on loss of motion under another diagnostic code, the Board finds that Diagnostic Code 5256 does not apply, as there is no evidence of knee ankylosis. Diagnostic Code 5055 contemplates prosthetic replacement of the knee joint. There is no evidence the Veteran has undergone a knee replacement, so Diagnostic Code 5055 is also inapplicable. 38 C.F.R. § 4.71a. After a review of all the evidence, lay and medical, the Board finds that the evidence is at least in equipoise as to whether an initial compensable rating under Diagnostic Code 5003 for the left knee disability is warranted. Here, as noted above, extension has been measured at 0 degrees, and therefore does not meet the criterion for even a noncompensable evaluation under Diagnostic Code 5261. Further, the left knee flexion, which, at worst, was 115 degrees, does not even meet the criterion for a noncompensable evaluation under Diagnostic Code 5260. Diagnostic Code 5003 rates degenerative arthritis, including painful motion associated with the arthritis, even when there is noncompensable limitation of motion. Diagnostic Code 5003 provides that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (e.g., Diagnostic Codes 5260 and 5261), provided the limitation of motion is compensable; however, when limitation of motion of the specific joint involved is noncompensable under the appropriate diagnostic codes (as is the case here), Diagnostic Code 5003 provides that a rating of 10 percent is for application for each such major joint affected by limitation of motion. The Diagnostic Code further states that limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In this case, the evidence relevant to the period prior to May 2, 2007 demonstrates flexion and extension that is noncompensable, but some limitation of flexion is demonstrated. Moreover, while there is no evidence of swelling or muscle spasm, and the 2006 VA examiner did not note any objective evidence of pain on range of motion testing, the Veteran has reported daily constant knee pain, and October 2006 treatment notes reflect tenderness to palpation of the knee. Thus, taking his complaints of pain into account and resolving any doubt in the Veteran's favor, the Board finds that an initial 10 percent evaluation for the left knee disability is warranted for the period prior to May 2, 2007. Next, the Board has considered whether an initial rating even higher than 10 percent is warranted for the left knee disability manifested by instability. Diagnostic Code 5257 contemplates impairment of the knee manifested by recurrent subluxation or lateral instability. Under Diagnostic Code 5257, where instability is severe, moderate and slight, disability evaluations of 30, 20, and 10 are assigned, respectively. 38 C.F.R. § 4.71a. After reviewing the lay and medical evidence relevant to the rating period on appeal prior to May 2, 2007, the Board finds that the weight of the evidence is against a grant of an initial rating in excess of 10 percent for the left knee disability manifested by subluxation or instability. No ligament instability has been found on any examination in the left knee throughout the rating period on appeal prior to May 2, 2007, which suggests that any instability the Veteran has is not more than slight. Thus, an initial rating in excess of 10 percent is not warranted under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board has also considered whether any other diagnostic code would allow for an increased rating for the Veteran's left knee disability manifested by instability. Diagnostic Code 5258 addresses dislocation of semilunar cartilage with frequent episodes of locking, pain and effusion into the joint, and provides for a 20 percent evaluation. Although the evidence demonstrates a torn meniscus in the left knee, it was surgically removed in June 2004. Therefore, the weight of the evidence is against a grant of a higher, 20 percent, evaluation under Diagnostic Code 5258. Diagnostic Code 5259 contemplates symptomatic removal of semilunar cartilage (meniscus), but only allows for a maximum of a 10 percent rating; thus, Diagnostic Code 5258 does not allow for an initial rating in excess of 10 percent. Diagnostic Codes 5262 and 5263 do not apply, as there is no evidence of malunion or nonunion of the tibia or fibula, and no evidence of genu recurvatum. 38 C.F.R. § 4.71a. The Board has also considered whether any separate ratings are available based on the evidence. In so doing, the Board acknowledges VAOPGCPREC 9-2004, where it was held that a claimant who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. In the present case, the evidence does not establish loss of extension to a compensable degree; thus, assignment of separate evaluations for limitation of flexion and extension of the leg is not appropriate here. In VAOPGCPREC 23-97, the VA General Counsel interpreted that a veteran who has arthritis and instability of the knee may, in some circumstances, be rated separately under Diagnostic Codes 5003 and 5257. See also VAOPGCPREC 9-98 (when X-ray findings of arthritis are present and a veteran's knee disability is evaluated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable evaluation under Diagnostic Code 5003 if the arthritis results in limitation of motion and/or objective findings or indicators of pain). In this case, however, there is no evidence of subluxation or instability, as noted in September 2006. Thus, a separate 10 percent disability rating under Diagnostic Code 5257 for instability is precluded. 38 C.F.R. § 4.71a. However, the Board finds that the evidence is at least in equipoise as to whether a separate rating is warranted under Diagnostic Code 5259, which contemplates symptomatic removal of semilunar cartilage (meniscus). As noted above, the Veteran underwent a meniscectomy in June 2004, and his knee has remained symptomatic since the surgery. A 10 percent rating is the maximum (and only) available rating under Diagnostic Code 5259. 38 C.F.R. § 4.71a. Thus, the Board finds that a separate 10 percent rating under Diagnostic Code 5259 for the left knee disability is warranted for the period prior to May 2, 2007, as well as the period from May 2, 2007, forward. Left Knee Disability Rating From May 2, 2007 The Board will next review the evidence most pertinent to the rating period on appeal from May 2, 2007, forward, to determine whether a rating in excess of 10 percent is warranted. The Veteran was afforded a VA examination in May 2007. He reported increased pain in the left knee with decreased endurance, as compared to the last VA examination in 2006. He stated that he was still unable to run and that it was good if he was able to walk. He had increased pain with prolonged walking or standing. He had received one injection in the knee in January 2007. He also reported giving way, instability, pain, stiffness, and weakness. He denied episodes of dislocation or subluxation. He stated, however, that he experienced several episodes of locking per week. He also reported repeated effusion, as well as weekly moderate flare-ups of knee pain lasting for one or two days, during which he had to limit his walking, standing, and lifting. On physical examination in May 2007, left knee active and passive flexion were to 105 degrees with pain throughout the range of motion; flexion against strong resistance was to 95 degrees, with pain throughout the range of motion. Active and passive extension were to zero degrees, with pain beginning at 50 degrees. Extension against strong resistance was also to zero degrees, with pain throughout the range of motion. The VA examiner noted that there were no additional losses of motion on repetitive use. The examiner also observed crepitus, painful movement, and weakness in the left knee, but no instability. The Veteran reported missing three or four weeks of work in the last twelve months secondary to his knee and shoulder conditions. A June 2007 X-ray study of the left knee, which was ordered based on pain and swelling with weight bearing, showed no bone, joint, or soft tissue abnormalities. The Board will first address the question of whether the left knee disability warrants a disability rating in excess of 10 percent for the period from May 2, 2007, based on arthritis and limitation of motion. As noted above, the left knee disability has been evaluated under Diagnostic Code 5260, which contemplates impairment of the knee manifested by limitation of flexion. In this case, the evidence shows that the Veteran had flexion to no worse than 95 degrees (with strong resistance) throughout the rating period on appeal from May 2, 2007, taking additional limitation due to pain into account. The 2007 VA examiner observed objective evidence of pain during range of motion testing, but no additional limitations after repetition. Thus, even if pain is taken into account, there is no credible evidence of record demonstrating flexion limited to 30 degrees or less (the minimum criterion for an evaluation in excess of 10 percent under Diagnostic Code 5260). Moreover, as the criteria for even a noncompensable disability rating under Diagnostic Code 5260 (limitation of flexion to 60 degrees) have not been met or more nearly approximated, the lay and medical evidence, which includes limitation of motion due to painful motion and other orthopedic factors, does not support a rating in excess of 10 percent under Diagnostic Code 5260 for the left knee disability for any period from May 2, 2007, forward. 38 C.F.R. § 4.71a. The Board has also considered whether any other diagnostic code would allow for a rating in excess of 10 percent for the Veteran's left knee disability, manifested by limitation of motion, pain, or other orthopedic factors such as weakness or fatigability. Diagnostic Code 5261 contemplates impairment of the knee manifested by limitation of extension, as discussed above. In this case, the evidence shows that the Veteran had extension to no worse than 0 degrees throughout the rating period on appeal from May 2, 2007, even taking pain into account. As the criteria for even a noncompensable disability rating under Diagnostic Code 5261 (limitation of extension to 5 degrees) have not been met or more nearly approximated, the lay and medical evidence, which includes limitation of motion due to painful motion and other orthopedic factors, does not support a rating in excess of 10 percent under Diagnostic Code 5261 for the left knee disability for any period from May 2, 2007. 38 C.F.R. § 4.71a. In considering whether a rating in excess of 10 percent is warranted based on loss of motion under another diagnostic code, the Board finds that Diagnostic Code 5256 does not apply, as there is no evidence of knee ankylosis. Diagnostic Code 5055 contemplates prosthetic replacement of the knee joint. There is no evidence the Veteran has undergone a knee replacement, so Diagnostic Code 5055 is also inapplicable. 38 C.F.R. § 4.71a. After a review of all the evidence, lay and medical, the Board finds that the evidence weighs against an increased rating under Diagnostic Code 5003 for left knee disability, including the pain and limitation of motion the Veteran has reported. Here, because there is only one major joint involved (the knee), and there are no incapacitating exacerbations, a 10 percent rating is the maximum available schedular disability rating under Diagnostic Code 5003. 38 C.F.R. § 4.71a. As the left knee disability is already rated as 10 percent disabling, and a 10 percent rating is the maximum rating provided for arthritis of a major joint under Diagnostic Code 5003, a rating in excess of 10 percent is not possible under Diagnostic Code 5003. Next, the Board has considered whether a rating in excess of 10 percent is warranted for the left knee disability manifested by instability. Diagnostic Code 5257 contemplates impairment of the knee manifested by recurrent subluxation or lateral instability, as discussed above. After reviewing the lay and medical evidence relevant to the rating period on appeal from May 2, 2007, the Board finds that the weight of the evidence is against a grant of a rating in excess of 10 percent for the left knee disability manifested by subluxation or instability. No ligament instability has been found on any examination in the left knee throughout the rating period on appeal from May 2, 2007, which suggests that any instability the Veteran has is not more than slight. Thus, a rating in excess of 10 percent is not warranted under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board has also considered whether any other diagnostic code would allow for an increased rating for the Veteran's left knee disability manifested by instability. Diagnostic Code 5258 addresses dislocation of semilunar cartilage with frequent episodes of locking, pain and effusion into the joint, and provides for a 20 percent evaluation. Although the evidence demonstrates a torn meniscus in the left knee, it was surgically removed in June 2004. Therefore, the weight of the evidence is against a grant of a higher, 20 percent, evaluation under Diagnostic Code 5258. Diagnostic Code 5259 contemplates symptomatic removal of semilunar cartilage (meniscus), but only allows for a maximum of a 10 percent rating; thus, Diagnostic Code 5258 does not allow for a rating in excess of 10 percent. Diagnostic Codes 5262 and 5263 do not apply, as there is no evidence of malunion or nonunion of the tibia or fibula, and no evidence of genu recurvatum. 38 C.F.R. § 4.71a. The Board has also considered whether any separate ratings are available based on the evidence. In so doing, the Board acknowledges VAOPGCPREC 9-2004, where it was held that a claimant who has both limitation of flexion and limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. In the present case, the evidence does not establish loss of extension to a compensable degree; thus, assignment of separate evaluations for limitation of flexion and extension of the leg is not appropriate here. In VAOPGCPREC 23-97, the VA General Counsel interpreted that a veteran who has arthritis and instability of the knee may, in some circumstances, be rated separately under Diagnostic Codes 5003 and 5257. See also VAOPGCPREC 9-98 (when X-ray findings of arthritis are present and a veteran's knee disability is evaluated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable evaluation under Diagnostic Code 5003 if the arthritis results in limitation of motion and/or objective findings or indicators of pain). In this case, however, there is no evidence of subluxation or instability, as noted by the 2007 VA examiner. Thus, a separate 10 percent disability rating under Diagnostic Code 5257 for instability is precluded. 38 C.F.R. § 4.71a. However, as noted above, the Board finds that a separate 10 percent rating under Diagnostic Code 5259 for the left knee disability is warranted for the period prior to May 2, 2007, as well as the period from May 2, 2007, forward. Bilateral Foot Disability Rating Analysis The Veteran is in receipt of a 10 percent disability rating for his bilateral foot disability for the entire rating period on appeal. The bilateral foot disability has been evaluated under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5276, which addresses acquired flatfoot. The Veteran contends that his bilateral foot disability warrants a higher rating. Specifically, he avers that he has a diagnosis of tarsal tunnel syndrome, a neurologic disorder, and thus, he is entitled to a higher disability rating. The Board will begin by reviewing the evidence most pertinent to the rating period on appeal (from May 2, 2007, forward) to determine whether a disability rating in excess of 10 percent is warranted. The Veteran was afforded a VA examination in May 2007. He reported constant pain in both feet and difficulty walking at the end of the day due to pain. He was wearing Lidoderm patches on both feet. He stated that rest and elevation provided partial relief of his symptoms, and that he also took medication in the form of the Lidoderm patches three times per week, as well as taking Mobic daily. He had not applied heat, cold, or had surgery. The Veteran said that the pain occurred while standing, walking, and at rest, and was located in the arch through the tarsals and the heel of the foot on the lateral and medial aspects. He denied swelling, heat, and redness, but reported stiffness in the lateral and medial aspects of the feet, fatigability of the entire foot, weakness in the arch and tarsals, and lack of endurance of the entire foot. He also reported flare-ups of pain that occurred weekly or more often and lasted one or two days; precipitating factors included increased activity and prolonged periods of standing or walking. The Veteran stated he was able to stand for up to one hour and able to walk more than a quarter mile, but less than one mile. He also said that he wore custom orthotic inserts. On physical examination in May 2007, there was no objective evidence of painful motion, swelling, instability, or weakness. There was objective evidence of tenderness in the medial and lateral aspects of both feet and the bilateral arches. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones. Achilles alignment was normal both with and without weight-bearing. There was no midfoot or forefoot malalignment and no pronation. An arch was present on non-weight-bearing, but not with weight-bearing. The weight-bearing line was over the great toe, bilaterally. There was no pain on manipulation, but valgus was not correctible with manipulation. There was no muscle atrophy of the foot. Gait was normal. X-rays were negative except for probable pes planus. The VA examiner assessed bilateral pes planus with plantar fasciitis and bilateral tarsal tunnel syndrome. After a review of the all the evidence of record, lay and medical, the Board finds that the weight of the evidence is against an evaluation in excess of 10 percent for the Veteran's bilateral foot disability under Diagnostic Code 5276. As noted above, under Diagnostic Code 5276, which addresses acquired flatfoot, a 10 percent evaluation is assigned when the condition is moderate in severity, the weight-bearing line is over or medial to the great toe, there is inward bowing of the tendo achillis, and pain on manipulation and use of the feet, bilateral or unilateral; 20 and 30 percent evaluations are assigned when the condition is severe, unilaterally or bilaterally, respectively, and there is objective evidence of marked deformity (pronation, abduction, etc.), accentuated pain on manipulation and use, indication of swelling on use, and characteristic callosities. 38 C.F.R. § 4.71a. In this case, the 2007 VA examiner noted no deformities, including pronation, of the feet, the Veteran denied any swelling, and there were no callosities noted by the VA examiner. Moreover, the VA examination noted no pain on manipulation of the feet, and although the Veteran did report pain with use of the feet, there is no indication that the pain could be characterized as accentuated, as the Veteran said he was able to walk between a quarter mile and one mile. Thus, even if pain is taken into account, there is no credible evidence of record demonstrating marked deformity, accentuated pain on manipulation and use, swelling on use, or characteristic callosities. As the criteria for a disability rating in excess of 10 percent under Diagnostic Code 5276 have not been met or more nearly approximated, the lay and medical evidence, which includes limitation of motion due to painful motion and other orthopedic factors, does not support a rating in excess of 10 percent under Diagnostic Code 5276 for the bilateral foot disability for any part of the rating period on appeal. 38 C.F.R. § 4.71a. The Board notes that the criteria for a 10 percent evaluation under Diagnostic Code 5276 specifically provide for both unilateral and bilateral symptoms; thus, a separate 10 percent rating for each foot under this Diagnostic Code is not possible. The Board has also considered whether any other diagnostic code would allow for a rating in excess of 10 percent for the Veteran's bilateral foot disability, manifested by limitation of motion, pain, or other orthopedic factors such as weakness or fatigability. Diagnostic Code 5277 contemplates impairment of the feet manifested by atrophy of the musculature, disturbed circulation, and weakness. Disabilities evaluated under this code are to be rated based on the underlying condition, and the minimum rating is to be 10 percent. 38 C.F.R. § 4.71a. Although the Veteran reported weakness in his feet, it was limited to the arch and tarsal areas. Moreover, there is no evidence of disturbed circulation or atrophy in this case. Thus, the Board finds that Diagnostic Code 5277 is inapplicable. In considering whether an initial compensable rating is warranted based on loss of motion under another diagnostic code, the Board finds that Diagnostic Code 5278 does not apply, as there is no evidence or contention of claw foot (pes cavus). Diagnostic Code 5279 contemplates unilateral or bilateral metatarsalgia. In addition to there being no evidence of metatarsalgia (the Veteran's pain was in the tarsal and heel areas), the maximum available rating under Diagnostic Code 5279 is 10 percent; thus, it does not allow for a higher rating. Diagnostic Codes 5280, 5281, and 5282 are not applicable, as there is no evidence of hallux valgus, hallux rigidus, or hammer toe. Diagnostic Code 5283 is not applicable, as the 2007 VA examiner specifically noted that there was no evidence of malunion or nonunion of the tarsal or metatarsal bones, as confirmed by X-ray studies. 38 C.F.R. § 4.71a. After a review of all the evidence, lay and medical, the Board finds that the evidence is at least in equipoise as to whether separate 10 percent ratings for each foot are warranted under Diagnostic Code 5284. Diagnostic Code 5284 contemplates foot injuries. Under this Diagnostic Code, a 10 percent rating is assigned when the injury is moderate, a 20 percent rating is assigned when the injury is moderately severe, and a 30 percent rating is assigned when the injury is severe. Further, if there is actual loss of use of the foot, a 40 percent rating can be assigned. 38 C.F.R. § 4.71a. As noted above, the 2007 VA examiner assessed tarsal tunnel syndrome in addition to the Veteran's bilateral pes planus with plantar fasciitis. The current Diagnostic Code (5276) only takes the pes planus into account, yet, as discussed above, the criteria for a higher rating under Diagnostic Code 5276 are not met or more nearly approximated by the evidence. Thus, taking the Veteran's additional diagnoses of plantar fasciitis and tarsal tunnel syndrome as well as his complaints of pain into account, and resolving any doubt in the Veteran's favor, the Board finds that separate 10 percent evaluations for each foot disability are warranted for the entire rating period on appeal from May 2, 2007, forward. The Board has also considered whether any separate ratings are available based on the evidence. However, the separate ratings assigned herein take into account the Veteran's various diagnoses of bilateral pes planus, plantar fasciitis, and tarsal tunnel syndrome. There are no other symptoms manifested by the Veteran's bilateral foot disability that would require a separate rating in addition to the one assigned herein. Finally, an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) also has been considered. The VA examinations in May 2007 note that the Veteran was employed full-time in sales. While the Veteran reportedly had to miss work because of his feet disabilities, the record does not show the Veteran has been rendered unemployable as a result of his left knee and feet disabilities. Therefore, any inferred TDIU claim is inapplicable in this case. Extraschedular Consideration In addition to the foregoing, the Board has considered whether referral for an extraschedular evaluation is warranted for the Veteran's knee disability. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Veteran's knee disability has manifested in arthritis and limitation of motion, including due to pain. The rating criteria specifically contemplate such symptomatology. The schedular rating criteria specifically provide ratings for such noncompensable limitation of motion due to painful arthritis (Diagnostic Code 5003, 38 C.F.R. § 4.59), and contemplate ratings based on limitation of motion (Diagnostic Codes 5256, 5260, 5261), including motion limited due to orthopedic factors such as pain, guarding of movement, and fatigability (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of the knee to the rating schedule, the degree of disability of each throughout the entire period under consideration is contemplated by the rating schedule and the assigned ratings are, therefore, adequate. In the absence of exceptional factors associated with the left knee disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2011). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment and earning capacity, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). The Board notes that the Veteran was apprised of VA's duties to both notify and assist in correspondence dated in April 2006 and May 2008. Although neither letter included the criteria for assigning effective dates, because the current appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for left knee and bilateral foot disabilities, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have held that, once service connection is granted and the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). The Veteran has been afforded adequate examinations on the issues of increased ratings for service-connected left knee and bilateral foot disabilities. VA provided the Veteran with examinations in June 2006 and May 2007. The Veteran's history was taken, and a complete examination with clinical measures was conducted, to include X-ray studies. Conclusions reached and diagnoses given were consistent with the examination report, including notation of whether there were additional losses of ranges of motion due to factors such as painful motion, weakness, impaired endurance, incoordination, or instability. For these reasons, the Board finds that the Veteran has been afforded adequate examinations on the issues of increased ratings for service-connected left knee and bilateral foot disabilities. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording VA examinations. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, VA examination reports, and the Veteran's statements. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. 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). ORDER An initial evaluation of 10 percent for left knee arthritis is granted for the period prior to May 2, 2007, subject to the rules governing payment of monetary benefits. An increased evaluation in excess of 10 percent for left knee arthritis is denied for the period from May 2, 2007, forward. A separate 10 percent disability evaluation for symptomatic removal of semilunar cartilage of the left knee is granted for the period prior to May 2, 2007, as well as the period from May 2, 2007, forward, subject to the rules governing payment of monetary benefits. An increased evaluation in excess of 10 percent for bilateral pes planus is denied for the entire rating period from May 2, 2007, forward. Separate 10 percent disability evaluations for each foot are granted for the entire rating period on appeal, from May 2, 2007, forward, subject to the rules governing the payment of monetary benefits. REMAND As noted above, in its July 2011 decision, the Board remanded the issue of entitlement to a higher initial evaluation on an extraschedular basis for a bilateral foot disability. Specifically, the Board noted that, during the May 2007 VA examination, the examiner noted that the Veteran's bilateral foot pain resulting from his service-connected disability caused increased absenteeism from work. Indeed, the VA examination report revealed that the Veteran missed six weeks of work in the past 12-month period. The Board considered this to be a possible indication of marked interference with employment, if true, such that the regular schedular standards were rendered impractical, and remanded the claim for an extraschedular evaluation for referral to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012). However, it does not appear that the RO has had the opportunity to carry out the remand directive of the Board's July 2011 decision, as the case has been before the Court. Therefore, the Board reiterates its July 2011 remand directives herein. Accordingly, the issue of entitlement to a higher initial evaluation on an extraschedular basis for a bilateral foot disability is REMANDED for the following action: 1. The RO/AMC should refer the case to the Director, Compensation and Pension Service, for a determination as to whether the Veteran is entitled to the assignment of an extraschedular rating for a bilateral foot disability in accordance with the provisions of §38 C.F.R. § 3.321(b). The Director, Compensation and Pension Service, is requested to provide adequate reasons and bases for any decision. 2. Upon a response from the Director, Compensation and Pension Service, the RO must undertake any adjudicative actions necessary. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded an opportunity to respond. The case should then be returned to the Board for further review, if 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). ______________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs