Citation Nr: 1312499 Decision Date: 04/16/13 Archive Date: 05/02/13 DOCKET NO. 09-03 414A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for skin disability, to include eczema of the neck, scalp, and hairline. 2. Evaluation of bilateral pes planus, rated as noncompensable. 3. Evaluation of residuals of right foot surgery with bunions and hallux valgus, rated as 10 percent disabling prior to June 19, 2009 and from December 1, 2009. 4. Evaluation of residuals of left foot surgery with bunions and hallux valgus, rated as 10 percent disabling. 5. Evaluation of scar of the right foot, residual of bunionectomy, rated as noncompensable. 6. Evaluation of scar of the left foot, residual of bunionectomy, rated as noncompensable. 7. Evaluation of rheumatoid arthritis, rated as 10 percent disabling. 8. Entitlement to a separate compensable rating for degenerative arthritis of the right wrist. 9. Entitlement to a separate compensable rating for degenerative arthritis of the left wrist. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD G. E. Wilkerson, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1987 to January 2008. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, as part of 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. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Board notes that the Veteran was initially granted service connection for rheumatoid arthritis of the right and left wrists, and assigned noncompensable ratings for each disability. However, given that the September 2007 pre-discharge examination reflects x-ray evidence of degenerative arthritis of both wrists, the Board will consider whether the Veteran is entitled to separate ratings for the wrist on the basis of degenerative arthritis, as noted on the title page. As regards the Veteran's service-connected rheumatoid arthritis, the records reflects that the RO initially granted service connection for rheumatoid arthritis of the knees, ankles, hands and knuckles, wrists, and elbows, and assigned separate noncompensable ratings for each. However, in an October 2008 rating decision, the RO awarded a single 10 percent evaluation based on arthritic involvement of multiple major joints and minor joint groups. As such, the Board has characterized the claims for increased ratings for rheumatoid arthritis of multiple joints as the single claim noted on the title page. The Veteran was also scheduled for a Board hearing at the RO in October 2012. However, the Veteran failed to appear. The Veteran has not presented a reason for her failure to appear, nor has she requested rescheduling of the hearing. Therefore, her request for a Board hearing is deemed withdrawn. See 38 C.F.R. § 20.704(d) (2012). The claims for service connection for a skin disability and for increased rating for rheumatoid arthritis, currently rated as 10 percent, 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. The Veteran's service-connected bilateral pes planus is severe and has been manifested by pronation, pain on manipulation, indications of swelling, and callosities. 2. The Veteran's service-connected residuals of right foot surgery with bunions and hallux valgus have been manifested by complaints of pain and recurrent hallux valgus, operated. 3. The Veteran's service-connected residuals of left foot surgery with bunions and hallux valgus have been manifested by complaints of pain and recurrent hallux valgus, operated. 4. The Veteran's service-connected scar of the right foot, residual of bunionectomy, is manifested by a well-healed linear scar. The scar is superficial, stable, not painful and does not produce limitation of function. 5. The Veteran's service-connected scar of the left foot, residual of bunionectomy, is manifested by a well-healed linear scar. The scar is superficial, stable, not painful, and does not produce limitation of function. 6. The Veteran's service-connected right wrist disability has been manifested by complaints of pain on motion of the right wrist examination with x-ray evidence of degenerative arthritis, but is not manifested by favorable or unfavorable ankylosis. 7. The Veteran's service-connected left wrist disability has been manifested by complaints of pain on motion of the right wrist examination with x-ray evidence of degenerative arthritis, but is not manifested by favorable or unfavorable ankylosis CONCLUSIONS OF LAW 1. The criteria for a 30 percent for bilateral pes planus are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a Diagnostic Code 5276 (2012). 2. The criteria for a rating in excess of 10 percent for residuals of right foot surgery with bunions and hallux valgus, prior to June 19, 2009 and from December 1, 2009, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.40, 4.45, 4.71a, Diagnostic Codes 5299-5280 (2012). 3. The criteria for a rating in excess of 10 percent for residuals of left foot surgery with bunions and hallux valgus are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.40, 4.45, 4.71a, Diagnostic Codes 5299-5280 (2012). 4. The criteria for a compensable rating for scar of the right foot, residual of bunionectomy have not been met. 38 U.S.C.A. §§1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800-05 (2012). 5. The criteria for a compensable rating for scar of the left foot, residual of bunionectomy have not been met. 38 U.S.C.A. §§ 1155, 5017 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800-05 (2012). 6. The criteria for a separate, 10 percent rating for degenerative arthritis of the right wrist have been met. 38 U.S.C.A. §§ 1155, 5017 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5215 (2012). 7. The criteria for a separate, 10 percent rating for degenerative arthritis of the left wrist have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.59, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5215 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The claims herein decided arise from the Veteran's disagreement with the ratings assigned in connection with the grant of service connection for these disabilities. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105 (West 2002). Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Consequently, further discussion of the VCAA's notification requirements with regard to the claims on appeal is unnecessary. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records and all of the identified post-service private and VA treatment records. The Veteran was also provided with a pre-discharge examinations in September 2007 and a VA examination in December 2009 as to her disabilities on appeal. As these examinations were based on review of the Veteran's symptoms and complaints and discuss her disabilities in relation to the pertinent rating criteria, they are adequate for adjudication purposes. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claims on appeal are thus ready to be considered on the merits. II. Analysis Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. 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. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). In this case, the disabilities have not significantly changed and uniform evaluations are warranted. In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, as several of the Veteran's disabilities are, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when her symptoms are most prevalent ("flare-ups") due to the extent of her pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. A. Bilateral Pes Planus and Residuals of Bilateral Foot Surgery with Bunions and Hallux Valgus The Veteran's bilateral pes planus is rated 0 percent (noncompensable) from February 1, 2008, under the criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5276. Under Diagnostic Code 5276, a 10 percent rating is warranted for moderate pes planus with the weight-bearing line over or medial to the great toe, inward bowing of the tendo Achilles, pain on manipulation and use of the feet, bilateral or unilateral. Severe pes planus manifested by objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, warrants the assignment of a 20 percent rating if unilateral and 30 percent rating if bilateral. Pronounced pes planus manifested by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achilles on manipulation, not improved by orthopedic shoes or appliances warrants the assignment of a 30 percent rating if unilateral and 50 percent rating if bilateral. As regards the Veteran's residuals of bilateral foot surgery with bunions and hallux valgus, each foot is rated at 10 percent from February 1, 2008, under the criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5299-5280. However, the Board notes that the Veteran was granted a total temporary 100 percent evaluation based on surgical treatment necessitating convalescence for the right foot for the period from June 19, 2009 to December 1, 2009. Accordingly, the Board will only discuss the 10 percent rating assigned prior to and following this period. Hyphenated diagnostic codes are used when a rating requires use of additional rating criteria to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.71a. In this case, the RO determined that the most closely analogous diagnostic code was 38 C.F.R. § 4.71a, Diagnostic Code 5280 for unilateral hallux valgus. Under Diagnostic Code 5280, unilateral hallux valgus warrants a 10 percent rating if operated with resection of the metatarsal head or if the condition is severe, if equivalent to amputation of the great toe. 38 C.F.R. § 4.71a, Diagnostic Code 5280. The Veteran's service treatment records reflect complaints of foot pain. In May 2007, the Veteran reported right foot stiffness and pain. The tendon below the ankle did not slip out of place, and there was no bone pain in the foot or heel or muscle cramps. There was no change in the arch of the foot and the foot did not appear deformed. There was joint pain in the toes but no toe joint swelling or joint stiffness in the toes. The Veteran was able to straighten the toes, though the toes had become deformed. She did not have a feeling of instability or joint looseness of the toes or soft tissue pain. There was no localized joint swelling. An impression of congenital deformity of the toes with hallux valgus was noted. On pre-discharge examination in September 2007, the Veteran reported that she had been diagnosed with pes planus, hallux valgus, hammertoes, and plantar fasciitis. She indicated that she wore a plantar plate for correction of the feet, as well as shoe insoles. Subjective complaints included pain in both feet, which she described as an aching, burning, and sharp pain elicited with physical activities. She rated the pain an 8 on a scale to 10. She had hardware inserted in the feet which was later removed in 2007. With respect to functional limitations, the Veteran reported pain going down stairs and pain walking barefoot and in shoes. On physical examination, hallux valgus and mild bunion formation persisted. The hallux valgus measured 30 degrees on the right and 20 degrees on the left. Otherwise, the examiner noted that there were no signs of painful motion, edema, disturbed circulation, weakness, atrophy of the musculature, or tenderness. The arches were low. Palpation of the plantar surfaces did not reveal any tenderness, and the Achilles tendons showed good alignment. Flexion and dorsiflexion of the toes did not induce pain. She did not wear special shoes, but wore arch supports in both shoes. An x-ray of the right foot with and without weight-bearing views reveals bunionectomy, head of the first metatarsal bone, with a few bony lesions in the distal diaphysis and metaphysis. There was no evidence of soft tissue swelling. An x-ray of the left foot with and without weight-bearing views was negative. The examiner diagnosed status post surgery to feet, with residual bunions and hallux valgus formations. A February 2008 treatment report from the King's Daughter Clinic reflects that the Veteran complained of bilateral foot pain, which she indicated had become progressively worse and led to difficulties with walking. A February 2008 private x-ray of the left foot revealed hallux valgus and hammertoe deformities. On the right, there were postsurgical changes of bunionectomy. Hallux valgus and mild pes planus deformity were also noted. A May 2008 treatment report from the King's Daughter Clinic reflects that the Veteran presented with complaints of significant foot pain. Musculoskeletal examination showed significant antalgic gait. X-rays of the feet were taken, after which a diagnosis of residual hallux abductovalgus deformity worse in the right foot when compared to the left was noted. A positional deformity of the right second and left second metatarsals and plantar flexion with significant contracture of the lesser toes was noted. A follow-up May 2008 report reflects that the Veteran had significant problems after previous bunion surgery, which removed part of the bunions but did not correct the significant metatarsal angles and did not address a significant pronatory problem, especially bad in her right foot. The examiner noted that the tarsal navicula on the right foot had a significant accessory sesamoid, which almost certainly contributed to severe posterior tibialis dysfunction. In addition, the Veteran had severe plantar flexion of the second metatarsal heads, which was an underlying cause of severe ongoing difficulty and pain. Surgical revision was discussed. A July 2008 VA podiatry consultation reflects that the Veteran complained of secondary metatarsal head pain on walking and bunion deformities on the right foot greater than the left foot. On physical examination, bilateral fleet feet with bunion-type angulation at the metacarpophalangeal joint of the right was noted. There was a very early callus formation and some tenderness on deep palpation of the second metatarsal head. X-rays of both feet noted marked pes planus, bunion-type deformity, particularly of the right foot. There was still fairly good maintenance of the joint space diffusely. An October 2008 VA outpatient treatment report reflects a history of bilateral foot pain following surgery and flat feet. It was noted that the Veteran wore shoe inserts. A June 2009 operative report from the Corpus Christi Surgery Center reflects that the Veteran underwent a revisional bunionectomy of the right foot. A post-surgical report dated in October 2009 reflects that the Veteran was good after use and use of orthotics in the future was discussed. On VA examination in December 2009, the Veteran continued to report bilateral foot pain. She stated that she entered service with flat feet but never had pain in the feet initially. She continued that she developed hammer toes and bunions while in service on both feet. She had surgery on the bunions in 2005 and surgery to correct the second and third toes in 2005. The Veteran also noted that she underwent corrective surgery for her bunionectomy with digital arthroplasty for recurrent hallux valgus deformity in June 2009. She continued to have some numbness to the lateral hallux with swelling between the second and third digit along with joint stiffness as well as tenderness to the proximal hallux. The Veteran endorsed bilateral foot pain, swelling and stiffness, but denied heat, redness, fatigability, weakness, or lack of endurance. She denied flare-ups of foot joint disease. Functional limitations included inability to stand more than 30 minutes or walk more than 1 mile. An examination of the left foot revealed no evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weightbearing. On the right, there was evidence of painful motion, swelling, tenderness, and weakness, but no evidence of instability or abnormal weight bearing. There was also tenderness with flexion of the first digit and tenderness to the mid-plantar region of the right foot. The Veteran was guarded with flexion examination of the digits. The examiner observed that the first, second, and third digit remained extended at all times and did not lay flush with the surface. The examiner also noted that she had bilateral flat feet. After examination, the examiner diagnosed residuals of right bunionectomy with screw fixation with recurrent hallux valgus deformity. The examiner noted that the Veteran was not employed but that the disability would cause mild effects on driving and moderate effects on exercise. As regards the claim for increased initial rating for bilateral flat feet, private treatment records include objective evidence of deformity-pronation-as noted in the May 2008 treatment report. There is also evidence of pain on manipulation and swelling, as noted in the December 2009 VA examination report. Callous formations are noted in both VA and private treatment records. Thus, a 30 percent rating is warranted for severe bilateral pes planus under Diagnostic Code 5276. However, as the records does not reflect bilateral pronounced pes planus manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances, a rating in excess of 30 percent under Diagnostic Code 5276 is not warranted. As regards the claims for increased initial ratings for right and left foot surgery with bunions and hallux valgus, the Board notes that the Veteran has been awarded 10 percent ratings for each foot, which is the maximum rating available under Diagnostic Code 5280. As such, higher ratings are not available. The Board has also considered whether a higher rating is warranted under any other potentially applicable diagnostic code but has determined that the most appropriate diagnostic code for rating the disability are the diagnostic codes for flat feet and hallux valgus, and that no reasonable basis exists for assigning a higher rating under another diagnostic code. The Veteran does not have claw foot, or malunion or nonunion of the tarsal or metatarsal bones; therefore, consideration of Diagnostic Codes 5278 or 5283 are not warranted. The evidence is also devoid of a showing of a severe foot injury as to warrant consideration of Diagnostic Code 5284. While the record includes occasional notation of hammertoes, there is no indication that the disability affects all toes of either foot, and, as such, a rating under Diagnostic Code 5282 is not warranted. Finally, the Board has also considered the Veteran's statements regarding the severity of her right and left foot symptoms. Certainly, as a lay person, the Veteran is competent to attest to physical symptoms that she experiences, such as persistent foot pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Generally, she has been credible, however, neither the medical evidence nor the lay evidence of record suggests that evaluations in excess of the 30 and 10 percent ratings assigned are warranted at this time. Her statements are non-specific and failed to establish a greater degree of functional impairment. Here, the medical findings (as provided in September 2007 pre-discharge examination report and December 2009 VA examination report) directly address the criteria under which the Veteran's foot disabilities are evaluated. We find the medical evidence to be far more probative of the degree of impairment that her lay statements. B. Scars of Feet The Veteran's scars of the right and left foot are each rated 0 percent (noncompensable) under the criteria of 38 C.F.R. § 4.118, Diagnostic Code 7805, effective February 1, 2008. The Board notes that other substantive changes to the criteria for rating scars were implemented by another regulatory amendment, effective October 23, 2008. The Board observes that the regulatory changes only apply to applications received by VA on or after October 23, 2008, or if the Veteran requests review under the clarified criteria. See 73 Fed. Reg. 54708 (Sept. 23, 2008). As neither situation applies in this case, the 2008 rating changes are inapplicable. Scars are evaluated under 38 C.F.R. § 4.118 , Diagnostic Codes 7800-7805. The criteria for evaluating scars were amended effective August 30, 2002. See 67 Fed. Reg. 49590 (July 31, 2002). Effective August 30, 2002, unstable superficial scars warranted a 10 percent rating under Diagnostic Code 7803. 38 C.F.R. § 4.118 (effective August 30, 2002). Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar and Note 2 provides that a superficial scar is one not associated with underlying soft tissue damage. Id. A superficial scar, painful on examination, also warranted a 10 percent rating under Diagnostic Code 7804. Id. Other scars were rated based on limitation of function of the affected part under DC 7805. Id. The pertinent evidence of record namely consists of a pre-discharge examination in September 2007. On examination, the examiner noted two well-healed scars, 4 centimeters in length by .1 centimeter over the dorsal aspect of the first metacarpal bone bilaterally, representing the sites of previous surgical operations to correct bunion formation and hallux formation. There was no tenderness, disfigurement, ulceration, adherence, inflammation, edema, tissue loss, keloid formation, hypo/hyper pigmentation, or abnormal texture. In conclusion, the examiner noted that the surfaces of these scars were flush with the surrounding skin, and there was no detectable alteration in sensory perception or vascular supply. He described the scars as well-healed. While additional VA and private outpatient treatment records reflect further complaints and treatment related to the feet, these records do not specifically discuss the scarring associated with the previous bunionectomies. Rather, these records discuss the Veteran's hallux valgus, pes planss, and other abnormalities as discussed above. After consideration of all evidence of record, the Board finds the preponderance of the evidence to be against the award of a compensable rating for the Veteran's scars of the right and left feet. According to the September 2007 examination report, the Veteran's residual bunionectomy scars are essentially limited to small scars of the each foot, without any significant functional impairment to the underlying strength, nerves, or range of motion of the foot. These scars are superficial and also do not result in any tenderness, edema, keloid formation, ulceration, or skin breakdown of the right or left foot. The Board is cognizant of the Veteran's complaints of bilateral foot pain, but notes that she has already been granted service connection for bilateral hallux valgus and pes planus, as noted above. The ratings for these disabilities contemplate her foot pain and other symptoms. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. Moreover, the Veteran has not specifically complained of pain or tenderness, stemming from the scars alone, and tender scars were not noted on examination. As such, a higher rating based upon painful or tender scarring is not warranted. C. Degenerative Arthritis of the Wrists As noted in the Introduction, the RO originally granted service connected for rheumatoid arthritis of both wrists; however, given that the record reflects diagnosis of degenerative arthritis of both wrists, the Board will consider whether the Veteran is entitled to separate evaluations for each wrist on the basis of degenerative arthritis. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion of the specific joint involved. When limitation of motion is noncompensable, a 10 percent rating is for application for each major joint. In the absence of limitation of motion, a maximum schedular 20 percent rating is assigned for degenerative arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes. Under Diagnostic Code 5215, wrist, limitation of motion, a 10 percent rating is assigned where wrist dorsiflexion is less than 15 degrees, or where palmar flexion is limited in line with the forearm. See 38 C.F.R. § 4.71a , Diagnostic Code 5215. Normal range of motion for the wrist is 70 degrees of dorsiflexion (extension); 80 degrees of palmar flexion; 45 degrees of ulnar deviation; and 20 degrees of radial deviation. See 38 C.F.R. § 4.71, Plate I. Under Diagnostic Code 5214, ankylosis of the wrist, favorable ankylosis in 20 to 30 degrees dorsiflexion warrants a 20 percent rating for the minor wrist and a 30 percent rating for the major wrist. Ankylosis and any other position, except favorable, warrants a 30 percent rating for the minor arm and 40 percent rating for the major arm. For unfavorable ankylosis of the wrist in any degree of palmar flexion or with ulnar or radial deviation, a 40 percent rating is warranted if the minor wrist is affected, while a 50 percent rating is warranted for the major wrist. On September 2007 pre-discharge examination, the Veteran endorsed weakness, stiffness, swelling, heat, giving way, locking and loss of mobility of the wrists, more apparent on the right than left. She rated the pain a 10 on a scale to 10 when she was flexing her wrist or lifting objects. Pain was elicited by physical activity and relieved by rest and medication. She could function with a wrist brace. She reported functional limitations due to her wrist pain including problems with writing, typing and opening doors. She was employed in human resources in the service and continued to work the same job without complications. She is right-hand dominant. On physical examination of the wrist, the examiner observed considerable compromise in the range of motion of the right wrist. Otherwise, the was no detectable alteration in form of the right and left wrists. There was no sign of edema, effusion, weakness, tenderness, redness, heat, or abnormal movement. No fixed position was identified. There was normal strength of both wrists. Range of motion testing of the right wrist revealed dorsiflexion to 20 degrees, palmar flexion to 30 degrees, radial deviation to 15 degrees, and ulnar deviation to 0 degrees. Range of motion testing of the left wrist revealed dorsiflexion to 70 degrees, palmar flexion to 80 degrees, radial deviation to 20 degrees, and ulnar deviation to 45 degrees. The examiner noted that pain, weakness, lack of endurance, fatigue, or incoordination did not further impact range of motion after repetitive use. X-ray of the right wrist revealed osteoarthritic degenerative changes of the joints of the wrist, while x-ray of the left wrist revealed mild degenerative changes involving the interphalangeal joint spaces and the metacarpophalangeal joint spaces. The examiner diagnosed rheumatoid arthritis with limitation in range of motion of the right wrist. February 2008 private x-ray of the right wrist revealed destructive changes involving the distal radial carpal joint with erosions involving the radial articular surfaces as well as the carpus. There was complete joint space obliteration with collapse of the articular surface of the radiocarpal joint. There was mild interphalangeal joint space narrowing and slight subluxation of the second and third metacarpophalangeal joints. On the left, there were destructive changes involving the articular surface of the distal radius and ulnar styloid process. There were also erosions involving the scaphoid, lunate, carpitate, and trapezium. In addition, there was collapse of the articular surface with marked joint space narrowing and sclerosis. Early fusion was possible. A July 2008 report from the King's Daughter Clinic reflects that the Veteran had continued complaints of left wrist pain. On examination, she had some decreased range of motion of the wrists with some tenderness upon palpation of the left wrist. There was no evidence of synovitis. VA outpatient treatment records document the Veteran's wrist-related complaints. In June 2008, the Veteran reported loss of mobility in both wrists. In July 2008, the Veteran complained of bilateral wrist pain, but range of motion was normal and there was no effusion. On VA treatment in October 2008, the examiner observed minimal localized swelling and tenderness of the wrists. In December 2008, the Veteran complained of pain in both wrists, especially with use. On examination, there was no swelling noted. Hand grip was normal. When rating disabilities based on limitation of motion, the intent of the Rating Schedule is to "recognize painful motion with joint or periarticular pathology as productive of disability," as well as to recognize that "actually painful" joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Similarly, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. 38 C.F.R. § 4.40. These regulations apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The September 2007 pre-discharge examination disclosing findings of degenerative arthritis with pain with range of motion is the symptomatology that 38 C.F.R. §§ 4.40 and 4.59 indicate would warrant a compensable, 10 percent rating. Consequently, the Board finds that a 10 percent rating, each, is warranted for the Veteran's degenerative arthritis of the wrists. This evaluation is consistent with painful motion. 38 C.F.R. § 4.59. It is also consistent with dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm. The Board notes that 10 percent is the highest rating available under Diagnostic Code 5214. In order to warrant a higher rating under Diagnostic Code 5215, there must be evidence of favorable or unfavorable ankylosis. Here, neither private nor VA treatment records reflect ankylosis, and the September 2007 examiner found no fixed position of either wrist. Although there was a report that there may have been early fusion, such was not confirmed and the appellant retained motion in the wrist. Therefore, the more probative evidence establishes that there is no ankylosis at this time. As such, ratings in excess of 10 percent on the basis of favorable or unfavorable ankylosis of the wrist are not warranted. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Here, the examiner specifically found that repetition on the range of motion three times did not increase any of these symptoms. Consequently, a higher rating is not warranted on this basis. The Board has considered the applicability of other diagnostic codes, but has found none. Finally, the Board has also considered the Veteran's statements regarding the severity of her right and left wrist symptoms. Again, as a lay person, the Veteran is competent to attest to physical symptoms that she experiences, such as persistent wrist pain. See Washington, 19 Vet. App. at 368. Generally, she has been credible, however, neither the medical evidence nor the lay evidence of record suggests that evaluations in excess of 10 percent is warranted at this time. Her statements non-specific and failed to establish a greater degree of functional impairment. Here, the medical findings (as provided in September 2007 pre-discharge examination report) directly address the criteria under which the Veteran's wrist disabilities are evaluated. We find the medical evidence to be far more probative of the degree of impairment that her lay statements. D. Extraschedular Consideration and Conclusion As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptomatology associated with the Veteran's disabilities is fully contemplated by the applicable rating criteria. The symptomatology reported by the Veteran and shown on examination is contemplated by the rating criteria used to assign disability evaluations, and there is no characteristic or manifestations shown that is outside the purview of the applicable rating criteria or is so exceptional as to render the criteria in applicable. All potentially relevant rating codes have been considered and evaluated. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is therefore not required. In any event, the Veteran did not claim, and the evidence does not reflect, that there has been marked interference with employment, frequent hospitalization, or that the Veteran's symptoms have otherwise rendered impractical the application of the regular schedular standards. The evidence of record certainly shows that the Veteran's disabilities have impacted his ability to work. However, the level of interference shown is contemplated by the numerous disability evaluations already assigned to the Veteran's disorders. Therefore, referral for consideration of an extraschedular rating for any of the disabilities on appeal is not warranted. 38 C.F.R. § 3.321(b)(1). For the foregoing reasons, the Board concludes that there is no basis for staged ratings of the Veteran's bilateral pes planus, residuals of right foot and left foot surgery with bunions and hallux valgus, scars of the right and left feet, and degenerative arthritis of the right and left wrists, as her symptoms have been primarily the same throughout the appeal period. The Board has favorably applied the benefit-of-the-doubt doctrine in reaching the decisions to award a 30 percent rating for bilateral pes planus and separate 10 percent ratings for degenerative arthritis of the right and left wrists, but finds that the preponderance of the evidence is against the assignment of any higher rating for these disabilities or any of the other disabilities on appeal. See 38 U.S.C.A. § 5107(b) ; 38 C.F.R. §§ 3.102 , 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A 30 percent rating for bilateral pes planus is granted, subject to the law and regulations governing the payment of monetary benefits. An evaluation in excess of 10 percent for residuals of right foot surgery with bunions and hallux valgus, prior to June 19, 2009 and from December 1, 2009, is denied. An evaluation in excess of 10 percent for residuals of left foot surgery with bunions and hallux valgus, is denied. A compensable evaluation for scar of the right foot, residual of bunionectomy, is denied A compensable evaluation of scar of the left foot, residual of bunionectomy, is denied. A separate rating of 10 percent for degenerative arthritis of the right wrist is granted, subject to the law and regulations governing the payment of monetary benefits. A separate rating of 10 percent for degenerative arthritis of the left wrist is granted, subject to the law and regulations governing the payment of monetary benefits. REMAND The Board's review of the claims file reveals that additional development on the remaining claims is warranted. With respect to the claim for service connection for skin disability, to include eczema of the neck, scalp, and hairline, the Veteran's service treatment records reflect a number of complaints with respect to the skin. An April 1990 treatment report notes the Veteran's complaints of a spreading rash on the back of her neck. An assessment of seborrhea of the scalp was indicated. In July 1993, the Veteran presented with complaints of rash to the lower legs and back of the neck. An assessment of contact dermatitis-allergic reaction to perfume and psoriasis to neck, possible lymph node reaction, was noted. Later in July 1993, the Veteran was seen for recurrence of itchy lesions on the back of the neck. A history of seborrhic dermatitis was noted. A March 1994 treatment report reflects that the Veteran suffered from chemical burns to the ears, neck, and head as the result of hair dye. An assessment of contact dermatitis was indicated. On a June 1994 report of medical history, the Veteran reported that she had an allergic reaction to a chemical dye for her hair, and was hospitalized for one night. She also noted that she had a skin disorder that flared up periodically. On examination, a rash of the hair line was indicated. On September 2007 pre-discharge examination, the Veteran reported that she had been treated for eczema of the neck, scalp and hairline. She reported that she experienced associated symptoms of itching and used topical medications as required for the condition. On physical inspection, the skin was healthy in appearance, texture, and pigmentation. There was no disfigurement from scars apparent. The examiner noted that the current physical examination did not reveal any alternation in the form, consistency, or pigmentation of the skin of the scalp and neck. He found no residual active pathology, complications, or disfigurement. Following service, on VA treatment in October 2008, the Veteran reported a past medical history of eczema. While no skin abnormalities were noted on examination, an assessment of eczema was indicated. VA will provide a medical examination or obtain a medical opinion if the record, including lay or medical evidence, contains competent evidence of a disability that may be associated with an event, injury, or disease that occurred in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. Based on the foregoing, it is unclear as to whether the Veteran has a current, post-service skin disability. While a current disability was not found on examination in 2007, treatment reports dated in 2008 do include notation of eczema. Given that the record reflects possible current eczema that may be related to the Veteran's skin complaints in service, the Board finds that a medical opinion-based on full consideration of the Veteran's documented medical history and assertions, and supported by clearly-stated rationale-would be helpful in resolving the claim for service connection. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As regards the evaluation for rheumatoid arthritis, currently rated as 10 percent disabling, the Board notes that 38 C.F.R. § 4.71a, Diagnostic Code 5002 (rheumatoid arthritis), provides that this disability can be rated as an active process or as chronic residuals. For rating as an active process, a 20 percent rating is warranted for 1 or 2 exacerbations a year in a well-established diagnosis, while a 40 percent rating is assigned where there are symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating episodes occurring 3 or more times a year. A 60 percent rating is warranted where there is weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year a lesser number over prolonged periods, but the symptoms do not warrant a 100 percent rating. Finally a 100 percent rating is warranted with constitutional manifestations associated with active joint involvement, totally incapacitating. 38 C.F.R. § 4.71a, Diagnostic Code 5002. If rating the disability as chronic residuals, residuals such as limitation of motion or ankylosis are to be rated under the appropriate diagnostic codes for the specific joint involved. Where limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation, to be combined, not added under Diagnostic Code 5002. 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, Diagnostic Code 5002. Here, the Veteran was afforded a pre-discharge examination in September 2007 to determine the nature and severity of her rheumatoid arthritis and its impact on the joints involved. This examination report, as well as the VA outpatient or private treatment records, discuss the Veteran's general treatment and complaints; however, these records fail to discuss whether the Veteran suffers from any incapacitating episodes of rheumatoid arthritis or symptoms combinations productive of impairment of health. Under these circumstances, the Board finds that a more contemporaneous examination with medical findings responsive to the applicable criteria for rating the disability under consideration is needed. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide a veteran with a thorough and contemporaneous medical examination); and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered contemporaneous"). Also, on remand, the RO/AMC should obtain and associate with the claims file all outstanding VA medical records. The record reflects that the Veteran has been receiving treatment at the Temple VA Medical Center (VAMC). While the Veteran's Virtual VA electronic claims file currently includes treatment records though April 2010, more recent treatment records may now be available. Moreover, the June 2010 Supplemental Statement of the Case references treatment for a skin disability-namely, seborrheic dermatitis in August 2009, and rheumatoid in November 2009; however, only treatment records dated though January 2009 and from January 2010 to April 2010 are associated with the electronic claims file. Records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain all outstanding pertinent VA treatment records from the Temple VAMC dated since January 2009. The RO must follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. If no records can be obtained after an exhaustive search, VA's efforts and any resolution determined must be fully documented for the record, and compliance with the requirements of 38 C.F.R. § 3.159(e)(i)-(iv) must be achieved. 2. The RO/AMC should send to the Veteran and her representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization, to enable it to obtain any additional evidence pertinent to the claims for service connection for skin disability and for increased rating for rheumatoid arthritis. If the Veteran identifies any other pertinent medical records that have not been obtained, the RO/AMC should undertake appropriate development to obtain a copy of those records. If the RO or the AMC is unsuccessful in its efforts to obtain any such evidence, it should so inform the Veteran and her representative and request them to submit the outstanding evidence. 3. After the Veteran responds and all available records and/or responses from each contacted entity are associated with the claims file, the RO/AMC should schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the claimed skin disability, to include eczema, psoriasis, seborrhea or residuals of contact dermatits. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner identify whether the Veteran has a skin disability. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that a current skin disability was incurred in service or is otherwise medically related to service. In providing the requested opinion, the examiner is asked to address the Veteran's service treatment records, which include a number of reports of contact dermatitis, seborrheic dermatitis, and rash. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should clearly so state, and the reasons and bases for the inability to provide the opinion must be included in the examination report. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and severity of the service-connected rheumatoid arthritis. The entire claims file must be made available to the examiner designated to examine the Veteran. The Board notes that the Veteran's claims have been processed using the Virtual VA paperless claims processing system. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner is requested to measure and record all subjective and objective symptomatology of the Veteran's rheumatoid arthritis, to include functional impairment. Specifically, the examiner is requested to identify whether the Veteran's rheumatoid arthritis is an active process. If so, the examiner is asked to address whether the Veteran's suffers from incapacitating episodes of rheumatoid and indicate their frequency, and/or whether there is objective support of symptom combinations productive of definite impairment of health, such as weight loss and anemia. The examiner must identify all affected jointsimpacted by chronic residuals and identify any impairment. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached 5. The RO/AMC should undertake any additional development deemed warranted. 6. Then, the RO/AMC should readjudicate the Veteran's claims. If the benefits sought on appeal are not granted, the Veteran and her representative should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs