Citation Nr: 1313716 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 08-21 330 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUES 1. Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). 2. Entitlement to increases in the ratings assigned for a low back disability (currently assigned "staged" ratings of 0 percent prior to August 18, 2006; 20 percent from August 18, 2006 to June 15, 2011; and 40 percent from that date). 3. Entitlement to a rating in excess of 10 percent for dermatophytosis of both feet. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from April 1966 to April 1969. These matters are before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision by the Waco, Texas VARO, which in pertinent part denied service connection for PTSD, continued a 0 percent rating for the low back disability, and continued a 10 percent rating for dermatophytosis of both feet. An interim [December 2007] rating decision increased the rating for the low back disability to 20 percent effective August 18, 2006, the date of the claim for an increased rating. In his substantive appeal on a July 2008 dated VA Form 9, the Veteran requested a Travel Board hearing; he withdrew the request in a statement received later that same month. In May 2011, the Board remanded the matters for additional development. An interim [August 2012] rating decision granted a 40 percent rating for chronic lumbar strain effective June 15, 2011. [The low back disability at issue was characterized as lumbar strain. Inasmuch as the record shows the Veteran has some intervertebral disc pathology (which the RO acknowledges is service-connected; see most recent supplemental statement of the case), it has been recharacterized as stated on the preceding page.] The issue of service connection for causalgia of the feet has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). See Veteran's representative's April 2013 statement. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of service connection for a psychiatric disability is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action on his part is required. FINDINGS OF FACT 1. It is reasonably shown that from August 18, 2005 (one year prior to the date of the increased rating claim) to June 15, 2011, the Veteran's service connected low back disability was manifested by flexion of the thoracolumbar spine greater than 30 degrees but less than 60 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; at no time prior to June 15, 2011 is the low back disability shown to have been manifested by limitation of thoracolumbar spine flexion to 30 degrees or less or by ankylosis of the spine; incapacitating episodes of disc disease and/or separately ratable neurological manifestations were not shown. 2. At no time from June 15, 2011 is the Veteran's low back disability shown to have been manifested by unfavorable ankylosis of the entire thoracolumbar spine, incapacitating episodes of disc disease, and/or additional separately ratable neurological manifestations. 3. At no time during the pendency of the claim is the Veteran's dermatophytosis of both feet shown to have affected 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas, or to have required systemic therapy such as with corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during a 12-month period.. CONCLUSIONS OF LAW 1. A 20 percent (but no higher) rating is warranted for the Veteran's chronic lumbar strain from (the earlier effective date of) August 18, 2005; ratings for the chronic lumbar strain in excess of 20 percent prior to June 15, 2011 and/or in excess of 40 percent from that date are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.21, 4.71a, Diagnostic Codes (Codes) 5243-5237 (2012). 2. A rating in excess of 10 percent for dermatophytosis of both feet is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.7, 4.21, 4.118, Codes 7806, 7813 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of his claims prior to the initial adjudication of the claims. An October 2006 letter explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. A May 2008 letter informed the Veteran of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record, and has not alleged that notice in this case was less than adequate. The Veteran's pertinent postservice treatment records have been secured. The RO arranged for VA examinations in January 2007, December 2007, June 2011, and December 2012, which will be discussed in greater detail below, though the Board finds these examinations (cumulatively) to be adequate as they included both a review of the Veteran's history and a physical examination that included all necessary findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Veteran has not identified any evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claims. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, and in Virtual VA (VA's electronic data storage system), with an emphasis on the evidence that is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period beginning one year before the claim was filed until VA makes a final decision on the claim. Id. Low Back Disability When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable Diagnostic Code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The RO has rated the Veteran's service-connected low back disability under Code 5237 as chronic lumbar strain, consistent with the diagnosis on VA examination (hereinafter "low back disability"). Inasmuch as there is a separate diagnostic code for intervertebral disc syndrome (Code 5243) and because that code provides for rating under alternate criteria in addition to those applicable to lumbar strain, and thus is potentially more favorable, the Board finds consideration of the criteria in Code 5243 appropriate. Intervertebral disc syndrome is rated either under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes whichever method results in the higher evaluation when all disabilities are combined under 4.25. 38 C.F.R. § 4.71a, Code 5243. Under the General Formula, a 20 percent rating for thoracolumbar disc disease is warranted when (1) forward flexion of the thoracolumbar spine is greater than 30 degrees but less than 60 degrees; (2) the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or (3) there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when (1) forward flexion of the thoracolumbar spine is limited to 30 degrees or less, or (2) when there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. The criteria apply with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a. Any associated neurological abnormalities including, but not limited to, bowel or bladder impairment are to be rated separately, under an appropriate diagnostic code. Note 1 following the General Formula. For purposes of rating under Code 5243, an "incapacitating episode" is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1. [As no episodes requiring bed rest prescribed by a physician and treatment by a physician are shown (or alleged) in the instant case, further discussion of the criteria for rating based on incapacitating episodes is not necessary.] The Veteran's claim for an increased rating was received in August 2006. The relevant period for consideration in this appeal begins one year prior to that submission (i.e., in August 2005). There is no medical evidence of record regarding the status of the Veteran's low back disability from August 2005 to March 2006. On March 2006 VA treatment, the Veteran complained of back symptoms bothering him once to twice per month. He reported pain in the low back and into the right leg and hip, and occasionally to the lower left leg. X-rays revealed osteoporosis and a slightly narrow L5/S1 disc. There were no compressions and the alignment was unremarkable. On May 2006 VA treatment, the Veteran complained of low back pain with radicular pain in the right leg. An MRI of the lumbar spine revealed multilevel desiccation of the intervertebral discs due to chronic degeneration but no focal disc protrusions were noted. There was no thecal compression or canal stenosis. There were edematous endplate degenerative changes at the lumbosacral junction. On June 2006 VA treatment, the Veteran reported that his back disability had been aggravated 3 years earlier by operating heavy equipment at work and had worsened gradually since. He reported severe symptoms at times with pain at 8 out of 10 in severity; he indicated that there was no right leg pain at the time of examination but that he had had pain (at a severity of 2 on a scale of 10) in the previous week. The pain was described as a constant ache with intermittent sharp cramping and tight severe right leg/calf pain. The radicular pain was described as occurring at the right buttock and across to the left buttock, and down both legs at times, worse on the right than the left. He reported associated symptoms of numbness and tingling with the leg pain. Aggravating factors included prolonged activity of any kind. He reported going through physical therapy for nearly 1 year with no benefit and receiving 2 injections with no benefit; he was taking "a bunch of medications" which he stopped taking 4 months earlier. On physical examination the Veteran's gait was antalgic and guarded. He was able to walk on his toes and heels in a slow and guarded manner. Unilateral calf raises were performed on both sides, with pain on each side. Trunk range of motion was severely guarded and limited in all directions, with pain on flexion, extension, side bending, and rotation. Spine alignment was normal. There was diffuse spinous process tenderness but no sciatic notch tenderness. There was myofascial tenderness to the lumbar paraspinals, gluteal, and piriformis bilaterally. The assessment was chronic lumbago with only mild degenerative disc disease on MRI; there was no clinical evidence of radiculopathy but intermittent radicular irritation was reported. On December 2007 VA spine examination, the Veteran reported difficulty sitting or bending and complained of a painful knot in his right lower back area. He reported a constant sharp pain in the lower back. He reported being unable to lie supine or prone without experiencing pain. He denied flare-up. He denied any numbness, weakness, or bowel or bladder incontinence. He denied use of braces or assistive devices. He reported that he previously operated heavy equipment, but lost that job secondary to his back disability. There were no incapacitating episodes in the previous 12 months. On physical examination, ambulation was with a slight limp. He was tender on the right lower lumbar area over a lipoma and in the right paraspinous musculature without spasm. On range of motion testing, forward flexion was 0 to 60 degrees with right sided lower back pain; extension was 0 to 10 degrees without pain; and right and left lateral rotation and right and left lateral flexion were each 0 to 30 degrees without pain. Straight leg raising was negative to 90 degrees in the sitting position with right sided lower back pain only. Motor strength was normal in all muscle groups of both lower extremities, and sensation was intact to sharp and dull in all dermatomes of both lower extremities. The only additional limitation following repetitive use was increased pain, with no further loss of motion. There were no flare-ups, and there was no effect of incoordination, fatigue, weakness, or lack of endurance on spine function. X-rays showed decreased L5-S1 disc mildly diminished in height. MRIs showed multilevel disc desiccation with mild degenerative joint disease of the L4-5 facets bilaterally. The diagnoses were of myofascial lumbar syndrome secondary to facet degenerative joint disease and degenerative disc disease, and tender lipoma in the subcutaneous tissue of the right lower back. In an April 2011 statement, the Veteran's representative stated that the Veteran believed that his low back disability had worsened since the last VA examination in December 2007. The May 2011 Board remand ordered a new VA spine examination to determine the current severity of the low back disability. On June 15, 2011 VA examination, the Veteran complained of right-sided low back pain with a "knot" in the right lower lumbar area. He did not take any medications for his back and did not wear a brace. The back pain was periodic, occurring once every 2 to 3 days; he had days that were pain-free. He had a long history of balance problems and frequent falls, especially when getting up from chairs. He had been unemployed for 5 or 6 years, after incurring an on-the-job back injury while driving a land scrapping machine (similar to a bulldozer); he did not return to work after that, as it made the right lower portion of his back worse. He was fairly sedentary now, but frequently walked about one block from his house to visit a friend and then walked back home. He did not have any backs problems while walking on such 0ccasions. He did not have incapacitating episodes of low back pain, or loss of bowel or bladder control. He reported increased limitation with repetitive use. On physical examination, the Veteran had some difficulty with balance when walking; his gait was broad based and somewhat antalgic. He also had balance difficulties when first getting out of a chair. There was tenderness in the midline at L5-S1 and in the right paraspinous area at the same level. There was a palpable lipoma estimated 2 inches diameter in the subcutaneous tissue over the right lower lumbar area. Active and passive ranges of motion were limited by right sided low back pain; flexion was from 0 to 40 degrees, extension was less than 5 degrees, lateral bending was from 0 to 10 degrees bilaterally, and rotation was from 0 to 30 degrees bilaterally. With repetitive motion, the Veteran had increased right sided low back pain, and flexion decreased to a 0 to 20 degrees arc. He was only able to make three repetitions and he then had increased back pain and increased difficulty with his balance, and had to sit down. Neurological examination of the lower extremities revealed that deep tendon reflexes were hyperflexed at the knee at 3+; Achilles was 2+; there was sustained clonus of both ankles; Babinski was negative; and motor strength was 5/5 bilaterally. Heel-toe walking was attempted but he had significant balance problems. He was able to demonstrate heel walking but was unable to do toe walking because he stumbled. Sensory was intact to sharp and dull in the right foot; there was loss of sharp sensation near the ends of toes three and five on the left foot. Straight leg raising was negative to 90 degrees bilaterally. There was right sided low back pain with maximum straight leg raising on the right. The impressions included chronic lumbar strain with degenerative disc disease and chronic intermittent right sided low back pain; and lumbar lipoma that was not contributing to the low back pain, although it was the knot the Veteran felt with his hand on that area. The examiner opined that the balance difficulty was unrelated to the lumbar spine chronic strain or degenerative disc disease. On December 2012 VA spine examination, the Veteran reported that flare-ups of symptoms impacted the function of his back; he reported lower back pain to be daily and constant. He reported getting muscle spasms. He denied any radiation or numbness in the legs. He did not use assistive devices and had not had surgery on the back. He reported that pain was sharp, averaging 7 to 8 out of 10 in severity; bending and sitting aggravated the back disability. On physical examination, forward flexion was to 85 degrees with painful motion beginning at 85 degrees. Extension was to 10 degrees, with painful motion beginning at 10 degrees. Lateral flexion was to 15 degrees bilaterally, with painful motion beginning at 15 degrees bilaterally. Lateral rotation was to 25 degrees bilaterally, with painful motion beginning at 25 degrees bilaterally. The Veteran was able to perform repetitive testing; there was no additional limitation in range of motion following repetitive use testing. The Veteran's functional impairment of the back consisted of pain on movement. There was no localized tenderness or pain to palpation for the joints and/or soft tissue of the thoracolumbar spine. Muscle strength testing found active movement against gravity, with no muscle atrophy. Deep tendon reflexes were normal at 2+. Sensory testing was normal, and straight leg raising was negative bilaterally. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. He had no other neurologic abnormalities or findings related to the back disability, such as bowel or bladder problems. He did not have incapacitating episodes of intervertebral disc syndrome. X-rays of the lumbar spine showed vertebral body heights to be maintained; multilevel degenerative disease and osteophyte formation were most severe and progressive at L5-S1. The diagnosis was lumbosacral strain, with X-rays showing multilevel degenerative changes. The examiner opined that the Veteran's thoracolumbar spine condition impacted on his ability to work, "manual but not sedentary". Additional VA and private treatment records through December 2012 show symptomatology largely similar to that found on the VA examinations described above. Regarding the effective date assigned for the award of a 20 percent rating for the Veteran's low back disability, the Board notes that such rating was assigned from the date the increased rating claim was received (on August 18, 2006). The Board also notes that the relevant appeal period is from one year prior to the filing of the claim (August 18, 2005). Significantly, the medical records show that symptoms of the Veteran's low back disability have been consistent from March 2006 (the earliest available medical evidence during the appeal period) through June 2011. Such record reasonably supports that the symptoms documented have been present since the beginning of the evaluation period; there is nothing in the record to suggest otherwise. Accordingly, the Board finds that the criteria for a 20 percent rating were met throughout from the start of the appeal period, and that a 20 percent rating is warranted from [the earlier effective date of] August 18, 2005. While the Veteran has reported chronic back pain and stiffness, at no time prior to the June 15, 2011 VA examination was there shown to be definitive evidence of flexion of the thoracolumbar spine limited to 30 degrees or less or of ankylosis of the entire thoracolumbar spine, even when taking into account additional loss of motion due to pain, fatigue, weakness, or lack of endurance. Normal flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 38 C.F.R. § 4.71a, Plate V. As the symptoms and associated impairment of function of the low back disability prior to June 15, 2011 fall squarely within the parameters of the criteria for the 20 percent rating assigned, and never meet (or approximate) the criteria for the next higher (40 percent) rating under the General Formula, a rating in excess of 20 percent under the General Formula criteria is clearly not warranted for that time period. Additionally, at no time throughout the evaluation period has there been any evidence of unfavorable ankylosis of the entire thoracolumbar spine, or any ankylosis of the spine at all. As the symptoms and associated impairment of function of the low back disability from June 15, 2011 to the present fall squarely within the parameters of the criteria for the 40 percent rating assigned, and never meet (or approximate) the criteria for the next higher (50 percent) rating under the General Formula, a rating in excess of 40 percent under the General Formula criteria is clearly not warranted at any time. As is noted above, lumbosacral disc disease may be alternatively rated based on incapacitating episodes. There is no evidence (and he does not allege otherwise) that the Veteran was ever on bedrest prescribed by a physician for his low back disability. Therefore, there is no basis for applying the Formula for Rating Intervertebral Disc Syndrome based on incapacitating episodes at any time during the evaluation period. Neurological manifestations of lumbosacral disc disease are to be separately rated under an appropriate Code (and such rating is then combined with the rating under the General Formula, outlined above). On VA examinations and treatment, no neurological manifestations were reported or diagnosed. Therefore, separate ratings for neurological manifestations of the low back disability are not warranted. Furthermore, the record does not include any evidence of a distinct period of time when the symptoms of the Veteran's low back disability exceeded what is encompassed by the 20 percent and 40 percent ratings assigned, and therefore a further "staged" increased rating is not warranted. The Board has considered whether this matter should be referred to the Chief Benefits Director or the Director, Compensation and Pension Service for consideration of an extraschedular evaluation under 38 C.F.R. § 3.321. In Thun v. Peake, 22 Vet. App. 111 (2008), the U.S. Court of Appeals for Veterans Claims (Court) clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Here, the symptoms of, and impairment of function resulting from, the Veteran's service-connected low back disability fall squarely within the criteria for the 20 percent and 40 percent schedular ratings assigned. The record does not reflect (or suggest) any symptoms/impairment not encompassed by the schedular criteria. Therefore, those criteria are not inadequate, and referral for extraschedular consideration is not warranted. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held, in essence, that when the matter of entitlement to a TDIU rating is raised by the record in a claim for increase, such matter becomes part of the increased rating claim. Here, while the Veteran's representative notes that, on December 2012 VA examination, the examiner stated that his back condition has an effect on his ability to work, limiting him to sedentary employment, such evidence does not indicate that by virtue of his back disability the Veteran is precluded from any substantially gainful employment. Accordingly, the matter of entitlement to a TDIU rating is not raised by the record. Dermatophytosis of both feet Dermatophytosis is rated as scars (under Codes 7801, 7802, 7804, 7805) or under Code 7806 (for dermatitis or eczema), depending on predominant disability. See 38 C.F.R. § 4.118, Code 7813. Here, the nature of the disability more closely resembles dermatitis. Under Code 7806, a 10 percent rating is warranted if at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted if 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. 38 C.F.R. § 4.118. The Veteran's claim for an increased rating was received by VA on August 18, 2006; the period for consideration is therefore from August 2005. On March 2006 VA treatment, dermatologic examination was noted to be "normal". On June 2006 VA treatment, skin was found to have good turgor with no rashes or lesions. On January 2007 VA skin examination, the Veteran reported that during the summertime he has symptoms of itching, burning, and swelling in his feet with a very foul odor. He reported having to wear open-toed shoes and having to change his socks multiple times because of the odor and increased sweating. He reported that the symptoms subside in the winter. On examination, he did not report any symptoms in his feet. On physical examination, no lesions were seen. The skin was flaky on the balls of the feet, but no lesions were seen between the toes or on the soles, bottoms, or tops of his feet. There were no scars, no residue was seen, and there was no foul smelling discharge. The examiner's impression was that there was no evidence of fungal infection in the feet on examination, though the Veteran reported that his symptoms recur during the summertime. The Veteran was not using any medications and had not seen any physicians for the problem. The percentage of exposed area affected was zero percent and the percentage of the entire body area affected was zero percent. No scarring was seen. The Veteran submitted lay statements (including a November 2006 statement from his daughter-in-law) reporting that he "gets big sores and rashes all over his feet". On December 2007 VA skin examination, the Veteran reported having fungal infections of the feet since being in the Army. He reported the symptoms as constant, waxing and waning in severity, and typically worse in the summertime. The symptoms were not progressive. He had not treated the symptoms with anything over the previous 12 months. He reported local burning but no systemic symptoms. He reported that the symptoms interfere with his activities and he cannot play golf or do other outdoor activities because his feet feel hot and sore. On physical examination, there was very minimal flaking of the plantar surface of both feet over the metatarsophalangeal joints and heels. There was no maceration, no edema, and no other changes. There were no interdigital abnormalities. There was mild deformity of the fifth toenails bilaterally. The percentage of exposed areas affected was 0 percent; the percentage of the total body affected was less than 1/100th of 1 percent. The diagnosis was dermatophytosis, with essentially normal examination, and no treatment for the condition. In an April 2011 statement, the Veteran's representative reiterates the Veteran's belief that his service-connected dermatophytosis has worsened since the last VA examination in December 2007. In May 2011, the Board remanded the matter to afford the Veteran a new VA examination. On June 2011 VA examination, the Veteran complained of a burning sensation on the bottom of his feet since service, unchanged through the present time, which he did not treat. He complained of worsening of the burning sensation when standing or walking, and it sometimes bothered him at night when he was in bed and not weight bearing; he treated it at night with ice. He denied itching of the feet or toes. On physical examination, the Veteran's feet had some extremely mild tinea pedis in some of the web spaces of both feet. On the plantar surfaces of the feet, the skin was completely normal except being slightly dry. Palpation of the feet produced no discomfort. There was no skin breakdown, and the skin was pink and warm all the way to the toes. Pulses were 2+ and capillary refill was normal. The impressions included causalgias of both feet beginning in Vietnam, and mild tinea pedis that was not causing the causalgias. On December 2012 VA skin examination, the diagnosis was toenail fungus. No other skin condition was diagnosed. The Veteran was found to have fungus on all toenails bilaterally; he had not received oral or topical medication treatment (or any other treatment or procedure) for a skin disorder in the prior 12 months. There had been no debilitating or non-debilitating episodes in the prior 12 months due to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. On physical examination, all toenails bilaterally were found to have fungus, as well as the third fingernail of the right hand. The examiner estimated that less than 1 percent of the Veteran's total body area, and 0 percent of his exposed body area, was affected. In a December 2012 addendum, another VA provider who reviewed the claims file opined that the Veteran's current skin disorder of fungal nails (onychomycosis of all toenails and the right third fingernail) was incurred in service. The VA treatment records and examination reports are highly probative evidence against this claim for increase. There are no treatment records or VA examination findings that show that the Veteran's dermatophytosis affects 20 to 40 percent of his entire body, or exposed areas (or approximates such level of involvement; see 38 C.F.R. § 4.7). There is also no evidence that systemic therapy such as corticosteroids or other immunosuppressive drugs was required for any duration during any 12 month period under consideration. Accordingly, the schedular criteria for the next higher, 30 percent, rating are neither met nor approximated, and a schedular rating in excess of the 10 percent currently assigned is not warranted. All symptoms of the Veteran's dermatophytosis of both feet are encompassed by the schedular criteria (outlined above), and those criteria are therefore not inadequate. Hence, referral of this case to the Compensation Service Director for consideration of an extraschedular rating is not warranted. See 38 C.F.R. § 3.321(b); Thun, supra. It is not shown (or suggested) by the record, or alleged that the Veteran's dermatophytosis renders him incapable of working; hence, the matter of entitlement to a TDIU rating is not raised in the context of this claim. ORDER A 20 percent rating is granted for the Veteran's low back disability from (the earlier effective date of) August 18, 2005, subject to the regulations governing payment of monetary awards; ratings for the low back disability in excess of 20 percent prior to June 15, 2011 and/or in excess of 40 percent from that date are denied. A rating in excess of 10 percent for dermatophytosis of both feet is denied. REMAND Regarding the claim for service connection for a psychiatric disability, the Board finds that further notice and development of the record are required to comply with VA's duties to notify the Veteran and to assist him in the development of the facts pertinent to his claim. See 38 C.F.R. § 3.159 (2012). The Veteran and his representative have raised a new (secondary service connection) theory of entitlement to this benefit sought; it is alleged that his service-connected low back disability has caused or aggravated his claimed psychiatric disability. 38 C.F.R. § 3.310(b). The Veteran has not received notice of what is needed to substantiate the secondary service connection theory of entitlement (or of his/VA's respective responsibilities in evidentiary development of this theory of entitlement), and the RO has not addressed this theory of entitlement in the first instance. The Board thus finds that a further VA opinion is needed as to this new causation theory. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following: 1. Regarding the matter of service connection for psychiatric disability, the RO should provide the Veteran with 38 C.F.R. § 3.159(b) notice for a claim of service connection for such disability on a secondary basis (specifically as secondary to the service-connected low back disability). He and his representative should have adequate opportunity to respond. The RO should arrange for any further development suggested, including securing for association with the claims file copies of the complete clinical records (those not already associated with the claims file) of all VA evaluations and/or treatment the Veteran has received for psychiatric disability. 2. The RO should then arrange for the Veteran's claims file to be returned to the June 2011 VA examiner for review and an opinion regarding the etiology of the Veteran's psychiatric disability. (If the June 2011 VA examiner is unavailable, the RO should then arrange for an examination of the Veteran by another appropriate examiner to secure the opinions sought.) Based on a review of the claims file, the examiner should provide an opinion that responds to the following: What is the most likely etiology for the Veteran's currently diagnoses psychiatric disability? Specifically, is it at least as likely as not (a 50% or greater probability) that it was either (i) caused or (ii) aggravated by (increased in severity due to) his service-connected disabilities (and specifically the low back disability)? The examiner must explain the rationale for all opinions, citing to supporting factual data or medical texts/treatises, as appropriate. 3. The RO should then review the record, and readjudicate the claim of service connection for a psychiatric disability, specifically including based on a secondary service connection theory of entitlement. If the claim remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs