Citation Nr: 1314826 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 09-46 321 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for a bilateral shoulder disability. 2. Entitlement to service connection for a bilateral knee disability. 3. Entitlement to an initial evaluation in excess of 10 percent for a right great toe disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The Veteran served on active duty from November 2003 to November 2007. This case comes before the Board of Veterans' Appeals (Board) on appeal of a September 2008 rating decision of the Department of Veterans Affairs (VA) regional office in Seattle, Washington (RO). The Veteran testified at a personal hearing before the undersigned Veterans Law Judge (VLJ) sitting at the RO in March 2013, and a transcript of the hearing is of record. FINDINGS OF FACT 1. The Veteran does not have a shoulder disability that is related to his military service. 2. The Veteran does not have a knee disability that is related to his military service. 3. The Veteran is currently assigned the maximum 10 percent rating for hallux valgus of the right great toe; the right great toe scar is 8 centimeters (cm) by .5 cm; and it is of no more than moderate severity. CONCLUSIONS OF LAW 1. The Veteran does not have a shoulder disability that was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The Veteran does not have a knee disability that was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 3. The criteria for an initial disability rating in excess of 10 percent for right great toe disability have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Code 5280 (2012); § 4.118, Diagnostic Code 7804 (2008), (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2012). The regulations implementing VCAA have been enacted. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the RO sent the Veteran a letter in June 2008, prior to adjudication, which informed him of the requirements needed to establish entitlement to service connection. In compliance with the duty to notify, the Veteran was informed in the June 2008 letter about disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Service connection was subsequently granted for a right great toe disability by rating decision in September 2008. Although the Veteran was not notified of the requirements to establish entitlement to an increased rating until April 2012, the VA General Counsel has held that 38 U.S.C.A. § 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate newly raised or "downstream" issues, such as the claims for increased compensation following the initial grant of service connection for a disability, in response to notice of its decision on a claim for which VA has already given the appropriate section 5103(a) notice. See VAOPGCPREC 8-2003 (Dec. 22, 2003). Consequently, notice has been given in this case with respect to the increased rating claim. In accordance with the requirements of VCAA, the June 2008 and April 2012 letters informed the Veteran what evidence and information he was responsible for and the evidence that was considered VA's responsibility. Additional relevant private evidence was subsequently added to the case after the June 2008 letter. VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. Relevant shoulder and knee evaluations, with nexus opinions, were conducted in June 2012, as was scar and foot examinations of the right foot. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions on the shoulders and knees obtained in this case are adequate, as they involve review of the claims file, relevant examination of the Veteran, and an opinion on whether the Veteran has shoulder and/or knee disability due to service. The examination of the Veteran's right foot provides his current symptomatology. Accordingly, the Board finds that VA's duty to assist in obtaining a VA examination with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board concludes that all available evidence has been obtained and that there is sufficient medical evidence on file on which to make a decision on the issues decided herein. The Veteran has been given ample opportunity to present evidence and argument in support of his claims, including at his March 2013 travel board hearing. The Board additionally finds that general due process considerations have been complied with by VA, and the Veteran has had a meaningful opportunity to participate in the development of the claims. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); 38 C.F.R. § 3.103 (2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court recently held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. The Veteran was assisted at the hearing by an accredited representative from Vietnam Veterans of America. The representative and the VLJ asked questions to ascertain the extent of any in-service event or injury and whether any current disability is related to service. They also asked questions to draw out the current state of the Veteran's disabilities. No pertinent evidence that might have been overlooked and that might substantiate any of the claims was identified by the Veteran or the representative. The hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for service connection and for an increased rating. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Analysis of the Claims Service Connection Claims The Veteran seeks service connection for bilateral shoulder and knee disabilities. He contends that his duties in service caused injury to his shoulders, that he injured his knees in boot camp, and that his right great toe disability causes extreme pain and discomfort of the right foot. Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 303, 305 (1992). In order to establish service connection for a disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Pond v. West, 12 Vet. App. 341, 346 (1999). . The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Although the Courts have also held that laypersons are competent to report symptoms regarding tinnitus as here, the determination of competency is different than that of credibility. See Charles v. Principi, 16 Vet. App. 370 (2002). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Veteran's service treatment records reveal that the Veteran complained in December 2003 of a bilateral knee injury; lateral collateral ligament tendonitis was diagnosed. He complained of knee pain on a medical history report dated in February 2004. X-rays of the right shoulder in July 2006 were normal. Chronic shoulder pain, questionable impingement, was diagnosed later in July 2006. The Veteran complained in September 2006 of right shoulder pain for the past year, which was worse when he lifted weights. The assessment was probable rotator cuff tendonitis. An MRI of the right shoulder in October 2006 did not show any evidence of bursitis, rotator cuff tear, or labral tear. The assessment in November 2006 was shoulder pain. The Veteran complained on his August 2007 separation medical history report of intermittent knee and shoulder pain; no disability was noted on the Veteran's August 2007 report of medical assessment. VA treatment reports for April 2008 reveal complaints of shoulder and knee pain, there was full range of motion of the shoulders and knees. According to a July 2008 treatment report, a 2006 MRI of the shoulders showed tendonitis. The Veteran was provided a QTC evaluation for VA purposes in July 2008. He noted a several year history of constant bilateral shoulder and knee pain. Examination of the shoulders and knees did not show any edema, effusion, weakness, tenderness, redness, heat, guarding of movement, subluxation, or ankylosis. Range of motion of the shoulders and knees was normal. Joint function of the shoulders and knees was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. X-rays of the shoulders and knees were considered essentially within normal limits. It was concluded on VA evaluation in July 2008 that there was no objective disability of the shoulders and knees. VA treatment reports for September and December 2008 contain an assessment of shoulder tendonitis. A January 2009 report from Three Rivers Physical Therapy reveals that the Veteran was to undergo physical therapy for shoulder and knee pain. VA treatment records for September 2010 reveal assessments of chondromalacia of the patella and tendonitis of the shoulders. A May 2012 report from Tri-City Radiology, for VA purposes, reveals that X-rays of the shoulders were considered to be normal and X-rays of the knees showed exostosis with no signs of trauma, arthritis, or infection. The Veteran was provided a QTC evaluation of the shoulders and knees for VA purposes in June 2012. He complained of shoulder and knee disability since service. Physical examination of the shoulders and knees did not reveal any objective abnormality. After review of the claims file and examination of the Veteran, the examiner concluded that a shoulder or knee disability was less likely than not due to service since no disability was shown. The Veteran testified in support of his claim at his travel board hearing in March 2013 that his duties in service, such as reaching overhead to tighten bolts, caused shoulder pain and that he injured his knees in boot camp. The Board notes that although the Veteran complained of shoulder and knee problems in service, and tendonitis was diagnosed, X-rays and an MRI of the right shoulder in service were considered normal and post-service VA evaluations of the shoulders and knees, which include X-rays, do not show any objective disability. The VA examiner concluded in June 2012 that it was less likely than not that the Veteran had a current shoulder or knee disability due to service because there was no objective medical evidence of a shoulder or knee disability. Although shoulder tendonitis was reported in some VA treatment records since service, this disability was not found on VA examinations in July 2008 and May/June 2012. There is no medical evidence on file linking a current shoulder or knee disability to service. Consequently, entitlement to service connection for a bilateral shoulder disability and for a bilateral knee disability is denied. The Veteran's contentions, including at his March 2013 travel board hearing, have been taken into consideration in this case. Although the Veteran is competent to report his shoulder and knee symptoms, such as pain, he is not competent to report that he has an acquired shoulder or knee disability due to service. The diagnosis of a specific shoulder or knee disability or the determination of etiology is a medical question and requires medical expertise. A layperson is not competent to address these issues. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Circ. 2007). When there is no disability, service-connection cannot be granted. Brammer v Derwinski, 3 Vet. App 223 (1992). Entitlement to service-connection can be granted if there was a disability at any point during the claims period, even if there is no current diagnosis. McClain v. Nicholson, 21 Vet. App. 319 (2007). There is insufficient competent evidence of a disability at any point during the claim or appeal period. Because the preponderance of the objective and probative medical evidence of record is against the Veteran's claims for service connection for bilateral shoulder and knee disabilities, the claims must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Increased Rating Claim The Veteran's claims were received by VA in June 2008. A September 2008 rating decision granted service connection for a right great toe disability and assigned a 10 percent rating effective November 18, 2007 under Diagnostic Codes 5280-7804. The Veteran timely appealed the assigned rating. The September 2008 rating decision also granted service connection for left great toe disability and assigned a 10 percent rating effective November 18, 2007. A July 2012 rating decision granted service connection for arthritis of the right first metatarsophalangeal joint, as secondary to the service-connected right great toe disability, and assigned a 10 percent rating effective June 21, 2012 under Diagnostic Code 5010-5284. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. See Butts v. Brown, 5 Vet. App. 532 (1993). In the selection of diagnostic codes assigned to disabilities, injuries will generally be represented by the number assigned to the residual condition on the basis of which the rating is determined. With injuries and diseases, preference is to be given to the number assigned to the injury or disease itself; if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen. 38 C.F.R. § 4.27 (2012). The United States Court of Appeals for Veterans Claims has held that when a Diagnostic Code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Under 38 C.F.R. § 4.71a, Diagnostic Code 5280, unilateral hallux valgus warrants a 10 percent evaluation if it is severe and equivalent to amputation of the great toe, or if it has been subject to surgical treatment with resection of the metatarsal head. The 10 percent rating is the maximum evaluation available under Diagnostic Code 5280 (2012). Under Diagnostic Code 5284, a 10 percent rating is assigned for moderate foot injuries; a 20 percent rating is assigned for moderately severe injuries, and a 30 percent rating is assigned for severe foot injuries. Note: A 40 percent rating is granted for actual loss of use of the foot. 38 C.F.R. § 4.71a, Diagnostic Code 5284 (2012). Scars (other than those involving the head, face, or neck) that are deep or that cause limited motion warrant a 10 percent for an area or areas exceeding 6 square inches (39 sq. cm.). A 20 percent rating is warranted for an area or areas of such scars exceeding 12 square inches (77 sq.cm.). 38 C.F.R. § 4.118, Diagnostic Code 7801 (2008). Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (1) (2008). A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801, Note (2) (2008). A 10 percent rating is warranted for scars (other than those on the head, face, or neck) that are superficial and that do not cause limited motion, provided that they cover an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, Diagnostic Code 7802 (2008). A 10 percent rating is warranted for scars which are superficial and unstable. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7803 (2008). A 10 percent rating is warranted for a superficial scar which is painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804 (2008). Other scars are rated base on the limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805 (2008). Effective October 23, 2008, VA revised the criteria for the evaluation of scars to allow for separate evaluations for scars that are both disfiguring and painful. 73 Fed. Reg. 54,710-12 (Sept. 23, 2008). The implementing regulation for the new rating criteria provides that these revisions apply only to applications for benefits received by VA on or after October 23, 2008. VA's General Counsel, in a precedent opinion, has held that when a new regulation is issued while a claim is pending before VA, unless clearly specified otherwise, VA must apply the new provision to the claim from the effective date of the change as long as the application would not produce retroactive effects. VAOPGCPREC 7-2003 (Nov. 19, 2003); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Veteran was provided the new regulations in the October 2009 Statement of the Case. Consequently, the Board will apply both the old and new regulations in this case. Under the most recent criteria, Diagnostic Code 7804 pertains to evaluation of scars that are unstable or painful, with the assignment of a 10 percent rating for one or two such scars, 20 percent rating for three or four scars, and 30 percent rating for five or more scars. Note 1 defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. Note 2 provides that where one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note 3 states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under 7804 when applicable. 38 C.F.R. § 4.118 (2012). Diagnostic Codes 7801 and 7802 continued to provide for assignment of disability evaluations on the basis of surface area of the affected scars. The revised Diagnostic Code 7805 applies to other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804. A rating is to be assigned on the basis of any disabling effect(s) not considered in a rating provided under diagnostic codes 7800-04 under another appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2012). The Veteran complained on QTC evaluation of the right foot for VA purposes in July 2008 of pain and tenderness of the right great toe, without functional impairment. It was reported that the Veteran worked as a Pipe Fitter. The right foot scar was described as 8 cm by .5 cm with tenderness but no disfigurement, ulceration, adherence, instability, edema, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, or abnormal tissue. Physical examination revealed tenderness over the surgical scar. There was active motion of the metatarsophalangeal joint of the right great toe. The Veteran's gait was normal. No other foot disorder was found. The Veteran was able to walk 1/4 mile at a slow pace. X-rays of the right foot revealed proximal fixation screws of the right first metatarsal ossicle, as well as shaving of the medial aspect of the head of the same ossicle. The diagnosis was status post bunionectomy. The examiner thought that the tenderness over the proximal base of the first right metatarsal was related to the screw from his bunionectomy. VA treatment records for June 2008 reveal that the Veteran had bilateral bunionectomy scars and his right great toe deviated laterally. May 2012 X-rays of the right foot from Tri-City Radiology reveal degenerative change in the first metatarsal phalangeal joint. The Veteran complained on QTC foot evaluation for VA purposes in June 2012 that he could not do prolonged standing or running. He did not have hallux valgus, hammer toes, hallux rigidus, pes cavus, Morton's neuroma, weak foot, or malunion or nonunion of the tarsal or metatarsal bones. His previous right bunionectomy was noted to be a foot injury of moderate severity. It was reported that the Veteran's right foot injury prevented prolonged standing or running. On QTC scar examination for VA purposes in June 2012, it was reported that the Veteran had a scar on the dorsal right great toe, longitudinal surgical scar, consistent with a bunionectomy. It was described as an 8 cm linear scar. No other right foot scar was reported. The scar did not cause limitation of function and did not impact his ability to work. The Veteran is currently assigned a 10 percent rating for his right great toe disability under Diagnostic Codes 5280-7804. The maximum rating of 10 percent under Diagnostic Code 5280 has already been assigned by the RO from the date of claim for the Veteran's right great toe disability. Consideration of pain and functional loss under DeLuca, however, is required only with respect to those Diagnostic Codes where the basis for rating is limitation of motion, and DC 5280 is not so based. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Consequently, a rating in excess of 10 percent is not available for the Veteran's right great toe disability under Diagnostic Code 5280; and most of the other diagnostic codes for the feet, Diagnostic Codes 5276-5283, are not applicable because the Veteran does not have pes planus, weak foot, claw foot, Morton's disease, hallux rigidus, hammer toe, or impairment of the tarsal or metatarsal bones. A rating in excess of 10 percent is also not warranted under Diagnostic Code 5284, for a foot injury, because the Veteran's right foot injury was considered moderate on evaluation in June 2012, which warrants a 10 percent rating. The Board must also determine whether a separate rating is warranted for the right great toe disability under Diagnostic Code 7804 based on scarring of the Veteran's right great toe under either the old or new rating criteria. To warrant a 10 percent rating under the rating criteria in effect prior to October 23, 2008, there would need to be evidence of an area or areas exceeding 6 square inches (39 sq.cm.). When examined in July 2008, the Veteran's right foot scar was 8 by .5 cm, which is much smaller than 39 square cm. Under the current rating criteria, a rating of 10 percent requires an unstable or painful scar. The June 2012 VA examination noted the Veteran's complaints of pain, but determined that the scar was not painful on objective testing. The VA examiner in July 2008 offered the opinion that the tenderness the Veteran was experiencing was related to the screw from his bunionectomy. Since there is no painful scar found on examination, and the Board will give more weight to the objective examination reports rather than to the subjective statements of the Veteran, there is no basis for a separate rating for a scar under either the old or new rating criteria. The Veteran is competent to report his subjective symptoms, such as pain and tenderness. His complaints are credible. However, the determination that the tenderness is a manifestation of the implanted screw, rather than of the scar is a medical determination that requires medical expertise to address. The Board has also considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). In this case, the Board finds that referral for extraschedular consideration is not warranted. As shown in the above discussion, the Veteran's service-connected right great toe disability is contemplated and reasonably described by the rating criteria discussed above. In fact, the Veteran's right great toe disability was considered of moderate severity and did not cause limitation of function when examined by VA in June 2012. The Veteran does not have symptoms associated with this disability that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. Accordingly, a comparison of the Veteran's symptoms and functional impairment with the schedular criteria does not show that the Veteran's right great toe disability presents "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability. In the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). Therefore, referral for extraschedular consideration is not warranted. A total disability rating based on individual unemployability due to service-connected disability (TDIU) is an element of any appeal for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2010). In this case, however, TDIU consideration is not warranted. The Veteran has not contended, and the evidence does not indicate, that the Veteran is unemployable as a result of his service-connected right great toe disability. In fact, it was noted on evaluations in July 2008 and June 2012 that the disability did not cause functional impairment. Finally, the Board finds that the preponderance of the evidence weighs against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and entitlement to an initial rating in excess of 10 percent for the Veteran's right great toe disability is denied. See 38 U.S.C.A. § 5107(b) ; 38 C.F.R. §§ 3.102 ; 4.3; Gilbert, 1 Vet. App. at 55. ORDER Entitlement to service connection for a bilateral shoulder disability is denied. Entitlement to service connection for a bilateral knee disability is denied. Entitlement to an initial evaluation in excess of 10 percent for a right great toe disability is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs