Citation Nr: 1302875 Decision Date: 01/25/13 Archive Date: 01/31/13 DOCKET NO. 08-29 852A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a compensable initial rating for psoriasis of the feet prior to November 10, 2011, and a rating in excess of 10 percent thereafter. 2. Entitlement to a compensable initial rating for plantar fasciitis, right foot prior to February 9, 2012, and a rating in excess of 10 percent thereafter. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Paul Sorisio, Counsel INTRODUCTION The Veteran served on active duty from May 1976 to November 1979 and from March 2003 to April 2005. He also had periods of active and inactive duty training with the U.S. Army Reserves. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which in part, granted service connection for psoriasis of the feet and plantar fasciitis, right foot. The Veteran testified before the undersigned at a Travel Board hearing in August 2010. A transcript of this hearing has been associated with the claims file. In a December 2011 rating decision, the RO increased the evaluation of psoriasis of the feet to 10 percent, effective November 10, 2011. Additionally, in a March 2012 rating decision, the RO increased the evaluation of the right foot plantar fasciitis to 10 percent, effective February 9, 2012. As the Veteran has not indicated full satisfaction with the current staged, initial ratings, the Board finds the claim remains in controversy and it will now adjudicate this appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (noting that the veteran is presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum benefit is awarded). The issue of entitlement to service connection for psoriasis of the upper extremities (hands/wrists/forearms) is raised by the record. See November 2011 VA examination report; August 2010 Board hearing transcript at 3. This issue has not yet been adjudicated by the agency of original jurisdiction (AOJ) and is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Prior to November 10, 2011, the Veteran's psoriasis of the feet has affected less than 5 percent of the entire body or exposed areas and has been treated only by topical therapy; he has not had any characteristics of disfigurement of the head, face or neck. 2. From November 10, 2011, service-connected psoriasis of the feet, at the most severe, is manifested by silvery scaly plaques that cover at least 5 percent, but less than 20 percent, of total body area and less than 5 percent of the exposed skin, using topical cream/ointment for treatment, but without systemic therapy. 3. Prior to February 9, 2012, the Veteran's plantar fasciitis of the right foot has been manifested by tenderness in the right heel with some limitation regarding walking and standing resulting in a mild disability picture. 4. From February 9, 2012, the Veteran's plantar fasciitis of the right foot is productive of moderate symptoms with pain on manipulation and use. CONCLUSIONS OF LAW 1. Prior to November 10, 2011, the criteria for an initial compensable rating for service-connected psoriasis of the feet have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Codes (DC) 7800 to 7805, 7816 (2012). 2. From November 10, 2011, the criteria for a rating in excess of 10 percent for service-connected psoriasis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.7, 4.10, 4.118, DC 7800 to 7805, 7816 (2012). 3. Prior to February 9, 2012, the criteria for the assignment of an initial compensable rating for the service-connected plantar fasciitis of the right foot have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, DC 5276 (2012). 4. From February 9, 2012, the criteria for the assignment of a rating in excess of 10 percent for the service-connected plantar fasciitis of the right foot have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.71a, DC 5276 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's 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). The VCAA applies to the instant claims. In this case, the Veteran is appealing the initial rating assignment as to his psoriasis of the feet and plantar fasciitis of the right foot. Because the June 2007 rating decision granted the Veteran's claims of entitlement to service connection, such claims are now substantiated. His filing of a notice of disagreement as to the June 2007 determination does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 73 Fed. Reg. 23,353 - 23,356 (Apr. 30, 2008) (as it amends 38 C.F.R. § 3.159 to add paragraph (b)(3), effective May 30, 2008). Rather, the Veteran's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Dingess/Hartman, 19 Vet. App. at 493. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as will be discussed below. The statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant DC for rating the skin and foot disabilities at issue (38 C.F.R. §§ 4.71a, 4.118; DC 5276, 7816), and included a description of the rating formulas for all possible schedular ratings under these DCs. The appellant was thus informed of what was needed not only to achieve the next-higher schedular ratings, but also to obtain all schedular ratings above the initial evaluations that the RO had assigned. Therefore, the Board finds that the appellant has been informed of what was necessary to achieve higher ratings for the service-connected disabilities at issue. Regarding the duty to assist, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the claimant in developing the facts pertinent to his issues. Essentially, all available evidence that could substantiate the issues has been obtained. Therefore, the Board will proceed to adjudicate the appeal. The Board finds that the there has been substantial compliance with its March 2011 remand. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). This Board remand directed that VA treatment records be obtained and that the Veteran be scheduled for dermatology and podiatry examinations. The record reflects that VA treatment records from Miami and West Palm Beach Medical Centers have been associated with the claims file. Additionally, the Veteran was afforded a VA examination of the skin in November 2011 and of the feet in November 2011 and February 2012. Therefore, the Board finds substantial compliance with it prior remand directives and will proceed to adjudicate the appeal. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations (skin and feet) obtained in this case are adequate, as they are predicated on a full review of the VA medical records in the Veteran's claims file. A subjective history of the Veteran's skin and feet disabilities was taken and objective examinations were performed. Accordingly, the Board finds that VA's duty to assist has been met with respect to ensuring that VA examinations obtained for this appeal are adequate for rating purposes. 38 C.F.R. § 3.159(c)(4); 38 C.F.R. § 4.2 (2012); see D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (noting that an opinion is adequate where it is based upon consideration of a veteran's prior medical history and examinations and also describes the disability in sufficient detail). Legal Criteria and Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. Id. § 4.3. In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, an appeal from the initial assignment of a disability rating, such as those for psoriasis and plantar fasciitis, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). In addition, the United States Court of Appeals for Veterans Claims (Court) has determined that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The Veteran's entire history is to be considered when making a disability determination. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has 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). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations, which are potentially applicable, based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Psoriasis of the feet The Board notes that during the pendency of the appeal, the applicable rating criteria for skin disorders, found at 38 C.F.R. § 4.118, were amended effective October 2008. However, the October 2008 revisions are only applicable to applications for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (Sept. 23, 2008). As the Veteran filed his claim in February 2006, only the pre-October 2008 version of the schedular criteria is applicable. The Veteran here did not specifically request consideration under the new provisions. Under DC 7816, the criteria for a higher rating for psoriasis is as follows: at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or if intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of less than six weeks during the past 12- month period (10 percent) and with 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or if systemic therapy such as corticosteroids or other immunosuppressive drugs is required for a total duration of six weeks or more, but not constantly, during the past 12-month period (30 percent). The provisions of DC 7816 also indicates that the psoriasis may be rated as disfigurement of the head, face, or neck under DC 7800 or as scars under DCs 7801 to 7805, depending on the predominant disability. 38 C.F.R. § 4.118, DC 7816. Under DC 7800, disfigurement of the head, face, or neck, a 10 percent rating is warranted when a veteran experiences one characteristic of disfigurement. A 30 percent rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or two or three of the aforementioned characteristics of disfigurement. The 8 characteristics of disfigurement for the purposes of evaluation under § 4.118 are: scar of 5 in. or more (13 or more cm) in length; scar at least 1/4 in. (0.6 cm) wide at its widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 sq. in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 sq. in. (39 sq. cm.); and skin indurated and inflexible in an area exceeding 6 sq. in. (39 sq. cm.). Scars, other than head, face, or neck, that are deep or that cause limited motion are rated under 38 C.F.R. § 4.118, DC 7801. A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7801, Note 2. Scars, other than head, face, or neck, that are superficial and that do not cause limited motion covering an area or areas of 144 sq. in. (929 sq. cm.) or greater are rated as 10 percent disabling under DC 7802. A superficial scar is one not associated with underlying soft tissue damage. DC 7802, Note 2. DC 7803 provides that a 10 percent rating is warranted for scars that are superficial and unstable. Scars which are superficial and painful on examination are rated as 10 percent disabling under DC 7804. A superficial scar is one not associated with underlying soft tissue damage. DC 7804, Note 1. Other scars are rated based upon limitation of function of affected part under DC 7805. After a careful review of the evidence of record, and for the reasons expressed below, the Board finds that the evidence of record does not demonstrate, or more nearly approximate, the requisite manifestations for the assignment of a compensable disability evaluation for psoriasis of the feet under DC 7816 prior to November 10, 2011. Upon physical examination at a May 2007 VA examination, the examiner stated that less than 5 percent of the Veteran's total body area was affected. It was also noted that there was no exposed areas (head, face, neck, hands) affected. The Veteran complained of a rash on his left foot with cracking of the skin on his feet. The examination report reflects that the Veteran's treatment consisted of topical Clobetasol steroid cream (0.05%) nearly constantly over the past 9 months. An August 2007 VA dermatology treatment report reflects objective sloughing and fissures of the entire plantar aspect of the right foot with mild discoloration of the toenail, first digit, right foot. Another VA dermatology report from October 2007 shows crusted plaques bilaterally on the plantar aspects of the feet with fissures and reported pain. The assessment was "dermatoses, eczema vs psoriasis vs tinea." A May 2008 emergency department record indicates that the Veteran had complaints of intense itching and continuing rash over extremities, chest wall, and abdominal wall. Additionally, in June 2008, an Individual Sick Slip indicates that the Veteran had a skin condition of both feet with a diagnosis of psoriasis. A February 2009 VA treatment record reflects that the Veteran had complaints of itching and redness on his feet. He was given hydrocortisone 2.5 and a medrol dose pak. The assessment, based upon digital photographs obtained by the primary care staff at a remote location, was areas of hyperkeratotic rhagadiform eczema. The signing physician further noted no signs of psoriasis or severe eczema. A review of the Veteran's skin, as noted in a November 2009 VA surgical history and physical record, revealed no complaints of rash or lesions. As discussed immediately above, the Veteran's symptoms associated with his service-connected psoriasis of the feet do not more nearly approximate the rating criteria for the next-higher 10 percent evaluation. Indeed, the May 2007 VA examiner found less than 5 percent of the entire body or exposed areas were affected. The Veteran's treatment consisted of topical therapy during the time period prior to November 10, 2011. Similarly, from November 10, 2011, the evidence does not reflect that the Veteran's psoriasis affects 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected. A November 2011 VA examination report (Disability Benefits Questionnaire (DBQ)) reflects 5 to 20 percent of total body being affected with less than 5 percent of exposed area affected. Regarding treatment, the Veteran was using topical corticosteroids (traimcinolone acet 0.1% ointment) twice daily. Additionally, this report reflects no disfigurement, benign/malignant skin neoplasms, or debilitating episodes. In light of the foregoing, the Board finds that a rating in excess of the current 10 percent evaluation from November 10, 2011, is not more nearly approximated under DC 7816. A higher rating is not warranted under DC 7800 as psoriasis does not involve the head, face or neck. In addition, DCs 7801 to 7805 are not applicable because the evidence does not show that psoriasis caused scarring. The Board has considered the Veteran's contentions with respect to this disability, and acknowledges that he is competent to report his skin symptoms (such as redness and itching) and their perceived severity. However, the more probative evidence consists of that prepared by neutral skilled professionals, and such evidence does not demonstrate that higher evaluations in this case are warranted. In summary, for the reasons and bases expressed above, the Board concludes that an initial compensable evaluation prior to November 10, 2011, and in excess of 10 percent thereafter is not warranted for psoriasis of the feet. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. As the preponderance is against higher initial, staged ratings, the appeal is denied. Plantar Fasciitis, right foot By rating action dated in June 2007, the RO granted service connection for plantar fasciitis of the right foot and assigned an initial noncompensable disability rating under DC 5276. Plantar fasciitis is not specifically listed in the rating schedule and, therefore, it is rated by analogy. When an unlisted condition is encountered it is permissible to rate it under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). Under DC 5276 a noncompensable disability rating is assigned where there is evidence of mild symptoms relieved by built-up shoe or arch support. A 10 percent disability rating is assigned, regardless of whether the condition is unilateral or bilateral, where there is evidence of moderate symptoms with the weight-bearing line over or medial to the great toe, inward bowing of the tendon Achilles, pain on manipulation and use of the feet. A 20 percent disability rating for unilateral pes planus or a 30 percent disability rating for bilateral pes planus is assigned where there is a severe condition with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indications of swelling on use, characteristic callosities. A 30 percent disability rating for unilateral pes planus or a 50 percent disability rating for bilateral pes planus requires a pronounced condition manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement, severe spasm of the tendon Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. Also for consideration in the rating of the Veteran's service-connected foot disability is DC 5284, which deals with other foot injuries. Under this DC, moderate residuals of other foot injuries warrant a 10 percent rating. A 20 percent rating requires moderately severe residuals. A 30 percent rating requires severe residuals. In cases, such as this, the Board must address, in conjunction with the otherwise applicable DC, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45 (2012). DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). In DeLuca, the Court held that 38 C.F.R. §§ 4.40 and 4.45 require the Board to consider the disabling effect of painful motion when rating joint disabilities. Id. at 205-06. Those regulations, in turn, direct VA to consider "the ability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance," taking into account such factors as pain, weakness, fatigue, and lack of coordination. 38 C.F.R. §§ 4.40, 4.45. The Veteran contends that a higher initial disability rating is warranted for his service-connected plantar fasciitis of the right foot. Prior to February 9, 2012, the evidence consists mainly of a May 2007 VA foot examination report and a November 2011 VA foot examination report. Indeed, it was noted in the November 2011 report that the Veteran was last evaluated by podiatry in approximately 2007. At the time of the May 2007 examination, the Veteran complained of pain in the right heel and that he was limited in standing (15-30 minutes) and walking (.25 mile). Despite these complaints, there was no painful motion, swelling, instability, weakness, redness, tenderness (except right heel), or abnormal weight bearing. The November 2011 report notes his complaints of pain in the bottom of the right foot and heel after prolonged standing and walking. The examiner stated the Veteran was taking naproxen, methadone, and Tylenol for "all his pains" and was wearing custom inserts. The Board finds that the symptoms noted in May 2007 and November 2011 VA foot examinations do not more nearly approximate a moderate flat foot disability as there was no painful motion on physical examination or any abnormal weight bearing. The Board also finds that, for similar reasons, these symptoms do not more nearly approximate a moderate foot disability under DC 5284. Although there was pain in the right heel and some limitations regarding standing and walking, the Veteran's overall disability picture related to his right foot appears to be fairly mild as there was no swelling, redness, weakness, among other symptoms, upon examination. Taken together, the Veteran's symptoms prior to February 9, 2012 reveal a mild disability picture. Therefore, he does not meet the criteria for an initial compensable rating prior to February 9, 2012. From February 9, 2012, the evidence mainly consists of a VA DBQ flatfoot examination in February 2012. The February 2012 DBQ flatfoot report notes the Veteran's complaints of right foot/heel pain after prolonged standing and walking. It was noted that he used inserts and would place more weight on his left foot and low back to prevent pressure on the right foot. After review of the pertinent evidence, the Board finds that the Veteran's service-connected right foot disability does not more nearly approximate a severe unilateral flatfoot disability under DC 5276. In this regard, the February 2012 report reflects that the Veteran did not have pain on manipulation of the feet although noting pain accentuated on use of both feet. The physical examination did not reveal any indication of swelling or characteristic calluses. Concerning alignment and deformity, there was no objective evidence of marked deformity of the foot, to include pronation and abduction. Again, the Board has considered DC 5284 (foot injuries, other), but finds that it does not provide for a higher/separate rating. As noted above a 10 percent rating under DC 5284 is for a moderate foot disability. Such is consistent with the presently assigned 10 percent analogous rating for moderate flatfoot under DC 5276. The February 2012 DBQ report notes no swelling, tenderness, calluses, marked pronation, abnormal weight bearing, inward bowing/displacement, scars, or assistive devices (other than inserts). It also indicates that the Veteran denied swelling, erythema, and warmth. In light of this evidence, the Board finds that the Veteran's service-connected plantar fasciitis of the right foot is more nearly approximated by the current 10 percent rating under DC 5276 from February 9, 2012 rather than a higher/separate rating under DC 5284. In making this determination, the Board has considered pain on use and functional limitation. It is unclear whether DeLuca applies to DC 5276 as this DC is not predicated on range of motion. This DC does note pain on manipulation under the next-higher criteria. In any case, the Board finds that the Veteran's complaints of pain have been considered in the Veteran's current 10 percent rating from February 9, 2012 when looking at his overall disability picture. His functional loss of the right foot is minimal, if any. Indeed, while this service-connected disability was noted to affect his ability to work, he only needed to take breaks to sit down. The Board also considered whether the Veteran's foot disability would warrant a higher disability rating under other DC pertaining to the foot but, finds that the criteria pertaining to bilateral weak foot, claw feet (pes cavus), metatarsalgia, hallux rigidus, hammer toe, malunion or nonunion of the tarsal or metatarsal bones, or other foot injuries under DCs 5277, 5278, 5279, 5281, 5282, 5283, 5284, respectively are not applicable. See May 2007 VA examination report; November 2011 and February 2012 VA examination (DBQ) reports. The appellant's lay testimony alone may be sufficient to inform the Board of the functional effects of his pain to the extent that he is describing symptoms capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (noting that lay persons are generally competent to provide evidence on observable symptoms); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (finding lay testimony is competent to establish the presence of an observable symptomatology and "may provide sufficient support for a claim of service connection"). The Veteran is competent to report the pain in his right foot. The Board also finds him credible in this regard. However, the Board finds that his competent and credible statements and testimony are outweighed by the objective evidence obtained and recorded by trained professionals at VA examinations during the appeal period. The Board has considered further staged rating, but finds that additional staging is not necessary for the reasons discussed above. As the preponderance of the evidence is against the claim for higher, staged ratings, the appeal is denied. Extraschedular Consideration Ordinarily, the VA Rating 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 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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran'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 foot and skin disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's feet and skin disabilities with the established criteria shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. Specifically, the Veteran most recently reported complaints of pain in the right foot after prolonged standing or walking. This report of pain on manipulation and use of the feet is directly contemplated by DC 5276 as rated by analogy since his compensable rating was granted in February 2012. Regarding the psoriasis, the Veteran was using topical therapy to treat his psoriasis. This is directly contemplated by the applicable DC as described previously. More recent examination in 2011 revealed silvery scaly plaques that cover at least 5 percent, but less than 20 percent, of total body area and less than 5 percent of the exposed skin. It was noted that he was using topical cream/ointment as treatment for the psoriasis. These symptoms and manifestations are also directly contemplated by DC 7816. Thus, the Board finds that the schedular, staged evaluations are not inadequate. Additionally, even if the schedular criteria are not adequate, this case does not present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. The May 2007 VA skin examination report indicates that there were no significant effects on the Veteran's occupation as a nurse. Similarly, the November 2011 VA skin examination revealed no functional impact on work. The May 2007 VA feet examination noted the Veteran's full-time employment as a staff nurse and indicated that he had no time lost from work over the past 12 months and there were no significant occupational effects. The February 2012 foot DBQ noted that the Veteran's right foot disability impacts his work because he has to take breaks to sit down. It was also indicated that he cannot run anymore. While it is noted that the Veteran had to take breaks to rest his right foot, the record does not reflect that he missed any work. In regards to his service-connected skin disability of the feet, the November 2011 VA examiner found no functional impact on his ability to work. Based on the above evidence, the Board finds this case does not reveal an exceptional or unusual disability picture so as to warrant a referral for extraschedular consideration. (CONTINUTED ON THE NEXT PAGE) ORDER Entitlement to a compensable initial rating for psoriasis of the feet prior to November 10, 2011, and a rating in excess of 10 percent thereafter, is denied. Entitlement to a compensable initial rating for plantar fasciitis, right foot, prior to February 9, 2012, and a rating in excess of 10 percent thereafter, is denied. ______________________________________________ TARA L. REYNOLDS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs