Citation Nr: 1311375 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 08-06 625 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine THE ISSUE Entitlement to an initial disability rating greater than 10 percent for the service-connected bilateral ankle and right great toe degenerative changes, plantar fasciitis of the feet, and a history of fracture of the right foot proximal second metatarsal. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Paul S. Rubin, Counsel INTRODUCTION The Veteran had active duty service in the U.S. Navy from November 1985 to November 2005. The issue on appeal initially came to the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision issued by the RO in Winston-Salem, North Carolina, because of the Veteran's participation in the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. Ultimately, the RO in Togus, Maine, has jurisdiction of the case, as it is closest to the Veteran's residence. In August 2011, the Board remanded the case to the RO for additional development. After completion of this development by the RO, the case has been returned to the Board for the purpose of appellate disposition. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The service-connected bilateral degenerative arthritis of the right and left ankle presents only "moderate" limitation of motion when considering pain and other factors of functional loss; ankylosis is not demonstrated. 2. The service-connected plantar fasciitis of the feet, right great toe degenerative changes, and a history of fracture of the right foot proximal second metatarsal are productive of no more than "moderate" impairment due to pain, occasional use of a brace, use of orthotics, necessity for prescription medication, difficulty standing or walking for extended periods of time, and other functional loss. CONCLUSIONS OF LAW 1. The criteria for the assignment of a separate initial disability rating of 10 percent, but no greater, for the service-connected RIGHT ankle degenerative arthritis are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.21, 4.27, 4.40, 4.45, 4.59, 4.71a including Diagnostic Codes 5003, 5271 (2012). 2. The criteria for the assignment of a separate initial disability rating of 10 percent, but no greater, for the service-connected LEFT ankle degenerative arthritis are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.21, 4.27, 4.40, 4.45, 4.59, 4.71a including Diagnostic Codes 5003, 5271 (2012). 3. The criteria for the assignment of a separate initial disability rating of 10 percent, but no greater, for the service-connected RIGHT foot plantar fasciitis are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.20, 4.21, 4.40, 4.45, 4.59, 4.63, 4.71a including Diagnostic Code 5284 (2012). 4. The criteria for the assignment of a separate initial disability rating of 10 percent, but no greater, for the service-connected LEFT foot plantar fasciitis are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.20, 4.21, 4.40, 4.45, 4.59, 4.63, 4.71a including Diagnostic Code 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist For the increased initial rating issue for the ankles and feet, review of the claims folder reveals compliance with the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The duty to notify was accomplished by way of VCAA letters from the RO to the Veteran dated in September 2005, November 2006 and August 2011. In any event, since the Board is granting the increased initial rating issue, there is no need to discuss whether there has been compliance with the notice and duty to assist provisions of VCAA because even if, for the sake of argument, there has not been, this is inconsequential and, therefore, at most harmless error. See 38 C.F.R. § 20.1102; Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). As pertinent to this point, a Veteran is presumed to be seeking the highest possible rating, unless he expressly indicates otherwise. AB v. Brown, 6 Vet. App. 35, 39 (1993). Here, the Veteran has requested separate 10 percent ratings for each foot / ankle. See September 2011 and June 2012 Veteran's statements. In the present decision, the Board is granting beyond what the Veteran has requested - specifically, the Board is granting four separate 10 percent ratings, accounting for distinct bilateral ankle and foot pathology. Therefore, the appeal is completely favorable to the Veteran, such that a full analysis of the duties to notify and assist for this issue is not necessary. See again 38 C.F.R. § 20.1102 (harmless error); Bernard, 4 Vet. App. at 392-94. Governing Laws and Regulations for Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 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 coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran's bilateral ankle and bilateral foot disabilities are currently evaluated as a combined 10 percent disabling under Diagnostic Code 5003, degenerative arthritis. 38 C.F.R. § 4.71a. The Veteran has appealed the original February 2006 rating decision that granted service connection at 10 percent. This could result in "staged ratings" based upon the facts found during the period in question. Fenderson v. West, 12 Vet. App. 119, 126 (1999). That is to say, the Board must consider whether there have been times since the effective date of his award when his disabilities have been more severe than at others. Id. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). With any form of arthritis, painful motion is an important factor of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Moreover, the Court has held that the application of 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. When § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, VA should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37; Layno v. Brown, 6 Vet. App. 465, 469 (1994). Analysis - Increased Rating for the Bilateral Ankles In general, evaluation of the same disability or the same manifestations of disability under multiple diagnoses (i.e., pyramiding) is to be avoided. 38 C.F.R. § 4.14. Where, however, separate and distinct manifestations have arisen from the same injury, separate disability ratings may be assigned where none of the symptomatology of the conditions overlaps. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board emphasizes that the critical inquiry in making such a determination is whether any of the disabling symptomatology is duplicative or overlapping. The Veteran is entitled to a combined rating where the symptomatology is distinct and separate. Id. In this regard, the Veteran is currently service-connected for bilateral ankle and right great toe degenerative changes, bilateral plantar fasciitis of the feet, and a history of fracture of the right foot proximal second metatarsal. Clearly, his service-connected disabilities affect multiple joints. Regardless, the Board sees that the RO has assigned a single 10 percent disability rating, despite the Veteran having separate and distinct bilateral foot and ankle disabilities, to include arthritis. Under 38 C.F.R. § 4.45(f), for the purpose of rating disability from arthritis, the ankle is a considered major joint. In addition, the interphalangeal, metatarsal and tarsal joints of the lower extremities are considered groups of minor joints, ratable on a parity with major joints. In other words, the Veteran has distinct service-connected injuries to separate joints - the ankles and the feet. As such, the Board will consider whether the Veteran is entitled to separate ratings for the ankles and the feet. The Veteran's service-connected bilateral ankle arthritis is currently evaluated as 10 percent disabling under Diagnostic Code 5003, degenerative arthritis. 38 C.F.R. § 4.71a. Pursuant to Diagnostic Code 5003, degenerative arthritis is rated based on limitation of motion of the affected part. When limitation of motion is noncompensable, Diagnostic Code 5003 provides that a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Read together, Diagnostic Code 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis, which is established by X-ray, is deemed to be limitation of motion and warrants the minimum rating for a joint, even if there is no actual limitation of motion. Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). Under Diagnostic Code 5003, in the absence of limitation of motion (or painful motion), a 10 percent rating is in order with X-ray evidence of involvement of two or more major joints or two or more minor joint groups; a 20 percent rating is appropriate with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a. See also 38 C.F.R. § 4.45(f) (for the purpose of rating disability from arthritis, the ankle is considered a major joint, while the interphalangeal, metatarsal and tarsal joints of the lower extremities are considered groups of minor joints, ratable on a parity with major joints. The assignment of a particular diagnostic code 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 diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Upon review of the evidence, the Board finds that a more appropriate evaluation for the Veteran's bilateral ankle degenerative changes would be under Diagnostic Code 5271, limitation of ankle motion. 38 C.F.R. § 4.71a. The Veteran has credibly reported and the medical evidence of record establishes painful, compensable limitation of motion and limited functional loss for both ankles upon prolonged walking or upon exercise, such that Diagnostic Code 5271 is applicable. Under Diagnostic Code 5271, a 10 percent evaluation is assigned when there is moderate limitation of ankle motion. A maximum 20 percent rating is awarded for marked limitation of ankle motion. Normal range of motion for the ankle is dorsiflexion to 20 degrees and plantar flexion to 45 degrees, as set forth at 38 C.F.R. § 4.71, Plate II. The words "moderate" or "marked" are not defined in Diagnostic Code 5271. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decision is "equitable and just." 38 C.F.R. § 4.6. The evidence of record supports separate, initial 10 percent ratings for the right and left ankle under Diagnostic Code 5271. 38 C.F.R. § 4.7. In making this determination, after reviewing the medical evidence and credible lay evidence of record, "moderate" limitation of bilateral ankle motion is revealed when considering the Deluca factors of functional loss. In the November 2006 Notice of Disagreement (NOD), the Veteran credibly reported that he had to give up running, in part, due to his bilateral ankle condition. In his February 2008 Substantive Appeal, the Veteran credibly indicated that excessive walking or running caused ankle pain. He stopped any weight-bearing activities for prolonged periods in order to avoid the necessity of cortisone shots. For both ankles, the October 2011 VA examiner documented 30 degrees of plantar flexion, and only 0 degrees of dorsiflexion, with consideration of pain on motion, as well as three repetitions. The Veteran credibly reported routine bilateral ankle pain. The Veteran's functional loss included pain on movement, tenderness, and less movement than normal. Although a September 2005 VA pre-discharge examiner assessed normal ankle motion, this was several months prior to discharge from service. Therefore, based on credible allegations from the Veteran as well as objective medical evidence of limitation of ankle motion with functional loss, the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 and the Deluca case have been considered, providing a basis for assigning separate, initial 10 percent ratings for the right and left ankle under Diagnostic Code 5271. There is no basis, however, for increasing the rating beyond the 10 percent level for each ankle. 38 C.F.R. § 4.7. The October 2011 VA examiner observed normal strength in each ankle, no laxity, no ankylosis, no need for assistive devices, no loss of use of the ankles, and no impact on the Veteran's ability to work. Simply stated, the medical and lay evidence of record is not indicative of a rating beyond 10 percent for each ankle under Diagnostic Code 5271, as "marked" limitation of motion is not demonstrated. The Veteran is already adequately compensated for the 30 degrees of plantar flexion and 0 degrees of dorsiflexion. In addition, other diagnostic codes for ankle disabilities that provide a rating greater than 10 percent are not more appropriate because the facts of the case do not support their application. See 38 C.F.R. § 4.71a, Diagnostic Code 5262 (impairment of the tibia and fibula), Diagnostic Code 5270 (ankylosis of the ankle), Diagnostic Code 5272 (ankylosis of the subastragalar or tarsal joint), Diagnostic Code 5273 (malunion of the os calcis or astragalus), and Diagnostic Code 5274 (astragalectomy). Therefore, these diagnostic codes will not be applied. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Accordingly, the Board finds that the evidence supports separate, initial 10 percent ratings, but no greater, for the Veteran's right and left ankle degenerative arthritis under Diagnostic Code 5271. 38 C.F.R. § 4.3. (The Board emphasizes it is replacing the previous 10 percent combined rating under Diagnostic Code 5003 with two separate 10 percent ratings for the right and left ankle under Diagnostic Code 5271). Analysis - Increased Rating for Bilateral Feet With regard to the feet, the Veteran is currently service-connected for right great toe degenerative changes, bilateral plantar fasciitis of the feet, and a history of fracture of the right foot proximal second metatarsal. As discussed in detail hereinabove, the RO previously assigned a single 10 percent disability rating under Diagnostic Code 5003 for the feet and ankles. Upon review of the evidence, the Board finds that a more appropriate evaluation for the Veteran's bilateral foot plantar fasciitis and right great toe degenerative changes would be under Diagnostic Code 5284, other foot injury. 38 C.F.R. § 4.71a (2012). The rating criteria do not have a specific diagnostic code for plantar fasciitis disability. The disorder is, therefore, rated as analogous to "other foot injuries" because the functions affected, the anatomical localization, and the symptomatology are most closely analogous to this disorder. See 38 C.F.R. § 4.20. Under Diagnostic Code 5284, a 10 percent evaluation is provided for a "moderate" foot injury. A 20 percent evaluation is provided for a "moderately severe" foot injury. A 30 percent evaluation is provided for a "severe" foot injury. The Note to Diagnostic Code 5284 indicates that a maximum 40 percent rating will be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a. The words "moderate," "moderately severe," and "severe" are not defined in Diagnostic Code 5284. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decision is "equitable and just." 38 C.F.R. § 4.6. "Loss of use of a foot" is defined as no effective function remaining other than that which would be equally well served by an amputation stump at the site of election below the knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function of balance, propulsion, etc., which could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. § 4.63. Examples under 38 C.F.R. 4.63 which constitute loss of use of a foot include extremely unfavorable ankylosis of the knee, complete ankylosis of two major joints of an extremity, shortening of the lower extremity of 3 1/2 inches or more, or complete paralysis of the external popliteal nerve and consequent footdrop. VA's Office of General Counsel has stated that Diagnostic Code 5284 is a more general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, VA's General Counsel concluded that, depending on the nature of the foot injury, Diagnostic Code 5284 may involve limitation of motion and therefore require consideration under 38 C.F.R. §§ 4.40, 4.45, and the DeLuca case. See VAOPGCPREC 9-98 (Aug. 14, 1998). Upon review of the evidence, the overall disability picture reflects that separate 10 percent ratings, but no higher, are warranted for the Veteran's right and left foot plantar fasciitis. 38 C.F.R. § 4.7. Separate ratings for each foot are warranted as Diagnostic Code 5284 does not expressly limit particular evaluations to unilateral or bilateral findings, in contrast to the diagnostic codes for flatfoot, weak foot, claw foot, hammer toes, or metatarsalgia. 38 C.F.R. § 4.71a, Diagnostic Codes 5276-5282. VA examinations, representative statements, and the Veteran's personal lay statements document bilateral plantar fasciitis that is "moderate" in severity for each foot. The Board has also factored in symptoms from the right great toe arthritis and history of fracture of the right foot proximal second metatarsal when assigning the 10 percent rating each foot. The September 2005 VA pre-discharge examiner noted that the Veteran has to receive steroid injections in his feet once a year. He experiences flare-ups upon prolonged walking or running. His flare-ups last for a day and improve with medication and rest. He has been fitted with orthotics for his service-connected plantar fasciitis. The X-ray studies revealed "moderate" degenerative changes to the first metatarsal phalangeal joint. There was also "mild" joint space narrowing. For the left foot, there was a "moderate" degree of narrowing at the first metatarsal phalangeal joint. The October 2011 VA foot examiner noted "occasional" use of a brace for the Veteran's plantar fasciitis. The Veteran reported pain at the bottom of the feet, worse for 2-3 days a week. The symptoms were worse in winter, and the feet hurt with walking or prolonged standing. Malunion of the right proximal second metatarsal bone was noted as well. This condition was "moderate" in severity according to the VA examiner. The Veteran's lay assertions also reveal subjective, yet credible complaints of pain and flare-ups for both feet related to the service-connected injuries. In a June 2012 statement the Veteran asserted daily foot pain, somewhat alleviated by prescription medication and stretching. He also reported bilateral foot pain in the November 2006 NOD and February 2008 Substantive Appeal. In increased rating claims, an appellant's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010) (noting that 38 U.S.C.A. 5103(a) requires the Secretary, for increased-rating claims, to notify the claimant that to substantiate such a claim the claimant should provide or ask the Secretary to obtain medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment) (emphasis added); Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (stating that "as a layperson, the appellant is competent to provide information regarding the visible, or otherwise observable, symptoms of disability"). The provisions of 38 C.F.R. §§ 4.40 and 4.45 and 4.59 and the Deluca case have been considered, providing a basis for assigning separate 10 percent ratings under Diagnostic Code 5284. See VAOPGCPREC 9-98 (Aug. 14, 1998). There is no basis, however, for increasing the rating beyond the 10 percent level for each foot. 38 C.F.R. § 4.7. That is, VA, private, and lay evidence of record do not meet the criteria for a "moderately severe" foot injury at the 20 percent level for either foot. The Veteran's own lay statements notably provide no basis for a 20 percent rating for either foot. The VA examiners consistently describe the Veteran's feet problems as "moderate" in severity. The Veteran wears no special shoes, does not use a cane, and does not need crutches. His gait is also normal. The provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 and the Deluca case have been considered, but do not provide a basis for assigning separate ratings greater than 10 percent under Diagnostic Code 5284 when considering limitation of motion. See VAOPGCPREC 9-98 (Aug. 14, 1998). The Veteran's bilateral foot symptoms are not "moderately severe" in nature. With regard to loss of use, medical and lay evidence of record does not show that the Veteran has actually lost the use of either the right or left foot. He is able to walk and stand, albeit with limitations, and clearly does not suffer from loss of use of either foot. The evidence demonstrates he has more function in both feet than would be served with an amputation stump. See 38 C.F.R. § 4.63. There is no evidence of ankylosis from this disability, shortening of the right or left extremity, or complete paralysis of the external popliteal nerve and consequent footdrop. Id. A higher rating therefore cannot be awarded on this basis. Furthermore, other diagnostic codes for bilateral foot disabilities are not more appropriate because the evidence of record does not support their application. See 38 C.F.R. § 4.71a, Diagnostic Code 5276 (flat foot), Diagnostic Code 5277 (weak foot), Diagnostic Code 5278 (claw foot), Diagnostic Code 5279 (Morton's disease), and Diagnostic Code 5282 (hammer toes). Although there is evidence of hallux rigidus and malunion of the metatarsal bones, this symptomatology has already been considered when awarding the separate 10 percent ratings under Diagnostic Code 5284. Manifestations of a disability under multiple diagnoses (i.e., pyramiding) is to be avoided under 38 C.F.R. § 4.14. The Board also emphasizes that Diagnostic Code 5284 is a more general diagnostic code under which a variety of foot injuries may be rated. See again VAOPGCPREC 9-98 (Aug. 14, 1998). Therefore, the Board will continue to evaluate the right and left foot disabilities under Diagnostic Code 5284 since it provides the potential for the most favorable ratings. See Butts v. Brown, 5 Vet. App. 532, 538 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Accordingly, the Board finds that the evidence supports separate, initial 10 percent ratings, but no greater, for the Veteran's right and left foot plantar fasciitis under Diagnostic Code 5284. 38 C.F.R. § 4.3. Fenderson Consideration The four separate 10 percent ratings assigned in the present case for the bilateral ankle and foot disabilities are effective throughout the entire appeal period, from December 1, 2005. It is not necessary to "stage" the Veteran's ankle and foot ratings, as his symptoms have been fairly consistent at the 10 percent level for each ankle and foot. Fenderson, 12 Vet. App. at 126. Extraschedular Consideration Finally, there is no evidence of exceptional or unusual circumstances to warrant referring the case for extraschedular consideration. 38 C.F.R. § 3.321(b)(1). Since the rating criteria reasonably describe the claimant's disability level and symptomatology for his bilateral ankle and foot disabilities, the Veteran's disability picture is contemplated by the Rating Schedule, such that the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115-116 (2008); VAOPGCPREC 6-96. The evidence fails to show anything unique or unusual about the service-connected bilateral ankle and foot disabilities that would render the schedular criteria inadequate. There are no additional symptoms of his bilateral ankle and foot disabilities that are not addressed by the Rating Schedule. The Board has considered the factors of functional loss listed in 38 C.F.R. §§ 4.40, 4.45, 4.59 and DeLuca v. Brown, 8 Vet. App. 202, 206 (1995) in determining the Veteran's four separate 10 percent schedular ratings. Moreover, to the extent that the Veteran's bilateral ankle and foot disabilities may interfere with his employability, such interference is contemplated by the schedular rating criteria. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Finally, there is no evidence or allegation of any other exceptional or unusual circumstances, such as marked interference with employment or frequent hospitalizations due to his service-connected bilateral ankle and foot disabilities, to suggest he is not adequately compensated for his disability by the regular Rating Schedule. See 38 C.F.R. § 3.321(b)(1); VAOPGCPREC 6-96. The Veteran's post-service treatment for his feet and ankles has been solely on an outpatient basis, and the October 2011 VA ankle and foot examiner opined that the service-connected ankle and foot disabilities did not impact his work. ORDER A separate initial 10 percent disability rating for the service-connected RIGHT ankle degenerative arthritis is granted, subject to the regulations controlling disbursement of VA monetary benefits. A separate initial 10 percent disability rating for the service-connected LEFT ankle degenerative arthritis is granted, subject to the regulations controlling disbursement of VA monetary benefits. A separate initial 10 percent disability rating for the service-connected RIGHT foot plantar fasciitis with arthritis is granted, subject to the regulations controlling disbursement of VA monetary benefits. A separate initial 10 percent disability rating for the service-connected LEFT foot plantar fasciitis is granted, subject to the regulations controlling disbursement of VA monetary benefits. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs