Citation Nr: 1312664 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 08-12 970 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a right wrist disability. 2. Entitlement to service connection for left hammertoes. 3. Entitlement to service connection for a respiratory disorder, to include asthma. 4. Entitlement to an increased initial rating for hypertension, rated as noncompensable prior to February 18, 2011, and as 10 percent disabling since February 18, 2011. 5. Entitlement to an increased initial rating for a right ankle disability, rated as noncompensable prior to June 8, 2010, and as 10 percent disabling since June 8, 2010. 6. Entitlement to an initial compensable rating for bilateral plantar fasciitis. 7. Entitlement to an initial compensable rating for right hammertoes. 8. Entitlement to an initial compensable rating for paradoxical vocal cord mobility. 9. Entitlement to an initial compensable rating for a left shoulder scar. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from August 1986 to August 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, that denied service connection for a right wrist disability, left hammer toes, and a respiratory disorder; and granted service connection and assigned 0 percent ratings for hypertension, a right ankle disability, bilateral plantar fasciitis, right hammer toes, paradoxical vocal cord mobility, and a left shoulder scar, all effective September 1, 2006. In December 2006, the Veteran filed a Notice of Disagreement. The RO furnished the Veteran a Statement of the Case in March 2008, and the Veteran filed a Substantive Appeal (VA Form 9) in April 2008. The claims file was subsequently transferred to the RO in Atlanta, Georgia. The Board notes that in April 2008, the Veteran also perfected an appeal for the issues of entitlement to service connection for a right foot disability and entitlement to a 10 percent rating for multiple non-compensable service-connected disabilities under 38 C.F.R. § 3.324. However, an April 2008 rating decision granted service connection for posttraumatic stress disorder and assigned a 10 percent rating, effective September 1, 2006. As the Veteran is now in receipt of a 10 percent rating, her claim for a 10 percent rating for multiple non-compensable service-connected disabilities under 38 C.F.R. § 3.324 is moot and therefore no longer before the Board. Additionally, a subsequent rating decision in March 2011 granted the claim for service connection for a right foot disability. This grant represents a full grant of the benefit sought on appeal for this issue, and therefore, this issue is also not before the Board. A November 2010 rating decision increased the disability rating for a right ankle disability, from 0 percent to 10 percent, effective June 8, 2010, and a March 2011 rating decision increased the disability rating for hypertension from 0 percent to 10 percent, effective February 18, 2011. However, as these grants do not represent total grants of benefits sought on appeal, the claims for increase remain before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified before the Board at a February 2013 video conference hearing. A transcript of this hearing has been associated with the claims file. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that certain documents, including a March 2011 rating decision and a February 2013 video conference hearing transcript, are potentially relevant to the issues on appeal. Thus, the Board has considered these electronic records in its adjudication of the Veteran's case. Any future consideration of this appellant's case should also take into consideration the existence of this electronic record. The issues of service connection for a respiratory disorder and increased initial rating for hypertension, a right ankle disability, bilateral plantar fasciitis, paradoxical vocal cord mobility, and a left shoulder scar 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. There is no competent and credible evidence establishing that the Veteran currently has a right wrist disability. 2. There is no competent and credible evidence establishing that the Veteran currently has a left hammer toe disability. 3. The Veteran's right hammer toes have been manifested by subjective complaints of pain, swelling, weakness, stiffness, fatigability, and lack of endurance. However, there is no evidence that all of the Veteran's right toes have been affected by hammer toe. There is also no x-ray evidence of arthritis in the interphalangeal joints. CONCLUSIONS OF LAW 1. The requirements for establishing service connection for a right wrist disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The requirements for establishing service connection for left hammer toes have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. The criteria for an initial compensable rating for right hammer toes have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5282 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 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, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant 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, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in a May 2006 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate her claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The May 2006 letter also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. The case was last readjudicated in March 2011. However, with respect to the issue of an increased initial rating for right hammer toes, the appeal arises from the initial award of service connection. In Dingess, the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i) (2012). Thus, because the notice that was provided before service connection was granted was sufficient, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA and private medical records, VA examination reports, the Veteran's hearing testimony, and the Veteran's statements. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate her claims, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. Thus, she was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Regarding the Veteran's left hammer toe claim, service treatment records show that in June 2004, the Veteran was found to have flexible hammer toe of the left second toe. On separation examination in April 2006, the Veteran made no complaints about her left foot, and her left foot was found to have no abnormalities. With respect to the Veteran's right wrist disability claim, service treatment records show that in June 1999, the Veteran was treated for right wrist strain after falling out of her car three days previously. Other than some discomfort on dorsiflexion, the examination of the right wrist was negative. An x-ray of the wrist was within normal limits. Treatment records dated in July 1999, August 1999, and October 1999 indicate that the Veteran continued to receive treatment for her right wrist strain, which was noted to be resolving. She was put on a temporary physical profile that prohibited push-ups and lifting greater than 10 pounds. Subsequently, in April 2000 and December 2001, the Veteran received treatment for right carpal tunnel syndrome that was mildly symptomatic. She was put on temporary physical profile that limited her push-ups. On separation examination, although the Veteran complained of numbness and tingling in the right hand due to carpal tunnel syndrome and chronic right wrist pain, her right wrist was found to have no abnormalities. In a June 2006 treatment record, the Veteran was treated for right forearm pain. An x-ray of the right forearm showed no fracture or dislocation. The post-service evidence indicates that on VA examination in July 2006, there was no pathology to render any diagnosis of a right wrist disability or left hammer toes. Examination of the right wrist and left foot were normal. An x-ray of the right wrist was within normal limits, and an x-ray of the left foot revealed no abnormalities other than a heel spur. The Board also notes that subsequent VA examinations of the feet dated in June 2010 and February 2011 were negative for any findings of left hammer toes. Indeed, these examinations only found right hammer toes, a disability for which the Veteran is already service-connected. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, a right wrist disability and left hammer toes fall outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms of wrist and toe pain, any actual diagnoses of a right wrist disability or left hammer toes require objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Moreover, whether symptoms the Veteran experienced in service or following service are in any way related to any current right wrist disability or hammer toe disability requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). To the extent that the Veteran herself believes that she has current right wrist disability and left hammer toes that are due to service, as a lay person, she is not shown to possess any specialized training in the medical field. The Veteran's opinions as to the etiology of her claimed current right wrist disability and left hammer toes are not competent medical evidence, as such questions require medical expertise to determine. Id. In any event, the Board concludes that the medical evidence, which reveals no complaints or findings of a right wrist disability or left hammer toes, is of greater probative value than the lay contentions of the Veteran. In this case, while there is current medical evidence of record dating from June 2006 through February 2011, none of this evidence reflects findings of a right wrist disability or left hammer toes. Accordingly, in the absence of objective evidence of a current right wrist disability or left hammer toes during the period of the claims, consideration of service connection for a right wrist disability and left hammer toes is not warranted on any basis. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110; 1131. In the absence of proof of present disabilities there can be no valid claims. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C.A. § 1131 requires existence of present disability for VA compensation purposes); see also Wamhoff v. Brown, 8 Vet. App. 517, 521 (1996). In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Service connection for right hammer toes was granted by the October 2006 rating decision, with a noncompensable rating assigned, effective September 1, 2006. 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. 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 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 which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40 (2012); see also 38 C.F.R. §§ 4.45, 4.59 (2012). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45 (2012). For the purpose of rating disability from arthritis, the interphalangeal joints are considered a group of minor joints. See 38 C.F.R. § 4.45. The Veteran's disability is rated under Diagnostic Code 5282, which contemplates hammer toe. Diagnostic Code 5282 provides for a 0 percent rating for hammer toe of single toes. A 10 percent rating is warranted for hammer toe of all toes, unilateral with claw foot. 38 C.F.R. § 4.71a, Diagnostic Code 5282 (2012). Arthritis shown by X-ray studies is rated based on limitation of motion of the affected joint. When limitation of motion would be noncompensable under a limitation-of-motion code, but there is at least some limitation of motion, a 10 percent rating may be assigned for each major joint or group of minor joints so affected. 38 C.F.R. § 4.71a, Diagnostic Codes 5003 (degenerative arthritis) and 5010 (traumatic arthritis). Diagnostic Code 5010, traumatic arthritis, directs that the evaluation of arthritis be conducted under Diagnostic Code 5003, which states that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. The 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 5010. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Diagnostic Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5010, Note 1. On VA examination in July 2006, the Veteran complained of burning, sharp foot pain that occurred once a month and lasted for 1 hour. She reported that the pain traveled to the bottom of the foot and was an 8-9/10 in severity. She stated that the pain could be elicited by physical activity and was relieved by rest and pain medication. She indicated that she had pain and swelling of the foot at rest and while standing or walking. She denied any functional impairment due to her hammer toes. Examination revealed no signs of abnormal weight bearing in the feet. There was no evidence of tenderness, weakness, edema, atrophy, or disturbed circulation. The Veteran was noted to have hammer toes on the right foot, including toes 2 and 3. She had no limitation with standing or walking and did not require any type of support with her shoes. An x-ray of the right foot showed a heel spur. The Veteran was diagnosed with right hammer toes. At a June 2010 VA examination, the Veteran reported development of a second hammer toe on the right foot. She complained that the pain was a 9/10 in severity and that she had dull pain at rest. She also indicated that she had weakness, stiffness, fatigability, and lack of endurance. She denied heat, redness, and the use of assistive devices. She stated that she could stand for one hour and walk 2 blocks. She maintained that she had severe flare-ups on rainy days and that they would last until it stopped raining. She reported that she took pain medication for her hammer toes. Aggravating factors were noted to be prolonged standing and walking, and rest was noted to be an alleviating factor. Examination revealed that there was no edema, redness, heat, effusion, calluses, or abnormal forefoot to rearfoot alignment. There was a normal arch on nonweightbearing with decreased medial arch on weightbearing. The Veteran was noted to have planus foot type, erectus rearfoot position, and a reducible right second hammer toe. She had full range of motion of the first metatarsophalangeal joint without pain. She also had moderate lateral deviation of the great toes, greater on the right side, and her hallux valgus deformity was noted to be flexible. An x-ray of the foot indicated that the Veteran had moderate hallux valgus deformity, dorsal contraction of the toes on lateral view of the right foot, and plantar inferior heel spur. The examiner diagnosed the Veteran with right second hammer toe, asymptomatic. On VA examination in February 2011, the Veteran complained that she experienced pain in her feet both with weightbearing and with rest. However, she explained that her pain was not constant in nature. She also reported right foot weakness, stiffness, fatigability, and lack of endurance. She stated that when necessary, she took over-the-counter medication for her foot pain. She indicated that she experienced 2 to 3 flare-ups of toe pain per week and that these flare-ups lasted 1 to 2 days. She maintained that her flare-ups were triggered by rainy weather or activities that required extended walking. She reported that her flare-ups were relieved by soaking her foot or sitting with her foot elevated. She complained that during a flare-up, she had to stay home and limit her walking to necessary activities only. She denied the use of inserts, crutches, braces, or other assistive devices for ambulation. She estimated that she could walk for 2 to 3 blocks and stand in one place for 30 minutes. The Veteran reported that her hammer toes caused no occupational limitations, but that she had to take frequent breaks when performing home maintenance chores that required extended standing and weightbearing. She also stated that she was limited recreationally by not being able to perform any activities that involved running. Examination revealed that there was a mild hallux valgus deformity at the base of the great toe with an angulation of less than 10 degrees. The second toe overlapped the third toe. The Veteran was noted to have a mild hammer toe deformity in toes 2 and 3 of the right foot with an angulation of each toe of about 10 degrees. The second and third toes of the right foot had tenderness to palpation, but there was no edema, erythema, painful motion, instability, weakness, calluses, breakdown, or unusual shoe wear pattern. Skin and gait were normal. There was full range of motion of the metatarsophalangeal joint of the great toe. An x-ray showed very mild hallux valgus deformity of the right great toe and hammer toe deformities in the right foot. The Veteran was diagnosed with hammer toe deformities of the right foot. Although the Veteran reported pain and functional limitation due to her right hammer toes, the evidence does not show that the Veteran had hammer toe deformities of all the toes on her right foot. Indeed, the above VA examinations reveal that the Veteran only had right hammer toe deformities in the second and third toes of her right foot. Therefore, the Board finds that the Veteran is not entitled to an increased initial rating under Diagnostic Code 5282 for her right hammer toes. See 38 C.F.R. § 4.71a, Diagnostic Code 5282. Additionally, there is no x-ray evidence that demonstrates that the Veteran has osteoarthritis involving the interphalangeal joints of the right foot. Therefore, the Board finds that the Veteran is not entitled to an increased rating for her disability under the diagnostic criteria pertaining to arthritis. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. The Board acknowledges that although the Veteran's most recent VA examination for her right hammer toes had occurred in February 2011, she had indicated at her February 2013 video conference hearing that her disability had worsened since her previous VA examination. She reported symptoms of increased toe pain and swelling and maintained that sometimes her right great toe would overlap with her second toe and that her third toe would overlap with her fourth toe. However, in this case, the applicable rating criteria only provide for higher ratings if all of the Veteran's right toes are affected by hammer toe or if the Veteran has limitation of motion and evidence of arthritis in her interphalangeal joints. The Veteran did not report that all of her right toes were affected by hammer toe, nor did she indicate that she had any limitation of motion in her toes. Thus, regardless of whether the Veteran's right hammer toes had worsening pain and swelling, there is no basis to grant a higher rating, and further remand to obtain a current VA examination is not necessary, especially given that the most recent examination had occurred only 2 years ago. See Soyini v. Principi, 1 Vet. App. 540, 546 (1991) (concluding that remand is unnecessary where it "would result in this Court's unnecessarily imposing additional burdens on the [Board] with no benefit flowing to the veteran"). The Board concludes that the medical findings on examinations are of greater probative value than the Veteran's allegations regarding the severity of her right hammer toes. The symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluation assigned and do not more nearly approximate the criteria for a higher evaluation at any time during all relevant periods on appeal. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5282 (2012); see also Fenderson, supra. The Board has also considered whether the Veteran's right hammer toes present an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptomatology than is shown by the evidence. The Veteran's 0 percent rating for her right hammer toes contemplated her subjective complaints of pain and functional impairment. There was no evidence that all of the Veteran's toes were affected by hammer toe, nor was there x-ray evidence of arthritis in the interphalangeal joints. Therefore, the Veteran's subjective complaints were included in the 0 percent rating. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for a right wrist disability is denied. Entitlement to service connection for left hammer toes is denied. An initial compensable rating for right hammer toes is denied. REMAND After a review of the record, the Board observes that further development is required prior to adjudicating the Veteran's claim for service connection for a respiratory disorder, to include asthma, and claims for increased initial rating for hypertension, a right ankle disability, bilateral plantar fasciitis, paradoxical vocal cord mobility, and left shoulder scar. Regarding the claim for service connection, the Veteran asserts that her current asthma had its onset during service in the 1990s when she caught 15 colds within a 12 month period. Service treatment records show that the Veteran received periodic treatment for various respiratory disorders. In July 1998, she was treated for an upper respiratory infection. She received treatment for sinusitis, pharyngitis, upper respiratory infection, pneumonia, and reactive airway infection in October 1998 and for acute bronchitis in October 2003. The Veteran was first diagnosed with asthma in April 2004 when she complained of wheezing, a harsh cough, and a sensation that her chest was on fire. The physician prescribed her with inhalers. A pulmonary function test (PFT) found no evidence of obstructive or restrictive lung defect. Due to her shortness of breath and chest pain, the Veteran was also put on a temporary physical profile to prohibit her from running, performing exertional calisthenic exercises, and carrying more than 20 pounds. In June 2004, the Veteran received continued treatment for asthma after she had an asthma attack. An October 2004 treatment record reveals that the Veteran had chest congestion, shortness of breath, paroxysmal nocturnal dyspnea, wheezing, and a cough. She was diagnosed with chronic obstructive asthma with acute exacerbation. The Veteran continued to receive treatment for asthma and dyspnea in November 2004 and throughout December 2004. In January 2005, the Veteran underwent a laryngoscopy. The results suggested that the Veteran had vocal cord dysfunction, which the physician found was a likely contributor to the Veteran's dyspnea. Her asthma therapy was discontinued. In March 2006, the Veteran received treatment for bronchitis as well as persistent asthma exacerbation vs. symptoms associated with vocal cord dysfunction. The physician indicated in a March 14, 2006 note that it was difficult to determine whether the Veteran's symptoms were associated with her non-compliance with medication or if the symptoms were caused by her known history of vocal cord dysfunction. She noted that the Veteran had completed full evaluation for her symptoms in the past, and the wheeze and associated symptoms had not been pulmonary-related. An April 2006 PFT showed evidence of possible vocal cord dysfunction. On separation examination in April 2006, the Veteran complained of having asthma and breathing problems. The examiner noted that the Veteran had been treated for asthma-like symptoms and had also been evaluated by a pulmonologist. She found that asthma and pulmonary etiology for the Veteran's shortness of breath and dyspnea had been ruled out and noted that PFTs had all been normal. The examiner indicated that the Veteran had been diagnosed with vocal cord dysfunction and had been given inhalers in the past for shortness of breath and dyspnea. She also noted that the Veteran had sinusitis and that the congestion was consistent with upper respiratory infections and acute sinusitis. A chest x-ray revealed a pulmonary nodule. The post-service evidence indicates that at a July 2006 VA examination, the Veteran had no complications secondary to her pulmonary disease, and there was no pathology to render a diagnosis of asthma. Similarly, a June 2010 VA examination with October 2010 addendum found that the Veteran had paradoxical vocal cord mobility with no clinical evidence of asthma. However, the requirement that a claimant have a current disability before service connection may be awarded for that disability is satisfied when a claimant has a disability present at any time since the filing of the claim, even if no disability is present at the time of the claim's adjudication. McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, VA and private medical records dated from September 2006 to September 2009 show that the Veteran was intermittently treated for reversible obstructive airway disease, bronchitis, other upper respiratory infection, pharyngitis, sinusitis, and asthma. Indeed, a December 2008 private medical report indicates that the Veteran had asthma exacerbation. Given the evidence outlined above, the Veteran should now be afforded a VA respiratory examination with a medical opinion clarifying whether the Veteran has a current respiratory disorder, including asthma, that arose during service or is otherwise related to any incident of service, or whether her respiratory symptoms can be attributed to her already service-connected paradoxical vocal cord mobility. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the increased initial rating claims, the Veteran was last afforded VA examinations for her right ankle disability and left shoulder scar in June 2010, almost 3 years ago. She was last afforded VA examinations for her hypertension, bilateral plantar fasciitis, and paradoxical vocal cord mobility in February 2011, over 2 years ago. Although these examinations are not unduly remote, the Veteran testified at her February 2013 hearing that all of her conditions had worsened since the most recent VA examinations. Specifically, she reported that her blood pressure readings had at times gone up to the 190s and that even with medication, her blood pressure readings were above 160 and 170. The Veteran also testified that she had problems with moving her right ankle. She stated that she suffered severe right ankle pain and that her ankle would frequently lock up and make popping noises. Regarding her bilateral plantar fasciitis, the Veteran complained of constant dull pain in her feet. She reported that sometimes when she walked, she would experience such a sharp pain in her feet that it would stop her in her tracks. She stated that she attempted to treat her plantar fasciitis with over-the-counter pain medication. With respect to her paradoxical vocal cord mobility, the Veteran maintained that she had to catch her breath just to pronounce certain words and that she became hoarse very easily. The Board also notes that on VA examination in February 2011 for paradoxical vocal cord mobility, the Veteran had recent symptoms of feeling a burning sensation and then vomiting up bitter mucous, and the examiner explained that this may be a gastroenterological problem. The examiner had recommended that the Veteran undergo a nasal endoscopy with video stroboscopy to determine whether the symptoms were gastroenterological in origin or related to her vocal cord mobility. In regards to the Veteran's left shoulder scar, she complained that it was constantly painful and was sometimes burning in cold weather. Because there may have been changes in the Veteran's conditions, the Board finds that new hypertension; joints; feet; nose, sinus, larynx, and pharynx; and skin examinations are needed to fully and fairly evaluate the Veteran's claims for increased initial rating. Allday v. Brown, 7 Vet. App. 517 (1995) (where the record does not adequately reveal current state of disability, fulfillment of duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since previous examination); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). Additionally, the Veteran indicated at her February 2013 hearing that she would be receiving treatment for her hypertension later in February 2013, and it does not appear that the treatment records from this medical appointment have been associated with the claims file. Relevant ongoing medical records should therefore be obtained on remand. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide the names, addresses, and approximate dates of treatment of all health care providers, both VA and private, who have treated her for her respiratory disorders, hypertension, right ankle disability, bilateral plantar fasciitis, paradoxical vocal cord mobility, and left shoulder scar. After securing any necessary releases, the RO/AMC should request any records identified which are not duplicates of those contained in the claims file. If any requested records are unavailable, then the file should be annotated as such and the Veteran should be so notified. In addition, obtain all relevant ongoing VA treatment records dating since February 2011 from the VA Medical Center in Augusta, Georgia. 2. Schedule the Veteran for a VA respiratory examination to obtain a medical opinion as to whether her current respiratory disorder, to include asthma, is possibly related to her period of service. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. Any tests or studies deemed necessary should be conducted, and the results should be reported in detail. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current respiratory disorder, to include asthma, arose during service or is otherwise related to any incident of service, to include in-service treatment for various respiratory disorders. In rendering the opinion, the examiner should state whether the post-service diagnoses of various respiratory disorders were appropriate, particularly the December 2008 diagnosis of asthma exacerbation, and whether any of these diagnoses are related to the Veteran's active service. If not caused by or related to service, the examiner should provide an opinion as to whether the Veteran's respiratory symptoms are instead attributable to her already service-connected paradoxical vocal cord mobility. The examiner should provide a rationale for the conclusions reached. 3. Schedule the Veteran for a hypertension examination to determine the current severity of her hypertension. The examiner must review the claims folder in conjunction with the examination. All indicated tests should be performed and the results reported. The examiner should describe all symptomatology related to the Veteran's service-connected hypertension. The examiner should determine the Veteran's diastolic pressure and systolic pressure. A rationale for any opinion expressed should be provided. 4. Schedule the Veteran for a joints examination to determine the current severity of her right ankle disability. The examiner must review the claims folder in conjunction with the examination. All indicated tests should be performed and the results reported. The examiner should describe all symptomatology related to the Veteran's service-connected right ankle disability. The examiner should determine whether the Veteran has limitation of motion of the ankle that is moderate or marked. The examiner should also indicate whether the Veteran's ankle is additionally limited due to pain, weakness, fatigability, incoordination, or lack of endurance. The examiner should also determine whether there is any ankylosis of the ankle, malunion of the os calcis or astragalus, or astragalectomy. A rationale for any opinion expressed should be provided. 5. Schedule the Veteran for a feet examination to determine the current severity of her bilateral plantar fasciitis. The examiner must review the claims folder in conjunction with the examination. All indicated tests should be performed and the results reported. The examiner should describe all symptomatology related to the Veteran's service-connected bilateral plantar fasciitis. The examiner should determine whether the Veteran's foot disability is considered to be moderate, moderately severe, or severe. The examiner should also indicate whether the Veteran has limitation of motion in the joints of the feet, and whether the feet are additionally limited due to pain, weakness, fatigability, incoordination, or lack of endurance. The examiner should also determine whether the Veteran has bilateral weak foot, Morton's disease, malunion or nonunion of the tarsal or metatarsal bones, or flatfoot. A rationale for any opinion expressed should be provided. 6. Schedule the Veteran for a nose, sinus, larynx, and pharynx examination to determine the current severity of her paradoxical vocal cord mobility. The examiner must review the claims folder in conjunction with the examination. All indicated tests should be performed and the results reported, including a nasal endoscopy with video stroboscopy. The examiner should describe all symptomatology related to the Veteran's service-connected paradoxical vocal cord mobility. The examiner should determine the Veteran's forced expiratory volume in one second and indicate whether her Flow-Volume loop is compatible with upper airway obstruction. If the Veteran's gastric symptoms are found to be attributable to her paradoxical vocal cord mobility, the examiner should describe this symptomatology as well. A rationale for any opinion expressed should be provided. 7. Schedule the Veteran for a skin examination to determine the current severity of her left shoulder scar. The examiner must review the claims folder in conjunction with the examination. All indicated tests should be performed and the results reported. The examiner should describe all symptomatology related to the Veteran's service-connected left shoulder scar. The examiner should determine whether the scar is superficial or deep, unstable, painful on examination, or causes limited motion or function. The examiner should also measure the area or areas of the scar. A rationale for any opinion expressed should be provided. 8. After the development requested above as well as any additional development deemed necessary has been completed, the record should again be reviewed. If the benefits sought on appeal remain denied, then the Veteran and her representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. 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). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs