Citation Nr: 1317147 Decision Date: 05/24/13 Archive Date: 05/31/13 DOCKET NO. 07-12 711 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for hammertoes of the left foot. 2. Entitlement to service connection for hammertoes of the right foot. 3. Entitlement to service connection for plantar fasciitis. 4. Entitlement to service connection for basal cell carcinoma, including as due to exposure to herbicides. 5. Entitlement to an increased rating in excess of 10 percent for hallux rigidus of the left great toe with arthritis. 6. Entitlement to an increased rating in excess of 10 percent for hallux rigidus of the right great toe with arthritis. 7. Entitlement to an increased rating in excess of 10 percent for status post excision, actinic keratosis with dysplasia, left nasal bridge, claimed as a skin disorder prior to February 25, 2011. 8. Entitlement to an increased rating in excess of 30 percent for status post excision, actinic keratosis with dysplasia, left nasal bridge, claimed as a skin disorder, since February 25, 2011. 9. Entitlement to a total disability rating for compensation purposes based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T.S. Willie, Counsel INTRODUCTION The Veteran served on active duty from August 1964 to August 1991. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans' Affairs (VA) Regional Office (RO) in Columbia, South Carolina. This case was remanded by the Board for further development in January 2011. The issue of entitlement to service connection for a heart disability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for bilateral hammertoes, plantar fasciitis and basal cell carcinoma 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. Hallux rigidus of the left great toe with arthritis is manifested by no more than moderate impairment. 2. Hallux rigidus of the right great toe with arthritis is manifested by no more than moderate impairment. 3. Prior to February 25, 2011, post excision, actinic keratosis with dysplasia, left nasal bridge was manifested by one characteristics of disfigurement. 4. Since February 25, 2011, post excision, actinic keratosis with dysplasia, left nasal bridge is manifested by two characteristics of disfigurement. 5. The Veteran's service-connected disabilities do not render him unable to obtain and retain substantially gainful employment. CONCLUSIONS OF LAW 1. Hallux rigidus of the left great toe with arthritis is no more than 10 percent disabling. 38 U.S.C.A. §§ 1155, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5280-5284 (2012). 2. Hallux rigidus of the right great toe with arthritis is no more than 10 percent disabling. 38 U.S.C.A. §§ 1155, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5280-5284 (2012). 3. Prior to February 25, 2011, the criteria for a rating in excess of 10 percent for post excision, actinic keratosis with dysplasia, left nasal bridge were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2008). 4. Since February 25, 2011, the criteria for a rating in excess of 30 percent for post excision, actinic keratosis with dysplasia, left nasal bridge have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2008). 5. The criteria for entitlement to a TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.158, 3.321, 3.340, 3.341, 4.15, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Additionally, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Prinicpi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial disability-rating and effective-date elements of a service connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the originating agency provided the Veteran with the notice required under the VCAA by letters dated in December 2006, January 2007 and April 2007. Thus, VA's duty to notify in this case has been satisfied. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In connection with the current appeal, available service and private treatment records have been obtained. The Veteran has also been afforded adequate VA examinations as they reflect a pertinent medical history, review of the documented medical history, clinical findings, a diagnosis, and opinion when applicable. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims. The evidence of record provides sufficient information to adequately evaluate the claims, and the Board is not aware of the existence of any additional relevant evidence which has not been obtained. No further assistance to the appellant with the development of evidence is required. 38 U.S.C.A. § 5103A (a) (2); 38 C.F.R. § 3.159(d). Accordingly, the Board will address the merits of the claim. RATINGS Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1 , 4.2, 4.10 (2012). If two evaluations are potentially applicable, the higher evaluation 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 (2012). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10 , 4.40 and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C .F.R. § 4.59. Hallux Rigidus of the Left and Right Great Toe The Veteran appeals the denial of a rating in excess of 10 percent for hallux rigidus of the left and right great toe with arthritis. The Veteran's disability is rated under Diagnostic Codes 5280-5281. Diagnostic Code 5281 provides that unilateral hallux rigidus which is severe may be rated by analogy to hallux valgus. Under 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. In the January 2007 VA examination, the Veteran reported that he felt like he walked on glass and could walk no farther than 25 feet before he had to sit. He denied swelling. He did not take any medications for his feet. With elevation of his feet, he had tingling but no pain. He was not working due to his inability to walk and/or stand for prolonged periods of time. The Veteran was unable to run and/or stand more than 10 minutes. Examination revealed that the Veteran was not in acute distress. He walked with a limp using no assistive device. His feet had normal arches and Achilles was aligned. There was pain on manipulation of his foot but no edema. Range of motion of the ankle revealed dorsiflexion and plantarflexion to 10 degrees with pain from 0 to 10. The bilateral great toes were unable to move actively. Passive range of motion showed the great toes were able to flex and extend to 10 degrees with pain from 0 to 10. He had callus on the right fifth toe. There was no pain on range of motion or flare ups of any of the joints, except as stated above. All above joints had no additional limitation by pain, fatigue, weakness or lack of endurance following repetitive use. Hallux rigidus of the right and left great toe was diagnosed. X ray findings revealed bilateral posterior arthritic changes with joint space narrowing and osteophyte formation at the first metatarsophalangeal joints. The Veteran was afforded another VA examination in August 2007. During this examination, he reported increased pain, stiffness, edema and erythema of the bilateral great toes since his last VA examination in January 2007. He expressed that he walked like a "duck "to avoid pressure on his great toes and to keep them from flexing. He had painful calluses between the fourth and fifth toes of the left foot. He could only stand or walk less than 20 minutes before he had sit down and elevate his feet, and he reported constant foot pain which was worse when standing. He denied any periods of flare ups. He recently obtained a walker which helped him get around his house. Examination of the feet revealed the skin of the bilateral feet was intact. Pedal pulses were +2/2 and sensation intact bilaterally. Bilateral first meta pharyngeal joint had essentially no range of motion. Plantarflexion of the right and left foot was 0 to 30 degrees without pain. Dorsiflexion of the right and left foot was 0 to 20 degrees without pain. There was no pain on range of motion or flare ups of any of the joints, except where noted. All joints had no additional limitation by pain, fatigue, weakness or lack of endurance following repetitive use. The VA examiner found that the Veteran had bilateral hallux rigidus, severe osteoarthritis bilaterally and callus of the left foot with no improvement with treatment of insert shoes, having increased pain and an inability to stand or walk for more than 20 minutes. In the February 2011 VA examination, the Veteran reported daily intermittent foot pain, and flares of pain with standing and walking. He described the pain 9 out of 10, and as stabbing and aching. Functionally the Veteran was unable to walk more than 10-15 feet, stand more than 5 minutes and/or run. He was unemployed and last worked in 1991 when he separated from service. Examination revealed the Veteran walked with a limped gait. He used a walker and a wheelchair. Achilles tracks midline bilaterally. There was no abnormal shoe break down bilaterally and/or callosities bilaterally. The arches were diminished but intact bilaterally and sensation was intact to light touch bilaterally. There was pain with manipulation of the Achilles tendon. The heel, plantar fascia aspect and all toes bilaterally were worse at the base of the bilateral first toes. There were no hammertoes and/or claw foot noted bilaterally. X rays revealed severe osteoarthritis involving the metatarsophalangeal joints of both feet without associated varus or valgus deformity. No evidence of prior fracture or other significant deformity was shown. Bilateral Achilles tendonitis, plantar fasciitis of the bilateral feet, osteoarthritis of the bilateral feet, bilateral hallux rigidus and bilateral inferior calcaneal spurs was diagnosed. After considering the degenerative nature and the objective pain that was seen upon physical exam of palpating the bilateral great toes, the VA examiner opined that the severity of the of the Veteran's bilateral hallux rigidus was moderate with pressure and mild without pressure as it is produces great pain with palpation but did not require daily medication management or surgical management. The examiner stated that the Veteran had additional diagnoses related to his foot pain including: bilateral Achilles tendonitis, plantar fasciitis of the bilateral feet, bilateral inferior calcaneal spurs, and osteoarthritis of the bilateral feet. He further stated that the Veteran's foot disorders were not analogous to claw feet and/or hammertoes as alleged by the Veteran. Based on the evidence presented, the Board finds that a higher rating is not warranted. In this regard, the currently assigned 10 percent rating is the maximum evaluation available under DC 5280. The Board has reviewed Diagnostic Codes 5276 (bilateral pes planus), 5277 (weak foot), 5278 claw foot (pes cavus), and 5283 (malunion of the tarsal or metatarsal bones), but find they are not for consideration, as there is no evidence that the Veteran has any of these disabilities. The Board further notes that service connection for bilateral hammertoes and plantar fasciitis are separately addressed in the remand section of this decision. The Board has also considered whether a higher rating is warranted under Diagnostic Code 5284 which evaluates foot injuries. Under this Code, a 20 percent rating is assigned for moderately severe foot injuries and a 30 percent rating is assigned for severe foot injuries. 38 C.F.R. § 4.72, Diagnostic Code 5284. The lay and medical findings discussed above show that the Veteran's hallux rigidus is manifested by pain and stiffness, and limits his ability to stand, sit and walk for prolonged periods of time. Although a higher evaluation of 20 percent can be assigned for a severe foot injury under Diagnostic Code 5284, the disability at issue involves the toes, rather than the foot, and the lay and medical findings noted above, especially the range of motion findings, do not show moderately severe foot impairment. To the extent that the Veteran's hallux rigidus of the left and right great toe has arthritic findings, the Board has considered whether a separate rating is warranted for arthritis. The Board notes that under 38 C.F.R. § 4.71a, Diagnostic Code 5003, 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. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent is assigned for each such major joint or group of minor joints, with occasional incapacitating exacerbations, affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The Board points out, however, that the Veteran is not entitled to separate ratings for arthritis of the great toes. In this regard, the Board has determined that the symptomatology associated with the service-connected hallux rigidus of the great toes is productive of, at most, moderate impairment. Significantly, these ratings were based primarily on the Veteran's reports of pain and limitation of motion. A separate rating based on arthritic findings would contemplate the same manifestations. Evaluation of the same manifestations under different diagnoses, or "pyramiding", is precluded by 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). Separate ratings may be granted only when "none of the symptomatology for any one of [the claimed conditions] is duplicative of or overlapping with the symptomatology of the other ... conditions." Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (emphasis in original). As such, the Board finds that assignment of separate, compensable ratings for the service-connected great toe disability under Diagnostic Codes 5003 and/or 5010 would constitute impermissible pyramiding. Lastly, the Board finds that the clinical evidence of record does not show his left and right great toe disorder is manifested by symptomatology that equates to amputation of the toe even when considering 38 C.F.R. §§ 4.40, 4.45 and the Court's holding in DeLuca, supra. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board has found no section that provides a basis upon which to assign a higher disability rating for his disability. The Board also points out that, because the Veteran is currently assigned the maximum schedular rating for hallux valgus, a higher rating based on functional impairment under 38 C.F.R. §§ 4.40, 4.45 and DeLuca cannot be assigned. To the extent the Veteran reports foot pain, pain is considered in the current evaluation. See 38 C.F.R. § 4.59. Accordingly, the claims are denied. Actinic Keratosis with Dysplasia, Left Nasal Bridge The Veteran appeals the denial of a rating in excess of 10 percent for status post excision, actinic keratosis with dysplasia, left nasal bridge, claimed as a skin disorder prior to February 25, 2011 and rated as 30 percent since February 25, 2011. His disability is rated under Diagnostic Code 7800. The Board initially notes that the criteria for rating scars were amended effective October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008) (codified at 38 C.F.R. § 4.118 , Diagnostic Codes 7800 to 7805 (2012)). The amendments only apply to those claims filed on or after that date, or in claims where the Veteran specifically requests to be evaluated under the new criteria. The Veteran's claim was filed prior to the October 2008 revision, Consideration under the old and new criteria has not been requested. Therefore, the old rating criteria will be applied. Under the prior criteria for rating the scars, DC 7800 provided for evaluation of scars of the head, face, or neck based on the degree of disfigurement that present. A 10 percent evaluation was for assignment with one characteristic of disfigurement. 38 C.F.R. § 4.118 , Diagnostic Code 7800. A 30 percent rating was warranted for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; with two or three characteristics of disfigurement. A 50 percent rating was warranted for visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent rating was warranted for visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. See 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (1). The 8 characteristics of disfigurement for purposes of evaluation under Diagnostic Code 7800 were: A scar 5 or more inches (13 or more cm.) in length; a scar at least one-quarter inch (0.6 cm.) wide at widest part; the surface contour of a scar is elevated or depressed on palpation; a scar adherent to underlying tissue; hypo-or hyper-pigmented scarring in an area exceeding six square inches (39 sq. cm.); abnormal skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); missing underlying soft tissue in an area exceeding six square inches (39 sq. cm.); and skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). The Board finds that prior to February 25, 2011 the criteria for a rating higher than 10 percent disabling were not met. In this regard, in the January 2007 VA examination, the Veteran expressed that the onset of his actinic keratosis was in the 1980s. His symptoms were located on his nose only and occurred every one and a half to two years. His lesions were either burned or cut off, his last lesion was removed in December 2006. Examination revealed the Veteran was not in acute distress. He had a scar in a kind of patchy form on his nose. It was 3 cm x 2 cm on the left lateral bridge of his nose. He had papule that was about 1 mm x 1 mm on the left lateral nose. There was no bleeding, and the lesions represented less than 1 percent of the entire body and less than 3 percent of the exposed skin. The Veteran was afforded another VA examination in August 2007. Since the last VA examination in January 2007, the Veteran developed a new red spot on the left side of the nose over the last 10 to 15 days. He wore sunscreen daily and tried to avoid sun exposure. Within the preceding six months, the Veteran noted three reddened spots returning to the left nasal area. Examination revealed there was 2 mm red macule on the left lateral nose. There was no bleeding, erythema and/or scarring. The left side of the forehead had a slightly rough patch, status post removal by cryosurgery in February 2007 with scaly red area, and no bleeding, erythema or pain. The lesions represented less than 1 percent of the entire body and less than 1 percent of the exposed skin. In May 2008, Dr. S stated that the Veteran had numerous actinic keratoses on his face which were frozen with liquid nitrogen. He recommended skin examinations every six months because of extensive actinic damage and complexion. The Veteran stated in June 2008 that he met the criteria for an 80 percent rating for disfigurement of the head and face. He expressed that he was scarred over his face and ears, and that the scars were due to the numerous facial medical procedures that he underwent since service. Prior to February 25, 2011, visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features, or; two or three characteristics of disfigurement was not shown. At most, one characteristic of disfigurement was shown by the evidence, i.e. a scar at least one-quarter inch wide at widest part. The Board acknowledges the Veteran's contention that his scars were not accurately measured in the August 2007 VA examination. The Board notes, however, that the Veteran was examined by a medical professional with expertise in this matter. The VA examiner made professional findings after a complete examination of the Veteran. The Board also notes that the findings of the August 2007 VA examination are similar to those of the January 2007 VA examination. The Board finds no basis to render the examination inadequate and the Veteran has not proffered a specific reason for his belief that the scars were measured incorrectly. In sum, prior to February 25, 2011, a rating higher than 10 percent disabling for the Veteran's skin disability was not warranted. Furthermore, the Board finds against a rating higher than 30 percent disabling since February 25, 2011. During his February 2011 VA examination, the Veteran reported that his actinic keratosis comes and goes. He stated that he gets them burned but they return and change locations on his face. The area most affected was the bridge of the nose and forehead. Examination revealed the Veteran's skin was clear without rashes and onychomycosis. He had a linear scar on the bridge of his nose measuring 7.5 cm x 2 cm. He also had a scar on his left upper forehead, by the hairline, measuring 9 cm x 6 cm. This area was 54 square cm. The scars were not tender to palpation and/or adhered to underlying tissue. They were smooth and stable, and without loss of covering skin. They were neither elevated nor depressed but superficial and hypopigmented. There was no inflammation, edema, or keloid formation, and/or limitation of function caused by scars. Scars on bridge of nose and left upper forehead secondary to actinic keratosis treatment and no clinical or objective findings to support the diagnosis of current actinic keratosis was diagnosed. The VA examiner found that the severity of the Veteran's actinic keratoses was mild as there were no actinic keratoses on physical but scarring from treatment was present. The above evidence is against a finding of visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement as to warrant a rating higher than 30 percent disabling. At most, two characteristics of disfigurement are shown during this period of time, i.e. a scar five of more inches in length and a scar at least one-quarter inches wide at the widest part. These findings at most support a 30 percent rating. To the extent that the Veteran's argues that a 30 percent rating for status post excision, actinic keratosis with dysplasia, left nasal bridge, claimed as a skin disorder should be assigned prior to February 25, 2011, the Board notes that the Veteran has been assigned a staged rating. See generally Fenderson, supra. Any earlier effective date issue that the Veteran has raised is essentially part and parcel of the issues addressed above and does not need to be separately adjudicated. All Claims While the Board finds that the Veteran has presented competent and credible testimony regarding the nature and extent of his disabilities to include his reports of pain and skin manifestations, neither the lay or medical evidence reflects that the requirements for a higher rating were met during any period addressed above. The Board has afforded greater probative value to the VA examinations than the Veteran's reports of symptomatology. The examinations were conducted by medical professionals with the expertise to comment and opine on the matters at issue. The examiners reviewed the records, which included the Veteran's contentions, and conducted a complete physical examination. The medical findings of record are also well reasoned and supported by the historical record. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath, 1 Vet. App. 589. The Board has found no section that provides a basis upon which to assign a higher disability rating for his disability. Accordingly, the claims are denied. Regarding referral for extraschedular consideration, consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Here, the Board finds that the Veteran has not required frequent periods of hospitalization for his disabilities and that the manifestations of his disabilities are contemplated by the schedular criteria. Therefore, there is no reason to believe that the average industrial impairment from the disabilities would be in excess of that contemplated by the schedular criteria. Therefore, referral of the case for extra-schedular consideration is not in order. TDIU The Veteran appeals the denial of TDIU. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. § 4.16(b). Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board observes that a claim for TDIU is, in essence, a claim for an increased rating. Norris v. West, 12 Vet. App. 413, 420-21 (1999). A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. The Veteran is service-connected for status post excision actinic keratosis with dysplasia, left nasal bridge, evaluated as 30 percent disabling; hallux rigidus of the right great toe, evaluated as 10 percent disabling; hallux rigidus of the left great toe, evaluated as 10 percent disabling; bilateral tinnitus, evaluated as 10 percent disabling; tendonitis of the left foot, evaluated as 10 percent; tendonitis of the right foot, evaluated as 10 percent; and bilateral hearing loss, evaluated as 0 percent disabling. The combined evaluation is 60 percent disabling. As such, the schedular requirements for a TDIU have not been met. However, where the percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. 38 C.F.R. § 4.16(b). The Veteran claims that he is unable to work due to the severity of his service-connected foot disability. The evidence shows that he last worked in 1991. In the January 2007 VA examination, the Veteran related that he was not working due to his inability to walk and/or stand for prolonged periods of time. The Veteran was unable to run and/or stand more than 10 minutes. In the August 2007 VA examination, the VA examiner stated that the Veteran had increased foot pain and the inability to stand or walk for more than 20 minutes. According to the examiner, the Veteran was unable to perform physical activities due to increased foot pain. He may, however, be able to perform non physical activities which would allow him to sit while working stated the examiner. The VA examiner further stated that actinic keratosis recurring skin lesions would not prevent the Veteran from activities indoors but would limit his outdoor activities. The Veteran must use sun screen and wear protective clothing from sun exposure should he work outdoors. In February 2008, the Veteran stated that chronic pain of both feet prevented him from holding a job as he could not stand, walk, or sit for any amount of time. He expressed during his February 2011 VA examination that he tried to work after he retired from service but he could not stand on his feet. He expressed that he "just could not stand on his feet and rather than getting fired" he told them he could not make it anymore. At that time, he worked at an auto body shop. Based on the evidence presented, the Board finds that the preponderance of the evidence is against the claim. In this regard, the Veteran is unemployed and last worked in 1991 when he separated from service. The Veteran contends that his service connected foot disability renders him unable to obtain and maintain substantially gainful employment. He has expressed difficulty with prolonged standing, sitting and/or walking due to his condition. The evidence, however, does not indicate that he is unable to engage in a substantially gainful occupation. While there is evidence that the Veteran's foot disability prevents him from engaging in physical activity for long period of time, it is not shown that the Veteran is unable to perform sedentary work. Rather, the VA examiner found that the Veteran may able to perform non physical activities which would allow him to sit while working. Regarding his skin disability, the VA examiner also found that the Veteran's actinic keratosis would not prevent him from activities indoors but would limit his outdoor activities. Although the Veteran believes that he cannot secure or follow a substantially gainful occupation as a result of his service-connected disabilities, the more probative evidence is against the claim. The Veteran is competent to report pain and discomfort. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds his complaints of pain with prolonged standing and walking credible. The Board concludes, however, that the Veteran's opinion is less probative than that of the skilled VA examiner. In this regard, the VA examiner's opinion was rendered after review of the record (containing pertinent information), examination of the Veteran, and consideration of the nature and extent of his service connected disabilities. The Board also is mindful that during the time frame in question the Veteran has been unemployed. The sole fact, however, that the Veteran is unemployed or has difficulty obtaining employment is not enough. In sum, the Board finds that the Veteran's service connected disabilities do not preclude substantially gainful employment. Therefore, a grant of TDIU is not warranted on a scheduler or extraschedular basis. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. ORDER A rating in excess of 10 percent for hallux rigidus of the left great toe with arthritis is denied. A rating in excess of 10 percent for hallux rigidus of the right great toe with arthritis is denied. A rating in excess of 10 percent for status post excision, actinic keratosis with dysplasia, left nasal bridge, claimed as a skin disorder, prior to February 25, 2011 is denied. A rating in excess of 30 percent for status post excision, actinic keratosis with dysplasia, left nasal bridge, claimed as a skin disorder, since February 25, 2011 is denied. A total disability rating for compensation on the basis of individual unemployability is denied. REMAND The Veteran appeals the denial of service connection for bilateral hammertoes, plantar fasciitis and basal cell carcinoma. In January 2013, the Veteran's representative stated that the record does not have complete service treatment records for the Veteran to include the 1964 enlistment physical, the 1968, 1972 and 1976 periodic examinations, and the 1991 retirement physical. The Board notes that the June 1976 periodic examination is of record. Also the April 1991 report of medical history is of record but the April 1991 report of examination is not. The other examinations identified by the Veteran's representative are not of record. As such, the Board concludes that further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C.A. § 5103A (West 2002). The Board finds that a remand is warranted so that the RO can attempt to locate the service treatment records and any other relevant private treatment records that have not been associated with the file. To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to the claims and to ensure full compliance with due process requirements, a remand is necessary. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and, after he is informed of what records are of file, ask him to specifically identify which service treatment records are missing from the file. Once the requested information is provided, obtain and associate with the file the identified service treatment records. If no records are available, such should be noted in the record. 2. The RO should ask the Veteran to identify all sources of treatment that he has received for his bilateral hammertoes, plantar fasciitis and basal cell carcinoma, and provide any releases necessary for VA to secure records of such treatment or evaluation. The RO should obtain for the record copies of the complete records of such treatment and evaluation from all identified sources. Any records obtained must be associated with the appellant's claims folder. If the RO cannot locate any identified record, the RO must specifically document the attempts that were made to locate them. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must be given an opportunity to respond. 3. Thereafter, the RO should readjudicate the Veteran's claims for service connection for bilateral hammertoes, plantar fasciitis and basal cell carcinoma, on the basis of all evidence of record and all applicable laws and regulations. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC), which includes a summary of additional evidence submitted, and any additional applicable laws and regulations. The SSOC must provide reasons and bases for the decision reached. Thereafter, the Veteran and his representative should be given the opportunity to respond. 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). ______________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs