Citation Nr: 1310242 Decision Date: 03/26/13 Archive Date: 04/02/13 DOCKET NO. 06-16 401 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to a disability rating higher than 10 percent for plantar fasciitis and plantar calcaneal heel spur syndrome of the right heel. 2. Entitlement to a disability rating higher than 10 percent for plantar fasciitis and plantar calcaneal heel spur syndrome of the left heel. WITNESSES AT HEARING ON APPEAL The Appellant and his spouse ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran had active military service from August 1992 to July 1999. This appeal to the Board of Veterans' Appeals (Board) is from a December 2004 decision of a Department of Veterans Affairs (VA) Regional Office (RO). As support for his claims, the Veteran and his wife testified at a videoconference hearing in July 2010 before the undersigned Veterans Law Judge of the Board. The Board subsequently, in September 2010, remanded the claims to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development and consideration, including especially obtaining records from the Social Security Administration (SSA). These records were obtained and the claims were again before the Board in July 2012, whereupon the Board again remanded them for still further development, this time including obtaining any additional outstanding private treatment records and having the Veteran undergo a VA examination reassessing the severity of his disabilities. To this end, he was contacted later in July 2012 and requested to provide any additional information regarding private treatment providers. He responded with a list of VA treatment providers, but did not indicate he also had been receiving private treatment. He was provided a VA examination in September 2012 concerning his claims, and the findings permit the Board to properly evaluate his disabilities and determine whether higher ratings are warranted. Therefore, the Board finds there has been compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). FINDING OF FACT Throughout the appeal the Veteran's bilateral foot disability has been manifested by subjective complaints of pain, burning, swelling and some limitation of motion. CONCLUSION OF LAW The criteria for ratings higher than 10 percent for the bilateral foot disability have not been met at any time during the appeal period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION In deciding these claims, the Board has reviewed all of the evidence in the Veteran's claims file, both in his physical claims file as well as his electronic ("Virtual VA") file. Although the Board has an obligation to review the entire record, the Board does not have to discuss each and every piece of evidence reviewed, certainly not in exhaustive detail. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). He thus must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to him). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, this doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists that does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The notice requirements were met in this case by way of a letter sent to the Veteran in July 2004. The letter advised him of the information and evidence not of record necessary to substantiate his claims and of his and VA's respective obligations in obtaining specified types of evidence that would help to substantiate his claims. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). The letter also advised him of how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). During the pendency of the appeal, the VCAA notice requirements were interpreted as follows. For an increased compensation claim, the Veteran must be notified that he must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on his employment and daily life. Additionally, he must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from 0 percent, i.e., noncompensable, to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (Vazquez-Flores I). He was notified of these changes in May 2008. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court) subsequently held that the notice described in 38 U.S.C. § 5103(a) need not be Veteran specific, i.e., it need not notify the Veteran of alternative diagnostic codes, and that that the statutory scheme does not require 'daily life' evidence for proper claim adjudication. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (Vazquez-Flores II) (vacating and remanding in part Vazquez-Flores I). Most recently, the lower U.S. Court of Appeals for Veterans Claims (Court/CAVC) clarified that the notice must advise the Veteran to submit evidence demonstrating the effect that the worsening of his disability has on his employment. Vazquez-Flores v. Shinseki, No. 05-0355, (U.S. Vet. App. October 22, 2010) (Vazquez-Flores III). The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Ideally, the notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). That was done in this case. As concerning the concomitant duty to assist the Veteran with his claim, his service treatment records (STRs) and VA treatment records are in the file. As already alluded to, rather than specifying any private treatment, apparently because there has not been any relevant to these claims, he provided instead a list of VA treatment providers in December 2012. And as noted in the January 2013 supplemental statement of the case (SSOC), these VA treatment records since have been obtained and associated with the claims file for consideration. 38 C.F.R. § 3.159(c)(2). He has not indicated there are any additional outstanding records needing to be obtained. The duty to assist with obtaining relevant medical records therefore has been satisfied. The duty to assist also includes, when appropriate, the obligation to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). And where the evidence of record does not reflect the current state of his disability, a VA examination must be performed reassessing its severity. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a). The Veteran was provided multiple VA medical examinations, most recently in September 2012 to determine the severity of his bilateral foot disability. These examinations and the opinions provided based on the findings were rendered by medical professionals following a thorough examination and interview of the Veteran and review of the claims file. The examiners obtained an accurate history. They also provided discussion of the rationale for their conclusions reached. There is no suggestion there has been a material change in the severity of these disabilities since they were last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the mere passage of time since an otherwise adequate VA examination was performed. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (April 7, 1995). Therefore, the Board finds that the examinations are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (requiring that VA ensure examinations and opinions obtained are adequate). In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the claims is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Whether Higher Ratings are Warranted Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating is assigned 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. His entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as in the present case, entitlement to compensation already has been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all of the evidence of record, the more critical evidence ("relevant temporal focus") is that generated during the appeal period, which in actuality is from one year prior to receipt of these increased-rating claims. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). See also Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. May 20, 2010) (explaining that the legislative history of 38 U.S.C.A. § 5110(b)(2) was to provide Veterans a one-year grace period for filing a claim following an increase in the severity of a service-connected disability). If it was factually ascertainable that an increase in rating was warranted during that immediately preceding year, then the effective date of the higher rating may go back to the date when this increase was shown, even if preceding the actual claim. See Harper v. Brown, 10 Vet. App. 125, 126 (1997). Also, if since one year immediately preceding the claim there have been occasions when the disability has been more severe than at others, then the rating for the disability must be "staged" to compensate the Veteran for this variance. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis, so must be considered when raised by the claimant or reasonably by the record, even in non-arthritis contexts. Burton v. Shinseki, 25 Vet. App. 1 (2011). If, however, a Veteran already has the maximum rating assignable based on limitation of motion, it is not necessary to consider these provisions. Johnston v. Brown, 10 Vet. App. 80 (1997). Moreover, the Court has clarified that, although pain may be a cause or manifestation of functional loss, pain itself does not constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id.; see 38 C.F.R. § 4.40. Turning now to the facts and circumstances of this particular case. The Veteran contends that each of his feet and heels should be assigned an evaluation higher than 10 percent because this existing rating for each foot and heel does not contemplate the extent of his impairment. His bilateral (right and left) foot and heel disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5284. Under this Diagnostic Code, moderate foot injuries are rated as 10-percent disabling. Moderately-severe foot injuries are rated as 20-percent disabling. Severe foot injuries are rated as 30-percent disabling. A Note to this Diagnostic Code states that, with actual loss of the use of the foot, an even higher 40 percent evaluation should be assigned. VA regulation provides that, where an unlisted condition is encountered, it may be rated under the DC for a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. See 38 C.F.R. § 4.20. Here, having considered the evidence of record, the Board finds that the Veteran is not entitled to ratings higher than 10 percent for his bilateral foot disability at any point during the appeal period. He had a VA compensation examination in August 2004. He reported pain and stiffness while standing or walking. An examination of his ankles revealed no deformity, however, although examination of his feet revealed tenderness bilaterally and some deformity of marked pronation. There were no heel spurs shown on X-ray. During his subsequent July 2006 VA examination, he indicated his plantar fasciitis was not relieved by physical therapy and foam orthotics. He was then currently taking pain medication, without improvement. He was using a cane at the time of that examination, which he explained was needed due to his foot problems. He did not have pain on manipulation of either foot, however, but he was tender to palpation about the plantar medial calcaneal tubercle regions bilaterally. There was no range of motion impairment in either foot. A June 2009 VA X-ray showed minimal degenerative joint disease, i.e., arthritis. In an August 2009 VA treatment record the Veteran reported bilateral foot pain that was worse in the morning. His then current pain level was 4/10 in severity. The evaluating physician explained that the heel spurs were not causing pain, but that the heel pain instead was a byproduct of downward force over the arch due to lack of arch support. The Veteran had another VA examination in December 2009. His then current complaints were burning, shooting pain along the plantar surface bilaterally. He also complained of weakness and the inability to walk barefoot. On objective physical examination, there was no gross deformity or swelling of either foot. There was tenderness and pain associated with range-of-motion testing in the right foot. There was no callus formation or tissue loss of either foot. The examiner could not offer an opinion regarding additional pain on flare ups without resorting to mere speculation. There was minimal degenerative joint disease on X-ray. The examiner stated there had been no periods of incapacitation or recommended bed rest within the past 12 months. The examiner found no impediment to activities of daily living. The Veteran contrarily testified during his July 2010 videoconference hearing before the Board that there are days when he is unable to get out of bed because of his foot pain. He called the VA Medical Center in February 2012 reportedly needing an injection for his bilateral heel pain because his then current pain medication reportedly was ineffective. He also received a medical examination for his feet in June 2012 when it was noted that he used a cane to help him walk. On X-ray there was some evidence of minimal hallux valgus bilaterally. The June 2012 examiner stated that the Veteran's foot disabilities make him unable to stand or walk for long periods of time. During his most recent VA examination in September 2012, he again complained of sharp burning pain in his heels and feet and noted the pain came on even while he was just sitting. He also reported swelling in his ankles and inability to stand for over 10 minutes or wear shoes for more than 2 hours. The examiner noted an intentional gait with bilateral limping. He noted the Veteran's use of crutches to rise up from a chair. The Veteran had complaints of tenderness at the anterior lateral joint line and lateral foot, but no swelling or discoloration. There was also subjective tenderness at the origin of the plantar fascia of the calcaneus. The examiner reviewed X-rays of the feet and found no significant abnormalities of either ankle. There also were no significant degenerative or acute skeletal abnormalities or soft tissue findings detected. He diagnosed plantar fasciitis and plantar calcaneal heel spur syndrome bilaterally. He found the subjective findings indicated more disability than the objective findings, and therefore, an additional bone scan was ordered. This was completed in October 2012 and showed just relatively mild bilateral increased uptake at the insertion of the plantar fascia consistent with just relatively mild chronic stress changes. The examiner's addendum elaborated that, while there were mild stress changes at the origin of the plantar fascia, there were no changes within the plantar fascia itself. Although the record on appeal is replete with the Veteran's complaints of bilateral heel and foot pain, it has not been shown he has consequent functional impairment to a level greater than 10 percent. As already explained, 38 C.F.R. §§ 4.40, 4.45 and 4.59 allow for consideration of functional loss due to pain or painful motion, weakness or weakened movement, premature or excess fatigability, and incoordination causing additional disability beyond that reflected in the range-of-motion measurements. DeLuca, supra. The Veteran's ankle range of motion was not limited by pain, fatigue, weakness, lack of endurance, or incoordination during his August 2004 VA examination. The December 2009 VA examiner noted some fatigue and weakness in the feet, but no lack of endurance or incoordination. The September 2012 VA examiner found the Veteran's range of motion was limited by pain, fatigue, weakness, or lack of endurance, but it has not been shown additionally that this is to an extent required for a rating higher than 10 percent. Having arthritic pain only entitles him to at most a 10 percent rating under 38 C.F.R. § 4.71a, DC 5003, if, as here, there is indication of X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, but not also occasional incapacitating exacerbations. He merely saying that his pain sometimes causes him to stay in bed is not equivalent or tantamount to these required incapacitations. The Board also has considered whether the application of still other diagnostic codes provides for the assignment of higher ratings. He has not been diagnosed with a majority of the foot disabilities listed in 38 C.F.R. § 4.71a. The examiners have specifically found no evidence of weak foot, claw foot, metatarsalgia, hallux rigidus, hammer toe, or malunion or nonunion of the tarsal or metatarsal bones. Therefore, DCs 5277-5279, and 5281-5283 are not for application. The August 2004 VA examiner noted pes planus (flat feet) and hallux valgus. The September 2012 examiner confirmed the Veteran has pes planus, but went on to explain that it was unrelated to his military service, instead hereditary. See also July 2006 VA examination report. In any event, although the Veteran has diagnoses of pes planus and hallux valgus, the maximum rating available for hallux valgus is 10 percent and therefore would not result in a higher rating. Moreover, VA cannot twice compensate him for the same symptoms like heel and foot pain that are attributable both to his plantar fasciitis and plantar calcaneal heel spur syndrome and his hallux valgus and pes planus, as this would overcompensate him for his actual impairment of earning capacity and violate VA's anti-pyramiding regulation - 38 C.F.R. § 4.14. His pes planus also has not been determined to be a service-connected disability, including secondarily by way of his plantar fasciitis and plantar calcaneal heel spur syndrome, as either caused or aggravated by this service-connected disability. To the contrary, it has been determined to be hereditary. See, e.g., September 2012 VA examination report. Accordingly, DCs 5276 and 5280 also do not apply. Congenital and developmental defects are not "diseases or injuries" within the meaning of applicable legislation for VA disability compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9. VA's General Counsel has held, however, that service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin if the evidence as a whole shows that the manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303(c), 3.306. The Court indicated that support for this position could be found in VA's regulations, themselves, noting that sickle cell anemia, although a familial disease, was included for rating purposes in the Schedule for Rating Disabilities (Rating Schedule). Also according to the VA General Counsel's opinion, although service connection cannot be granted for a congenital or developmental defect, such a defect can be subject to superimposed disease or injury, and if that superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90. Thus, to allow for proper legal analysis of a Veteran's claim as it pertains to the claimed disability, medical clarification may be necessary as to whether the Veteran's condition is a congenital or developmental "disease" or "defect." See id; Quirin v. Shinseki, 22 Vet. App. 390, 395 (2009). If the claimed disorder is a disease, an opinion may be required as to whether it was as likely as not aggravated by the Veteran's period of active service beyond its natural progression. If the claimed disorder instead is a defect, an opinion may be required as to whether it was as likely as not subject to a superimposed disease or injury during military service that resulted in disability apart from the congenital or developmental defect. The VA examiners have not indicated either as concerning the Veteran's pes planus. The Board also has considered the Veteran's and his wife's lay statements and testimony regarding the nature and severity of his bilateral foot and heel symptoms. Their opinions and observations, 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); 38 C.F.R. § 3.159(a)(1) and (2). That said, they are certainly competent to report that his symptoms are worse and that a higher disability rating is warranted. Layno v. Brown, 6 Vet. App. 465, 470 (1994). But even still, they are not competent to identify a specific level of disability in relation to the criteria of the applicable diagnostic codes. This comment concerning the nature and extent of his service-connected bilateral heel and foot disability has been provided by VA compensation examiners and others who have had occasion to evaluate him during the pendency of this appeal. Their objective medical findings directly address the criteria under which his disability is rated. And these medical records and evaluation reports, not just his and his wife's lay testimony, must be considered collectively in assessing whether his existing ratings are still appropriate. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). For the reasons and bases discussed, the Board finds that the Veteran is not entitled to higher ratings for his bilateral foot disability at any point during the appeal period. As the preponderance of the evidence is against his claims, the benefit-of-the-doubt rule does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Extra-Schedular Consideration There is no evidence of exceptional or unusual circumstances to warrant referring these claims for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional 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 extra-schedular rating under 38 C.F.R. § 3.321(b)(1). The Board finds no such evidence in this particular instance, however. The Veteran's complaints related to his bilateral foot disability are considered under the appropriate diagnostic codes. His primary symptoms are chronic pain, swelling, burning, and some limitation of motion. But all of his symptoms are accounted for in the regular schedular rating criteria. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule 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. Indeed, in Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993), the Court reiterated this, noting the disability rating, itself, is recognition that industrial capabilities are impaired. As the assigned schedular evaluation for the service-connected bilateral foot disability is adequate, referral for an extra-schedular rating is unnecessary. Thun, supra. Furthermore, there is no evidence of any exceptional or unusual circumstances, such as frequent hospitalizations, suggesting he is not adequately compensated for this disability by the regular Rating Schedule. His evaluation and treatment for this disability has been entirely on an outpatient basis, not as an inpatient, much less frequent inpatient. So extra-schedular referral is not warranted under the circumstances presented. See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER The claim of entitlement to a disability rating higher than 10 percent for plantar fasciitis and plantar calcaneal heel spur syndrome of the right heel is denied. The claim for entitlement to a disability rating higher than 10 percent for plantar fasciitis and plantar calcaneal heel spur syndrome of the left heel is denied. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs