Citation Nr: 1309505 Decision Date: 03/20/13 Archive Date: 04/01/13 DOCKET NO. 03-26 546 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a heart condition. 2. Entitlement to service connection for a generalized arthritic condition, to include scleroderma and CREST syndrome. 3. Entitlement to service connection for a respiratory disability due to a chest wall condition. 4. Entitlement to an initial compensable disability rating for Raynaud's syndrome, from October 19, 2000, to November 18, 2012. 5. Entitlement to an initial disability rating in excess of 40 percent for Raynaud's syndrome, since November 19, 2012. 6. Entitlement to a disability rating in excess of 10 percent for bilateral plantar fasciitis, prior to February 27, 2007. 7. Entitlement to a disability rating in excess of 30 percent for bilateral plantar fasciitis since February 27, 2007. 8. Entitlement to a compensable disability rating for residuals of a left pectoral muscle strain. REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs WITNESSES AT HEARING ON APPEAL Veteran and her husband ATTORNEY FOR THE BOARD L. J. Wells-Green, Counsel INTRODUCTION The Veteran served on active duty from August 1978 to October 1991. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a June 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which relevantly denied service connection for respiratory, heart, arthritis and skin disabilities, and for a chest injury. Increased disability ratings were also denied for residuals of a left pectoral muscle injury and for bilateral plantar fasciitis. Service connection was granted for Raynaud's syndrome, and a noncompensable disability rating, effective October 19, 2000, was assigned. The case was subsequently transferred to the RO in Newark, New Jersey. In December 2003, the Veteran testified at a travel board hearing at the RO before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with her claims folder. In a September 2004 decision, the Board relevantly denied service connection for heart and respiratory conditions and an increased disability rating for bilateral plantar fasciitis; the claims for service connection for a skin disorder and for an increased initial disability rating for Raynaud's syndrome and an increased disability rating for residuals of a left pectoral muscle strain were remanded for further development. The Veteran appealed the Board's September 2004 decision to the United States Court of Appeals for Veterans Claims (Court) and in an Order dated in May 2006 the Court relevantly vacated that part of the Board's decision denying service connection for a heart condition and a chest disability to include a respiratory disability and denial of a disability rating in excess of 10 percent for bilateral plantar fasciitis, pursuant to a Joint Motion (JMR). In September 2006 the Board remanded the case for further development in compliance with the JMR. A June 2007 rating decision granted an increased 30 percent disability rating for bilateral plantar fasciitis, effective from February 27, 2007. The Board again remanded the case for further development in April 2011. A December 2012 rating decision granted service connection for a skin condition and granted an increased 40 percent disability rating for Raynaud's syndrome, effective November 19, 2012. During the course of the Veteran's appeal, service connection was granted for depression, assigned a 70 percent disability rating; and a skin disability, assigned a noncompensable disability rating. As the Veteran has expressed no disagreement with the assigned disability ratings for these disabilities or the effective dates, they are no longer for appellate consideration. The Veteran's current combined schedular disability rating is 90 percent and she has been assigned a total disability rating based on individual unemployability (TDIU). The issues have been recharacterized to comport with the evidence of record and the development of the Veteran's claims. The issues of entitlement to service connection for heart and generalized arthritic conditions are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Any current respiratory disability, to include diagnosed emphysema, chronic obstructive pulmonary disease (COPD) and restrictive lung disease, did not have its onset in service and has not been etiologically linked to the Veteran's service, any incident therein, or to a service-connected disability. 2. For the entire appellate period, Raynaud's syndrome is manifested by reports of characteristic attacks occurring on a daily basis; there was no objective evidence of digital ulcers or autoamputation of one or more digits. 3. Prior to February 27, 2007, bilateral plantar fasciitis was manifested by no more than moderate symptoms; there was no evidence of marked deformity, accentuated pain, or swelling. 4. Since February 27, 2007, bilateral plantar fasciitis is manifest by no more than severe symptoms; there is no evidence of marked pronation, extreme tenderness, marked inward displacement or severe spasm of the tendo achillis on manipulation. 5. Residuals of a left pectoral muscle strain are manifest by complaints of intermittent chest pain with objective evidence of no more than mild chest wall tenderness and no evidence of any defect or moderate functional muscle impairment. CONCLUSIONS OF LAW 1. A respiratory disability, to include emphysema, COPD and a restrictive lung disease, was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. The criteria for an initial 40 percent disability rating, and no more, for Raynaud's syndrome, from October 19, 2000, to November 18, 2012, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7117 (2012). 3. The criteria for an initial disability rating in excess of 40 percent for Raynaud's syndrome since November 19, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7117 (2012). 4. The criteria for a disability rating in excess of 10 percent for bilateral plantar fasciitis prior to February 27, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5276 (2012). 5. The criteria for a disability rating in excess of 30 percent for bilateral plantar fasciitis since February 27, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5276 (2012). 6. The criteria for a compensable disability rating for residuals of a left pectoral muscle strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.73, Diagnostic Codes 5302, 5321 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties To Notify And Assist Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. At her December 2003 hearing, the Veteran waived any error in the content or timing of the notice provided. The duty to notify the Veteran is satisfied. 38 U.S.C.A. § 5103. The Veteran's service treatment records, VA medical treatment records and private treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Evidence from the Social Security Administration is also of record. 38 C.F.R. § 3.159(c)(2). VA examinations were conducted in November 2000, February 2002, November 2004, December 2004, February 2007, April 2011, May 2011, October 2012 and December 2012; the Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). These examinations, in aggregate with medical treatment records, are adequate as they are predicated on examinations of the Veteran and either offer opinions regarding the etiology of any current disabilities or fully address the rating criteria relevant to evaluating the Veteran's service-connected disabilities. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 at 486 (2006); Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Analysis Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F. 3d at 1316; Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007) (Holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). In addition to the above-cited statutes and regulations, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Lay assertions of record must be fully considered in making all determinations. A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Whether lay evidence is competent must determined on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, supra. The Veteran contends that she currently has a respiratory disability that had its onset in service as evidenced by repeated treatment for sinusitis. Alternatively, the Veteran contends that her respiratory disability is either proximately caused by or aggravated by either her service-connected residuals of a left pectoral muscle strain or Raynaud's syndrome. Service treatment records are negative for complaints, findings, treatment or diagnoses for any respiratory disability. She was treated on several occasions for sinusitis and upper respiratory infections or colds that resolved with treatment. Her June 1991 report of medical history shows she denied any shortness of breath, and the accompanying discharge examination report shows that clinical evaluation of the lungs and chest was normal. A chest X-ray study at the time was also normal. The earliest post-discharge evidence of a respiratory disability is a February 2002 VA pulmonary function test (PFT) which indicates a mild restrictive defect. An August 2004 PFT shows a mild obstructive process that was consistent with early COPD. A July 2004 VA treatment record notes the Veteran complained of a daily cough and that she reported that recent private chest X-ray and CAT scan studies were abnormal. She denied any shortness of breath or dyspnea on exertion at the time. Another July 2004 VA treatment record shows that there were rales in the bases of both lungs and that the Veteran was assessed with lung nodules. A February 2005 VA treatment record notes the Veteran's report that she had been told that she had restrictive lung disease secondary to scleroderma. Finally a February 2007 private treatment record shows a diagnosis of emphysema. Numerous treatment records note the Veteran's ongoing smoking history. None of the medical evidence of record etiologically links the Veteran's current respiratory disability to her service, in-service treatment for sinusitis and upper respiratory infections, or to her service-connected Raynaud's syndrome or residuals of a left pectoral muscle strain. Nor is the Veteran competent to provide the necessary etiological link to either her service or any service-connected disability. There is no evidence of record indicating any respiratory disability until February 2002, more than 10 years after the Veteran's discharge from service or linking any such disability to her service or to any of her service-connected disabilities. The preponderance of the evidence is against the claim for service connection for a respiratory disability, to include COPD, emphysema and restrictive disease; there is no doubt to be resolved; and service connection for a respiratory disability is not warranted. Increased Disability Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. 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. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). Raynaud's Syndrome The Veteran's service-connected Raynaud's syndrome is currently rated at 0 percent (noncompensable) prior to November 19, 2012, and at 40 percent since under 38 C.F.R. § 4.104, Diagnostic Code 7117. Under Diagnostic Code 7117, a 10 percent disability rating is warranted for characteristic attacks occurring one to three times a week. A rating of 20 percent is warranted when there are characteristic attacks occurring four to six times a week. A rating of 40 percent is warranted when there are characteristic attacks occurring at least daily. A rating of 60 percent is warranted when there are two or more digital ulcers and a history of characteristic attacks. A rating of 100 percent is warranted when there are two or more digital ulcers, plus autoamputation of one or more digits and a history of characteristic attacks. A characteristic attack consists of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and parethesias and precipitated by exposure to cold or by emotional upsets. See Note, Diagnostic Code 7117. Additionally, the evaluations are for the disease as a whole, regardless of the number of extremities involved or whether the nose and ears are involved. Id. VA and private treatment records, dating from January 2000 show the Veteran frequently complained of bilateral foot and hand pain, intermittently accompanied by numbness and discoloration of digits. VA and private treatment records, while repeatedly showing that examination of the hands and feet revealed the skin to be warm and dry, with no evidence of swelling or edema, tenderness on palpation or limitation of motion, frequently do note discoloration in either the hands or feet and some thickening of the skin. Physical examination during her February 2002 VA examination revealed hyperpigmentation on both the fingers and the soles and interdigital spaces of the feet that could not be disassociated with Raynaud's. Although several private and VA treatment records also note pruritic or macular lesions on either the feet or hands, these findings have repeatedly been attributed to her diagnosed eczema and tinea, which the February 2002 VA examiner opined was unrelated to her Raynaud's syndrome. Indeed, as noted above, the Veteran has been granted service connection for a separate skin disability. A December 2004 VA examination report further notes that there was no evidence of punctuates, scarring or fingertip infarcts and opined that her symptoms appeared to be mild and possibly moderate at times. However, none of the treatment records or the February 2002 or December 2004 VA examiners indicate how frequently the Veteran experienced characteristic Raynaud's attacks during this period. The Veteran is competent to report and describe observable symptoms; her statements regarding hand and foot pain, numbness, and discoloration are credible as there is no evidence of record that indicates any inconsistencies. Although she does not describe her Raynaud's symptoms as "attacks" the Veteran has consistently contended and testified that she has symptoms on a daily basis. Likewise, in a December 2003 claim for SSA disability benefits, she again indicated that she experienced Raynaud's symptoms "all day long." In a November 19, 2012, addendum to an earlier October 2012 VA rheumatology examination, the VA examiner indicates that the Veteran currently has Raynaud's syndrome with characteristic attacks occurring at least daily. She did not have 2 or more digital ulcers or autoamputation of 1 or more digits. There were no finger tip pits or scars and nail folds were normal with no tissue loss in the left foot. The left radial pulse was stronger than the right. The examiner linked 3 tender cracks on her hand to eczema rather than her Raynaud's. The examiner opined that there was no sequella to her Raynaud's syndrome other than the discomfort of the attack and believed she may have overstated the duration of her attacks. While the December 2003 VA examiner indicates that her symptoms are no more than mild to moderate, and the October 2012 VA examiner felt she overstated the duration of her attacks, there is frequent objective evidence of hyperpigmentation to both the hands and feet and some evidence of associated skin thickening. The Veteran has consistently affirmed that she experiences these symptoms on a daily basis. Based on these findings, the Veteran had daily Raynaud's syndrome attacks with discoloration and pain in the bilateral hands and feet and the evidence is, at worst, in equipoise as to whether a 40 percent rating is warranted. Resolving all reasonable doubt in favor of the Veteran, a 40 percent rating is warranted for the entire appellate period, beginning October 19, 2000. Although the record indicates that the Veteran periodically had some lesions on both her hands and feet, these lesions were consistently attributed to her diagnosed eczema and tinea. The February 2002 VA examiner specifically found that the Veteran's "atopy" and tinea pedis were unrelated to her Raynaud's syndrome. Nor is there any evidence of any autoamputation. Therefore, the criteria for an initial evaluation in excess of 40 percent have not been met at any time during the pendency of the appeal. Consequently, a rating in excess of 40 percent for Raynaud's syndrome is not warranted. Bilateral Plantar Fasciitis The Veteran's service-connected bilateral plantar fasciitis is currently rated at 10 percent prior to February 27, 2007, and at 30 percent since under 38 C.F.R. § 4.71a, Diagnostic Code 5276. Diagnostic Code 5276 provides ratings for acquired flatfoot or pes planus. Mild flatfoot with symptoms relieved by built-up shoe or arch support warrants a 0 percent rating. Moderate flatfoot with weight-bearing line over or medial to the great toe, inward bowing of the tendo Achillis, pain on manipulation and use of the feet warrants a 10 percent rating, whether it is bilateral or unilateral. Severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, warrants a 30 percent rating for bilateral disability. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo Achillis on manipulation that is not improved by orthopedic shoes or appliances warrants a 50 percent rating for bilateral disability. 38 C.F.R. § 4.71a. 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 weakened movement, excess fatigability and incoordination. Prior to February 27, 2007 Despite the Veteran's repeated complaints of severe bilateral foot pain, rated as 8/10 in an October 2004 private treatment record, the medical evidence of record for this period repeatedly shows no objective evidence of marked deformity, swelling or pain on manipulation. Indeed, an April 2000 VA treatment record notes that her heel was not too painful if she used orthotics. The November 2000 VA examiner noted that the Veteran currently wore orthotics that relieved her foot pain. Both the November 2000 and February 2002 VA orthopedic examiners, on examination of the Veteran's feet, found no evidence of swelling, increased heat or erythema, or tenderness to palpation. The November 2000 examiner noted that she could stand on her toes and heels with mild discomfort and the February 2002 VA examiner noted that the Veteran had full range of motion in both feet and ankles and that there were no signs of pathology. November 2000 X-ray studies of both feet were negative for any abnormalities. Likewise private October 2004 X-ray studies of the feet showed no evidence of fracture, tumor or congenital abnormality. An October 2006 private treatment record found pain to palpation of the plantar-medial heel bilaterally with an assessment of calcaneal spur that was determined to be moderate in severity. Although VA and private treatment records during this period do intermittently note calluses on the feet, several specifically identify the calluses as being located on her toes and associated with hammertoe and bunion deformities which a May 2011 VA orthopedic examiner later found to be unrelated to her plantar fasciitis. Likewise, while the Veteran has indicated that her foot pain is accentuated by use, the medical evidence during this period shows that her bilateral plantar fasciitis was no more than moderate in severity during this period. As there is no objective evidence of marked deformity, pain on manipulation, swelling or callosities associated with her plantar fasciitis and evidence of no more than moderate disability, the preponderance of the evidence is against the claim for a disability rating in excess of 10 percent for bilateral plantar fasciitis; there is no doubt to be resolved; and a rating in excess of 10 percent prior to February 27, 2007, is not warranted. Since February 27, 2007 The February 27, 2007, VA orthopedic examination report shows that the Veteran reported she experienced pain in both feet and swelling of the entire foot. She also complained of weakness, heat, redness, stiffness, fatigability and a lack of endurance in both feet with flare-ups occurring on at least a weekly basis. She also reported having cramps. The Veteran was observed to have a severely antalgic gait with short shuffling steps. Examination revealed objective evidence of painful motion, severe tenderness, instability, and weakness in both feet with no objective evidence of swelling. Abnormal weight bearing in both feet was evidenced by callosities and unusual shoe wear patterns. There was pain on manipulation in both feet. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones, with normal alignment of the forefoot and mid foot in both feet. The Veteran had normal left foot alignment of the Achilles, but moderate pronation. There was evidence of inward bowing of the Achilles with both non weight bearing and weight bearing in the right foot that was correctable with an orthotic. There was mild right foot pronation. The weight bearing line was medial to great toe in the right foot and over the great toe in the left foot. There was evidence of severe muscle atrophy in both feet. There was no spasm with repeated use of the Achilles tendon. The assessment was severe bilateral plantar fasciitis. Subsequent private treatment records show ongoing treatment for bilateral plantar fasciitis in May, July and August 2007, noted to be moderate in May and July 2007, and as improving in August 2007. A May 2011 VA examination of the Veteran's feet shows she complained of pain in both feet with walking and standing and also of swelling in both feet with walking and standing. She did not identify symptoms of redness, heat, stiffness, fatigability, weakness or lack of endurance for either foot. She wore shoe inserts that had fair efficacy. There was objective evidence of tenderness along the plantar fascia of both feet and evidence of abnormal weight bearing as evidenced by callosities. There was no evidence of malunion or nonunion of the tarsal or metatarsal bone, or other foot deformities. There was no evidence of any muscle atrophy. The Veteran had an antalgic gait. The examiner found no functional limitation of the range of motion of the subtalar or ankle joints in either foot, noting that the Veteran had adequate dorsiflexion, but that she was disabled by pain. The position of her feet affected her gait and, while it would affect her in physical employment, would not affect sedentary employment. Although the Veteran has continued to complain of severe foot pain, the medical evidence since February 27, 2007, shows that her bilateral plantar fasciitis is no more than severe during this period. There is no objective evidence of marked pronation, marked inward displacement or spasm of the tendo achillis on manipulation. While severe tenderness was noted during the February 2007 VA examination, subsequent private treatment records and the May 2011 VA examination report do not show evidence of extreme tenderness of the plantar surfaces of her feet. The preponderance of the evidence is against the claim for a disability rating in excess of 30 percent for bilateral plantar fasciitis for this period; there is no doubt to be resolved; and a rating in excess of 30 percent since February 27, 2007, is not warranted. Residuals of a Left Pectoral Muscle Strain The Veteran's service-connected residuals of a left pectoral muscle strain are currently rated by analogy under muscle Diagnostic Code 5302 for Group II muscles. The function of Muscle Group II is the depression of arm from vertically overhead to hanging at side (the extrinsic muscles of the shoulder girdle involved are the Pectoralis major II (costosternal); latissimus dorsi and teres major (teres major, although technically an intrinsic muscle, is included with latissimus dorsi). This muscle group also allows for the downward rotation of scapula using the pectoralis minor; and the rhomboid, which are also extrinsic muscles of the shoulder girdle; and acts with Group III in forward and backward swinging of the arm. Under Diagnostic Code 5302, a 0 percent evaluation is warranted for a slight muscle disability; a 10 percent evaluation is warranted for moderate muscle disability; and a 20 percent evaluation is warranted for a moderately severe or severe disability. 38 C.F.R. § 4.73, Diagnostic Code 5302. Diagnostic Code 5321 addresses muscle injuries to Group XXI muscles of respiration: Thoracic muscle group. The function of these muscles is for respiration. A 0 percent evaluation is warranted for a slight muscle disability; a 10 percent evaluation is warranted for moderate muscle disability; and a 20 percent evaluation is warranted for a moderately severe or severe muscle disability. 38 C.F.R. § 4.73, Diagnostic Code 5321. A muscle injury evaluation will not be combined with a peripheral nerve paralysis evaluation of the same body part unless the injuries affect entirely different functions. 38 C.F.R. § 4.55(a). For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). The type of injury associated with a slight muscle disability is a simple wound of the muscle without debridement or infection. The history with regard to this sort of injury would include service department records of superficial wound with brief treatment and return to duty, healing with good functional results and no cardinal signs or symptoms of muscle disability. Objective findings should include minimal scar, no evidence of fascial defect, atrophy, or impaired tonus and no impairment of function or metallic fragments retained in muscle tissue. 38 C.F.R. § 4.56(d)(1). The type of injury associated with a moderate muscle disability is a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. A history with regard to this type of injury should include service department evidence or other evidence of in-service treatment for the wound and consistent complaints of one or more of the cardinal signs and symptoms of muscle disability, particularly lowered threshold of fatigue after average use affecting the particular functions controlled by the injured muscles. Objective findings should include entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue and some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). The Veteran's service treatment records show that she was intermittently treated for chest wall pain as early as February 1983, that was later attributed to a left pectoralis muscle strain in August 1984. During the pendency of the Veteran's appeal, VA and private treatment records show she intermittently complained of chest wall pain diagnosed as chest wall syndrome or costochondritis. A November 2000 VA examination notes the Veteran's complaints of intermittent exacerbations of pain on the left side of her chest in the costosternal area or sternal border area. Examination revealed tenderness to palpation along the costosternal border to the left. The Veteran had full range of motion in both upper extremities with some discomfort. A February 2002 VA examiner found mild tenderness to palpation over the 3rd and 4th ribs with full range of motion of the left shoulder. The examiner found no significant pathology on clinical or radiographic examination of the ribs or costochondral joints. A November 2004 VA neurological examiner, found chest wall muscle tenderness on palpation, assessed as moderately severe pain. However, a December 2004 VA orthopedic examiner, while noting chest wall tenderness, observed the Veteran had normal strength and function in the left pectoralis major muscle. The examiner opined that tenderness in the chest wall did not necessarily mean there was any pathology and opined that the injury to the pectoralis major had completely healed as shown on an earlier CT scan. During a May 2011 VA orthopedic examination, the Veteran complained of on and off chest pain with no recent treatment, incapacitating episodes or flare-ups. She denied any problems with repetitive use. Palpation of the left chest wall revealed no deformities, with complaints of pain with deep palpation over the sternum. Motor strength of the pectoralis major muscle was 5/5 and there was no muscle atrophy. Deep respirations were unhindered and there were no chest wall deformities. There was no objective or subjective signs of pain with deep respirations. Left shoulder forward flexion and abduction was to 180 degrees without pain. Although the Veteran subjectively complained of left chest wall pain with left shoulder range of motion testing, there was no objective sign of such. There were also no additional limitations of joint function with repetitive range of motion testing. The assessment was a normal examination of the left anterior chest wall and left pectoralis major muscle. Although the Veteran has complained of intermittent chest wall pain during the pendency of her claim, the medical evidence, with the exception of the November 2004 VA neurological examination, shows that her residuals of a left pectoral muscle strain cause no more than slight impairment to either muscle groups II or XXI. There is no objective evidence of any loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue. While moderately severe pain was noted during the November 2004 VA examination, the subsequent December 2004 VA examination report showed no associated functional limitations. Likewise, the May 2011 VA examination shows there are no functional limitations to the respiratory muscles. The preponderance of the evidence is against the claim for a disability rating in excess of 0 percent for residuals of a left pectoral muscle strain; there is no doubt to be resolved; and a rating in excess of 0 is not warranted. The evidence does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned ratings with the established criteria found in the rating schedule shows that the rating criteria reasonably describes the Veteran's disability levels and symptomatology for each disability. As such, it cannot be said that the available schedular evaluations are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). A claim for a total evaluation due to individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board has jurisdiction to consider the Veteran's possible entitlement to TDIU rating when the issue is raised by an assertion or is reasonably indicated by the evidence and is predicated at least in part on the severity of the service-connected disability in question, regardless of whether the RO has expressly addressed this additional issue. During the pendency of this appeal, TDIU has been awarded effective November 24, 2003, and the Veteran has not appealed this determination. ORDER Entitlement to service connection for a respiratory disability is denied. Entitlement to an initial 40 percent disability rating, and no more, for Raynaud's syndrome, from October 19, 2000, to November 18, 2012, is granted. Entitlement to an initial disability rating in excess of 40 percent for Raynaud's syndrome, from November 19, 2012, is denied. Entitlement to a disability rating in excess of 10 percent for bilateral plantar fasciitis, prior to February 27, 2007, is denied. Entitlement to a disability rating in excess of 30 percent for bilateral plantar fasciitis, since February 27, 2007, is denied. Entitlement to a disability rating in excess of 0 percent for residuals of a left pectoral muscle strain is denied. REMAND The case was previously remanded in April 2011, in part, to afford the Veteran another VA examination to determine whether she had a current generalized joint condition that was independent of or related to Raynaud's syndrome, to include scleroderma or CREST syndrome. For all identified conditions, the examiner was to provide an opinion as to whether it was at least as likely as not that the disability was caused or aggravated by the Veteran's service or a service-connected disability. Pursuant to the April 2011 Board remand, the Veteran underwent a VA rheumatoid examination in October 2012. Although the examiner diagnosed arthralgia and opined that it was unrelated to her Raynaud's syndrome, he did not provide an opinion as to whether it was at least as likely as not caused or aggravated by service or a service-connected disability as directed. With regard to the Veteran's claim for service connection for a heart condition, although service treatment records indicate she was treated intermittently for noncardiac chest pain associated with a pectoralis muscle strain or costochondritis, on one occasion, in August 1984, she was evaluated for atypical chest pain with episodes of trigeminy. An EKG was abnormal with sinus bradycardia and nonspecific ST and T changes. However, a consultation report shows benign unifocal PVC's with a benign cardiac examination. A November 1992 VA examination, conducted just one year and one month after her discharge from service notes her complaints of "infraclavicular pain" and the examiner diagnosed atypical chest pain. The examination report notes that an EKG, while showing normal sinus rhythm, also indicated possible left atrial enlargement. The Veteran has been diagnosed with aortic insufficiency and coronary artery disease since March 2000. A February 2002 VA cardiac examination report did not address the abnormal 1984 and 1992 EKG studies and did not provide an opinion as to whether any current cardiac disability had its onset in service or is otherwise etiologically linked to the Veteran's service. Consequently, the record still does not contain sufficient medical evidence to adequately adjudicate the claims for service connection for generalized arthritic and heart conditions. Another remand is necessary to provide the VA physician who conducted the October 2012 rheumatoid examination (or, alternatively, another appropriate clinician) the opportunity to review the Veteran's claims file in its entirety and provide an opinion with a detailed supportive rationale regarding the initial onset of the Veteran's currently diagnosed arthralgia. Likewise, the Veteran must be provided another VA cardiac examination to determine whether any currently diagnosed cardiac disability had its onset in service or is otherwise etiologically linked to service with consideration of the reported abnormal EKGs in August 1984 and November 1992. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claim file copies of all of the Veteran's VA treatment records not already in the claim file. 2. Return the claim file to the October 2012 VA examiner, if available, to include a copy of this remand. The entire claim file must be reviewed by the examiner. Based on review of all the evidence of record, the examiner must provide an opinion regarding whether it is at least as likely as not that the Veteran's currently diagnosed arthralgia had its onset in service or is aggravated by the Veteran's service-connected Raynaud's syndrome or causally related to or aggravated by any other service-connected disabilities. A clear rationale for all opinions must be provided with a discussion of the facts and medical principles involved. If the October 2012 VA examiner is unavailable, schedule the Veteran for another examination by an appropriately qualified medical professional who is to examine the Veteran and provide the above opinions. The Veteran is hereby advised that failure to report for any scheduled VA examination without good cause shown may have adverse effects on her claim. 3. Schedule the Veteran for a VA cardiac examination by an appropriate medical professional to determine the current nature and etiology of any heart condition found to be present. The entire claims file (i.e., the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All necessary studies or tests should be accomplished. Based on review of all the evidence of record, the examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's current aortic insufficiency and CAD are related to service. A clear rationale for all opinions must be provided with a discussion of the facts and medical principles involved. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Review the claims file to ensure that all of the foregoing development has been completed, and arrange for any additional development indicated. Then readjudicate the issues on appeal. If either benefit remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and her representative an appropriate period of time to respond. The case is to then be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs