Citation Nr: 1304774 Decision Date: 02/08/13 Archive Date: 02/19/13 DOCKET NO. 07-23 898 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a lumbar spine disorder, to include as secondary to any service-connected disabilities. 2. Entitlement to an initial rating, in excess of 10 percent, for a right great toe disability. 3. Entitlement to an initial rating, in excess of 10 percent, for a left great toe disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C. Bruce, Counsel INTRODUCTION The Veteran had active duty service from September 1954 to August 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2007 and November 2007 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran timely appealed the above noted issues. The Veteran testified at a Board hearing before the undersigned Acting Veterans Law Judge in March 2010; a transcript of that hearing is associated with the claims file. This case was initially before the Board in July 2010, when the Board reopened issues of service connection for lumbar spine and left shoulder disabilities, but denied reopening a claim of service connection for sleep apnea, which is considered final at this time. The Board remanded those reopened claims, as well as a claim to reopen service connection for a right shoulder disorder and claims for increased evaluation for bilateral toe disabilities, for further development, including the issuance of a statement of the case on the right shoulder issue. The Veteran did not respond to the October 2010 statement of the case on the right shoulder issue, and therefore, that issue is considered final. The Board again addressed the issues of service connection for lumbar spine and left shoulder disabilities as well as the claims for increased evaluation for bilateral toe disabilities in an April 2012 Board decision. The issue of service connection for a left shoulder disability was denied, and therefore, that issue is considered final. The issues of service connection for a lumbar spine condition and an increased rating for bilateral toe disabilities were remanded for further development. That development having been accomplished those issues now return for further appellate review. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran is currently shown to have degenerative arthritis of the lumbar spine with chronic pain during the appeal period; such arthritis was not shown to have been diagnosed within one year of discharge from service. 2. The Veteran is not credible insofar as he asserts that he was subjected to multiple impact traumas to his lumbar spine as a result of his duties as a paratrooper during military service. 3. The probative evidence of record does not demonstrate that the Veteran's currently-diagnosed lumbar spine disorder is related to his military service. 4. The Veteran's right great toe disability is manifested by moderate symptomatology including fusion of the first MTP joint and distal ITP joint, pain on standing and walking, degenerative changes, and the use of corrective shoes prior to June 20, 2011. 5. The Veteran's right great toe disability is manifested by incoordination, marked fatigue, lack of endurance, difficulty ambulating without use of an assistive device (corrective shoes, walker, cane, or wheelchair), no motion in his toes, hallux rigidus, weak foot, and degenerative changes from June 20, 2011. 6. The Veteran's left great toe disability is manifested by nonunion of the first MTP joint, pain on standing and walking, degenerative changes, and the use of corrective shoes prior to June 20, 2011. 7. The Veteran's left great toe disability is manifested by incoordination, marked fatigue, lack of endurance, difficulty ambulating without use of an assistive device (corrective shoes, walker, cane, or wheelchair), no motion in his toes, hallux rigidus, weak foot, and degenerative changes from June 20, 2011. CONCLUSIONS OF LAW 1. The criteria establishing service connection for a lumbar spine disorder have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for an initial evaluation in excess of 10 percent, for a right great toe disability have not been met prior to June 20, 2011. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). 3. The criteria for an initial evaluation of 20 percent, but no greater, for a right great toe disability have been met from June 20, 2011. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). 4. The criteria for an initial evaluation, in excess of 10 percent, for a left great toe disability have not been met prior to June 20, 2011. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). 5. The criteria for an initial evaluation of 20 percent, but no greater, for a left great toe disability have been met from June 20, 2011. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in December 2006 and May 2008 that provided information as to what evidence was required to substantiate his claims for service connection for a lumbar spine disability and an increased rating for bilateral toes and of the division of responsibilities between VA and a claimant in developing an appeal. These letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a March 2010 hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any available outstanding evidence with respect to the Veteran's claim herein decided. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant 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). Analysis The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the 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 claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. Service Connection-Lumbar Spine Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b) (2012). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d) (2012). In order to prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of a service-connected disease or injury or that a service-connected disease or injury has chronically worsened the disability for which service connection is sought. 38 C.F.R. § 3.310(a) (2011); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). On appeal, the Veteran has asserted that he hurt his lumbar back during service when he was a paratrooper. He stated at his March 2010 hearing that he had to wear a steel shank from his heel to his toe during service because of a prior injury to his feet. He further noted that the steel shank would not allow him to land on his toes and roll like he was supposed to, but rather, he had to land on his heels. Landing on his heels meant he jarred his back every time he landed. He reported that he participated in 25 or 26 jumps while in service. The Veteran's service treatment records showed only one complaint for low back pain in April 1955. The treatment note indicated that the Veteran injured his lumbar region during an authorized parachute jump. He was diagnosed with a lumbar sprain. The Veteran's September 1954 entrance examination listed the Veteran's spine as normal as did a January 1955 examination for parachute duty. Finally, the Veteran's July 1957 separation examination failed to note any diagnosis or treatment of a lumbar spine condition and indeed listed the Veteran's spine as normal. Post service treatment records noted that the next complaint of lumbar back pain was in August of 1980. There was no diagnosis provided. The Veteran again complained of low back pain in July 1983 following a motor vehicle accident. The Veteran was subsequently diagnosed with lumbar strain. The Veteran had a second motor vehicle accident in February 1992 and reported neck and back pain in a March 1992 private treatment record. He was diagnosed with slowly resolving lumbosacral mulsculoskeletal strain and possible radiculopathy. A March 1994 VA treatment record noted that the Veteran had a history of back surgery approximately a year prior. It was noted he had degenerative joint disease of the lumbar spine. The Veteran again complained of low back pain in July 1998 following another motor vehicle accident that occurred in March 1998. The Veteran reported stiffness in his lower back. A February 2006 VA treatment report noted that the Veteran had chronic low back pain for 30 years. The Veteran reported no history of injury or back surgery. Back surgery was performed in September 2006 for left L4 through S1 radiofrequency ablation of medial branch lumbar facet joint. The Veteran provided a September 2008 letter from his treating private orthopedic surgeon which noted the Veteran's chronic pain in his lumbar spine resulting from his experience as a paratrooper in the military. The private doctor noted the Veteran's chronic low back pain and specifically stated that the Veteran had reported this pain was not from a motor vehicle accident from which the Veteran had whiplash. The doctor stated that he had reviewed Veteran's service record and VA treatment records. In his opinion, the Veteran's lumbar spine pathology was consistent with the multiple jumps that he performed between approximately 1954 and 1957. He further noted that he found nothing more acute or inconsistent with the Veteran's claimed injury and given the approximate force and the continued sequelae from 1957 to the present, the injuries were service related. Finally he noted that the natural history of the degenerative disc disease shows that symptoms may be seen as many as 10 years after an initial injury and the Veteran did not engage in activities after his services that would impact his lumbar spine to the same degree that parachuting would. The Veteran was afforded a VA examination in December 2008. The Veteran stated that he had back pain for 30 years with no history of injury. He further stated that he had injured himself while parachuting in service, but it was significant and he had no residuals from that pain in service for a long time after service. He reported aching pain that shot down through his legs. He treated the pain with medication, but did not use any assistive devices. Upon examination the Veteran had normal lumbar lordosis and no pain on palpation. He did exhibit some limitation of motion, but normal neurological testing. The examiner noted a March 2006 MRI report which revealed degenerative changes with desiccation of the three caudal discs with a bulge of the L4-L5 disc that slightly narrowed the thecal sac and the canal. A February 2006 x-ray report revealed mild anterior spondylosis. The Veteran was diagnosed with degenerative joint disease of the lumbar spine with radiculopathy. The examiner opined that the Veteran's in-service complaint of low back pain, which was insignificant without any subsequent sequel in the following years, did not contribute to his current degenerative condition of the lower back which is generalized in the joints including the facet joints. The examiner determined that his work and daily living activities over the last 50 years would have had a greater impact than his parachute jumps. Moreover, his condition was more consistent with the aging process than with any injury. The examiner specifically noted that he disagreed with the private orthopedic surgeon's assessment. In this regard the examiner noted the absence of any sequelae and lack of chronicity indicated that the Veteran's service activities did not contribute to his current back disability. The examiner found that the Veteran's current lumbar back condition was less likely as not caused by or the result of his one complaint of back pain in service. The Veteran was afforded another VA examination in June 2011. The Veteran reported that he has constant pain in his low back that he treats with medication. He further noted that he now had to use a walker to ambulate. Upon examination it was noted that the Veteran exhibited some limitation of motion as well as neurological deficiencies. The Veteran was diagnosed with degenerative arthritis of the lumbar spine with chronic pain. In a November 2011 addendum opinion, following the review of the claims folder, the June 2011 VA examiner opined that it was less likely as not that the current lumbar condition was caused by, aggravated by, or the result of active military service. The examiner, by way of rationale, noted that the Veteran reported one incident of back pain in service, but no other treatment prior to discharge in 1957. The Veteran was not diagnosed with degenerative disease of the lumbar spine while in military service and there were no complaints of chronic or recurrent lumbar spine issues upon separation. Finally he noted that the current level of degeneration of the joints and discs were no more than would be expected based on the Veteran's age alone. The Veteran was afforded a third VA examination in July 2012. The examination dealt primarily with the Veteran's service-connected toes, but the examiner did provide an opinion with regard to whether the Veteran's lumbar spine condition could have been caused by or aggravated by his service-connected bilateral toes. In this regard, the examiner opined it was less likely as not that the Veteran's current lumbar degenerative disease was caused by, aggravated by, or the result of the Veteran's service-connected foot condition. The examiner explained that he knew of no medical authority or peer reviewed medical literature which attributed causation of lumbar degenerative disease to a bilateral foot condition. The examiner further explained that lumbar degenerative disease is the result of chronic weight bearing on the lumbar disc mechanism over time, and is more likely as not caused by the Veteran's advanced age. Additionally, the examiner opined that it was less likely as not that the Veteran's repetitive parachute jumps led to the Veteran's current condition. The examiner explained that had the Veteran injured his back during a parachute jump, it would be a significant injury and there would be evidence of medical treatment sought and the Veteran's separation examination is absent any complaints of chronic or recurrent lumbar conditions. Finally the examiner addressed the positive opinion provided by the Veteran's treating orthopedic surgeon. In this regard he noted that the private doctor did not provide a valid rationale with regard to service connection of the Veteran's lumbar degenerative disease. He speculated that the Veteran's parachute jumps could have led to the Veteran's current lumbar degenerative disease, although no evidence of degenerative disease of the spine was found in the service treatment records. The Veteran had a single report of back pain in service with no evidence of chronicity or repetition found in the service treatment records. Indeed the separation examination revealed no chronic lumbar conditions. On the basis of the following, the Board must find that service connection for the Veteran's lumbar spine condition is not warranted on the evidence of record. Initially, the Board notes that the Veteran was discharged in 1957 and there is no evidence of arthritis on his separation examination or within one year of his discharge from service. Thus, the Board cannot grant service connection on the basis of the presumptive regulations in this case. See 38 C.F.R. §§3.307, 3.309. The Board, however, concedes that the Veteran's has been diagnosed with degenerative arthritis of the lumbar spine with chronic pain during the appeal period. Thus, the Veteran meets the first element necessary for service connection. See McClain v. Nicholson, 21 Vet. App. 319 (2007). However, review of the Veteran's service treatment records does not disclose any recurrent or chronic complaint or diagnosis of any lumbar condition. There is one complaint in service of low back pain in April 1955, but no mention of back pain again during active duty service. While the Veteran has maintained that the repetitive stress of parachute jumping is the cause of his lumbar spine condition, there is evidence that the Veteran has had lumbar spine pain associated with additional incidents including three separate motor vehicle accidents. The Board acknowledges the positive etiological opinion provided by the Veteran's private treating orthopedic surgeon, however, given that the private doctor's opinion does not note which service treatment records he was looking at or a particular incident in service during which the Veteran injured his lumbar spine during a parachute jump, or a multitude of different impact traumas as a result of his paratrooper duties, the Board is forced to conclude that there is no objective basis on which he can rationally base his opinion. The Veteran gave him a history of numerous impact traumas to his feet, legs and back-of which the private doctor's opinion also addresses-but such a generalized history given by the Veteran does not document any specific trauma incident in which he injured his lumbar spine. While the Board is cognizant that it cannot merely disregard a medical opinion on the basis that the rationale for the opinion is given by the Veteran, the Board is not doing so in this case. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005). Simply put, the Board finds the Veteran's history that he had multiple impact traumas to his lumbar spine while parachuting during active duty service is not credible in this case, particularly given his lack of admittance with regard to post-service traumas and surgeries. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curium, 78 F.3d 604 (Fed. Cir. 1996) (when determining whether lay evidence is satisfactory, the Board may properly consider internal consistency, facial plausibility, consistency with other evidence submitted, and the demeanor of the witness (if a hearing held)); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (lack of contemporaneous medical records does not, in and of itself, render lay testimony not credible; as a finder of fact, though, the Board may weigh the absence of contemporaneous records when assessing the credibility of the lay evidence). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. As is true with any piece of evidence, the credibility and weight to be attached to medical opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Winsett v. West, 11 Vet. App. 420 (1998) (Court affirmed the Board's decision which weighed two medical opinions, from an expert and a treating physician); Owens v. Brown, 7 Vet. App. 429,433 (1995) (Board favoring one medical opinion over another is not error). Consequently, the Board finds the basis for private doctor's opinion to be not credible-that the Veteran injured his lumbar spine in service as a result of numerous impact traumas during his paratrooper duties-and gives that opinion no probative weight. Instead, the Board finds the various VA examiners' opinions to be the most probative evidence in this case. In this regard the Board notes that the various VA examiners stated that the Veteran's lumbar spine condition was not the result of his parachute jumping in service, but rather the result of the normal aging process. Additionally, the November 2011 VA examiner additionally denied that the Veteran's lumbar spine condition was the result of, aggravated by, or caused by the Veteran's service-connected bilateral toes. As a result of no chronic or recurrent complaint of a back injury being documented during military service, the examiners concluded that the Veteran's lumbar spine was not the result of, caused by or aggravated by military service or any incident therein. In conclusion, the Board finds that while the Veteran's service treatment records do document a complaint of lumbar pain, there is no evidence of a chronic or recurrent complaint or diagnosis of a lumbar spine condition that was the result of injury or event during service. Additionally, the Board finds any assertions by the Veteran that he suffered numerous impact traumas to his lumbar spine as a result of his paratrooper jumps without seeking medical treatment for any of those traumas to be not credible. Finally, the more probative evidence, in particular the etiological opinions of the various VA examiners, indicates that the Veteran's lumbar spine condition is more likely the result of the normal aging process and not any incident of his active duty service, to include his service-connected bilateral toes. Therefore, the Board is forced to conclude in this case that the competent and probative evidence of record fails to demonstrate that the Veteran's currently diagnosed lumbar spine disorder is caused or aggravated by military service or any incident thereof to include his service-connected bilateral toes disorder. Accordingly, the Board must find that service connection for a lumbar spine disorder is not warranted on the evidence of record. See 38 C.F.R. §§ 3.102, 3.303. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the more probative evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). II. Increased Rating-Bilateral Toes The Veteran contends that he is entitled to a higher initial rating than his currently assigned 10 percent for a right great toe disability and 10 percent for left great toe disability. The Board notes initially that the Veteran was assigned a temporary 100 percent rating for each great toe from September 6, 2011 to November 1, 2011. As such, that time period will not be addressed in this decision. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. As such, the Board has considered all evidence of record in evaluating the Veteran's disabilities. Also, in Fenderson, the Court discussed the concept of the "staging" of ratings, finding that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a Veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). As such, in accordance with Fenderson, the Board has considered the propriety of assigning initial staged ratings for the Veteran's service-connected disabilities. Disability ratings are determined by applying the criteria set forth in the VA 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 (West 2002); 38 C.F.R. § 4.1 (2012). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). 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. 38 C.F.R. § 4.7 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45, see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. In general, all disabilities, including those arising from a single disease entity, are rated separately, and disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disabilities of the foot are rated under Diagnostic Codes 5276 to 5284. 38 C.F.R. § 4.71a. The Veteran is currently service connected at 10 percent under Diagnostic Code 5280-5284 for degenerative changes, right great toe status post fusion of the first metatarsophalangeal (MTP) and distal interphalangeal (ITP) joints and 10 percent under Diagnostic Code 5283 for non-union of metatarsophalangeal joint, left great toe. The Board notes that hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Under DC 5283, malunion or nonunion of the tarsal or metatarsal bones is assigned a 10 percent evaluation where it is moderate, a 20 percent evaluation where it is moderately severe, or a 30 percent evaluation if it is severe. 38 C.F.R. § 4.71a, (2012). Similarly, under DC 5284, other foot injuries are assigned a 10 percent evaluation if the disability is moderate, a 20 percent evaluation if the disability is moderately severe, or a 30 percent evaluation if the disability is severe. Id. A note to Diagnostic Code 5284 provides that a 40 percent disability evaluation will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284. The Board notes that words such as "severe" and "moderate" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6 (2012). Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C.A. § 7104 (West 2002); 38 C.F.R. §§ 4.2, 4.6 (2012). The Veteran was afforded a VA examination in November 2007. He reported that he had constant pain at rest, when standing, or walking. He noted no weakness, swelling, fatigability, or flare-ups. He reported that he used corrected shoes, but no other assistive device. He reported that weight bearing was painful in both feet. It was noted he underwent fusion of the left great toes at the MTP joint. Upon examination it was noted he had a normal gait, but constant pain when standing and walking. He had no passive or active motion in either first MTP joint or the right great toe ITP joint. It was noted that pes planus was not an issue. X-rays revealed degenerative changes in both great toes and the Veteran was diagnosed with fusion of the right first MTP joint and right distal ITP joint and nonunion of the left first MTP joint with attempted fusion. The Veteran was again afforded a VA examination in June 2011. The Veteran reported daily constant pain that limited his ability to walk. The Veteran noted he had to wear special shoes and that he used a walker. The Veteran further reported some incoordination, marked fatigue, and lack of endurance, which render him fairly homebound. He had marked pain and difficulty with ambulation. Upon examination of the right great toe it was noted that the Veteran had no motion in his toes, and the right great toe is shortened. The Veteran exhibited normal weight bearing. There was no pes planus, the Achilles tendon was aligned, and circulation was adequate. Examination of the left foot revealed a hammertoe of the second toe of the left foot and no motion in his toes. There was no abnormal weight bearing, the Achilles tendon was aligned, and circulation was adequate. X-rays associated revealed fusion between first metatarsal and cuneiform bone with degenerative changes on the right great toe. X-ray of the left great toe showed internal fixation of the first MTP joint. Another VA examination was afforded in July 2012. The Veteran was diagnosed with bilateral multiple joint degenerative joint disease of the feet secondary to a crush injury with bilateral aggravation by military service. The examiner noted that the Veteran had a severe bilateral crush injury around 1953, prior to his active duty service, and underwent 4 surgeries on his feet prior to admission into the service. The Veteran complained of generalized pain of the bilateral feet from the ankles to all toes. He reported surgery on his right foot in 2008 and 2010 and his condition had worsened since. He reported that he had burning pain generalized on both feet and that he was only able to ambulate with the use of a walker or a cane and even then only with great difficulty. Upon examination it was noted the Veteran had hammertoes on the second and third toe of the right foot, but none on the left foot. The Veteran also exhibited hallux rigidus on the right great toe that was severe with function equivalent to amputation of the right great toe. It was noted that the Veteran did not have Morton's neuroma, metatarsalgia, hallux valgus, pes cavus, or malunion or nonunion or tarsal or metatarsal bones. It was noted he had severe crush injury prior to military service with residuals of generalized foot tenderness bilaterally from the ankle throughout the feet that increased with passive movement of any toes. It was noted the condition was severe in both feet. There was evidence of bilateral weak foot. The Veteran also had scars, but they were not painful or unstable. Finally it was noted that the Veteran used a wheelchair as an assistive device in addition to the cane and the walker. X-rays revealed degenerative arthritis in multiple joints in both feet. As noted, the Veteran is currently rated 10 percent under Diagnostic Code 5280-5284 for his right great toe and 10 percent under Diagnostic Code 5283 for the left great toe. In this instance, the Board finds that it is proper to consider the rating criteria under Diagnostic Code 5284 for both great toes, as that diagnostic code has the potential to provide a higher rating for the Veteran's great toes. The assignment of a particular DC is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology; any change in a DC by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In consideration of the above noted VA examinations, the Board finds that ratings in excess of 10 percent in the right great toe and 10 percent rating in the left great toe are not warranted prior to June 20, 2011; however, increased ratings of 20 percent in the right great toe and 20 percent in the left great toe are warranted from June 20, 2011. In this regard, the Board notes that at the time of the November 2007 VA examination the Veteran exhibited no weakness, swelling, fatigability, or flare-ups. While the Veteran did not exhibit any passive or active motion in the either first MTP joint or the right ITP joint, the Veteran had a normal gait and did not use an assistive device other than corrected shoes. The noted symptomatology is indicative of a moderate injury. The Board notes the Veteran was diagnosed with nonunion of the left first MTP joint, which makes the Veteran eligible for a rating under Diagnostic Code 5283, but as the Veteran's disability is not indicative of anything more than a moderate disability, no higher rating can be assigned under that diagnostic code. As a result, the Board finds that an increased rating, in excess of 10 percent is not warranted prior to June 20, 2011. The June 2011 VA examination noted incoordination, marked fatigue, and a lack of endurance. The examination further noted no movement in any of the toes on either foot. The Veteran reported that he had difficulty ambulating and had to use a walker. The severity level of the Veteran's disability clearly increased from the previous examination. Moreover, the July 2012 VA examination noted further worsening of the Veteran's condition in that he could no longer ambulate without great difficulty and use of assistive devices including a cane, a walker, or a wheelchair. The examiner determined the Veteran's bilateral great toe disabilities were severe. The July 2012 VA examiner was asked to distinguish between how much of the Veteran's great toe disabilities were related to the pre-existing crush injury as opposed to the aggravation caused during active duty service. To that end, the examiner stated the Veteran had severe changes in his feet prior to service, secondary to the crush injury. He complained several times during service for pain, especially in his right great MP joint and he was provided special shoes. The examiner did not believe the Veteran's parachute jumping had significantly aggravated the Veteran's pre-existing foot injuries because there was no evidence that medical treatment was sought for such. The examiner opined that only 10 percent of the Veteran's current total bilateral foot disability could be attributed to the aggravation caused by his three years of active military service. While the Veteran's residuals of the crush injury were aggravated by service, the examiner found that 90 percent of current disability is due to the natural progression of the Veteran's severe bilateral crush injuries. Without evidence of a specific injury during a parachute jump, the examiner stated he did not believe that the Veteran's military service materially added to the Veteran's bilateral foot condition. The Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998). However, in this case, the examiner made it clear that the Veteran's current bilateral great toe disabilities are primarily related to his pre-service crush injury, and not his active military service. As such, the Board will consider this when determining the correct rating for the Veteran's bilateral great toe disabilities. As previously noted, the July 2012 found the Veteran's bilateral great toe disabilities to be severe. Under Diagnostic Code 5284, a 30 percent rating is warranted for other foot injuries that are severe; however, with consideration of the examiner's opinion that only 10 percent of the Veteran's current bilateral great toe disability is the result of his active duty military service, the Board finds that a 20 percent rating under Diagnostic Code 5284 for a moderately severe foot injury is warranted from June 20, 2011, the date of the second VA examination. The Board has also considered DeLuca v. Brown, 8 Vet. App. 202 (1995, in reaching its conclusion in this case. However, the record does not include evidence that is both credible and persuasive documenting any additional functional limitation which would warrant a rating higher than those already assigned. As such, the provisions of 38 C.F.R. §§ 4.40, 4.45 have been considered, but they do not provide a basis for the assignment of a higher rating. Although the Board is required to consider the effect of the Veteran's pain when making a rating determination, and has done so in this case, the Rating Schedule does not require a separate rating for pain. Rather, it provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. Spurgeon v. Brown, 10 Vet. App. 194 (1997). In this case, the 10 percent rating prior to June 20, 2011 and the 20 percent rating from June 20, 2011, in both the right and left great toes, adequately compensates him for any painful motion and function loss. Ratings may also be assigned to several other foot disabilities, if shown. These are flatfoot (DC 5276), weak foot (DC 5277), claw foot (DC 5278), metatarsalgia (DC 5279), and hallux valgus (DC 5280). 38 C.F.R. § 4.71a (2012). However, the medical evidence does not show that any of these conditions have been demonstrated and shown to be a manifestation of the service-connected disability, and the Veteran does not claim that any of them are present. Additionally, the Board observes that the Veteran has exhibited hallux rigidus (DC 5281), and hammertoe (DC 5282) during the appeal period, however as neither of those two diagnostic codes will allow for a higher rating than that already assigned, the Board will not address those codes. 38 C.F.R. § 4.71a (2012). The Board acknowledges the Veteran's statements that his service-connected disabilities are worse than the assigned ratings. However, the Board places significantly more weight on the objective clinical findings reported on examination than the Veteran's own subjective statements in support of his claim. See Smith v. Derwinski, 1 Vet. App. 235, 237 (1991) (determining the credibility of evidence is a function for the Board). Furthermore, the opinions and observations of the Veteran alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a with respect to determining the severity of his service-connected disabilities. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992); 38 C.F.R. § 3.159(a)(1) and (2) (2012). In evaluating the Veteran's claims for higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's bilateral great toe disabilities, with the established criteria found in the rating schedule for those disabilities show that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for his disabilities. There is no persuasive evidence in the record to indicate that this service-connected disabilities on appeal would cause any impairment with employment over and above that which is already contemplated in the assigned schedular rating. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Further, 38 C.F.R. § 4.1 specifically sets out that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." Factors such as requiring periodic medical attention are clearly contemplated in the Schedule and provided for in the evaluations assigned herein. What the evidence does not demonstrate in this case is that the manifestations of the Veteran's service-connected disabilities have resulted in unusual disability or impairment that has rendered the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate. Accordingly, consideration of 38 C.F.R. § 3.321(b)(1) is not warranted in this case. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Given the benefit of the doubt doctrine the Board finds that the Veteran is entitled to an increased rating to 20 percent, but no greater, for a right great toe disability and 20 percent, but no greater for a left great toe disability, for the period of the appeal from June 20, 2011. The benefit of the doubt doctrine, however, is not applicable for either issue for the period of the appeal prior to June 20, 2011 as the preponderance of the evidence is against a rating in excess of that currently assigned. ORDER Service connection for a lumbar spine disorder, to include as secondary to any service-connected disabilities is denied. An initial rating, in excess of 10 percent, for a right great toe disability prior to June 20, 2011, is denied. An initial rating of 20 percent, but no greater, for a right great toe disability from June 20, 2011, is granted. An initial rating, in excess of 10 percent, for a left great toe disability prior to June 20, 2011, is denied. An initial rating of 20 percent, but no greater, for a left great toe disability from June 20, 2011, is granted. ______________________________________________ ROBERT O'BRIEN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs