Citation Nr: 1317836 Decision Date: 05/31/13 Archive Date: 06/06/13 DOCKET NO. 08-39 355 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial rating greater than 10 percent for irritable bowel syndrome (IBS) prior to August 26, 2008. 2. Entitlement to a rating greater than 10 percent for IBS from August 26, 2008. 3. Entitlement to an initial rating in excess of 10 percent for lumbar spine, degenerative joint disease. 4. Entitlement to an initial rating in excess of 10 percent for residuals of right foot neuroma with metatarsalgia of the second metatarsal head. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran served on active duty from February 1986 to July 2006. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran appeared at a hearing before the undersigned Veterans Law Judge in July 2012. A transcript of the hearing is in the Veteran's file. In September 2012, the Board remanded the case for further development, which has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. Prior to August 26, 2008, IBS manifested with recurring diarrhea and gas. 2. From August 26, 2008, IBS manifested with more or less constant abdominal distress in the form of alternating diarrhea and constipation, cramps, gas, occasional incontinence, and symptoms of gastroesophageal reflux disease. 3. Throughout the appeal, lumbar spine degenerative joint disease has manifested with pain and forward flexion to no less than 60 degrees, including upon repetitive motion; without ankylosis, incapacitating episodes due to intervertebral disc syndrome (IVDS), or any neurological involvement of the lower extremities. 4. The symptoms associated with the Veteran's service-connected residuals of a right foot neuroma with metatarsalgia of the second metatarsal head have manifested with symptoms of chronic pain, gait disturbance, swelling, and numbness that more nearly approximate the criteria for a severe foot injury. CONCLUSIONS OF LAW 1. Prior to August 26, 2008, the criteria for an initial rating in excess of 10 percent for IBS have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.114, Diagnostic Code (DC) 7319 (2012). 2. From August 26, 2008, the criteria for a rating of 30 percent, and no more, for IBS have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.114, Diagnostic Code (DC) 7319 (2012). 3. The criteria for an initial rating in excess of 10 percent for lumbar spine degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5237, 5243 (2012). 4. The criteria for an initial rating of 30 percent, and no more, for residuals of right foot neuroma with metatarsalgia of the second metatarsal head have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5284 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. A letter sent in December 2006 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); 38 C.F.R. § 3.159(b) (1). This letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of a disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was informed of the need to show the impact of disabilities on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Veteran's service treatment records and VA and private medical treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that she is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c)(2). In a letter sent to the Veteran in October 2012, following the Board's September 2012 remand, the RO requested that the Veteran identify any additional medical providers and submit and/or identify outstanding treatment records pertinent to her claim. The Veteran did not respond to this letter or otherwise identify any additional sources of evidence. VA examinations were conducted in August 2006 and August 2008. Although the Veteran has argued that the August 2006 examination is inadequate for rating purposes, the record does not reflect such. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Notwithstanding, the Veteran was scheduled for a new VA examination in October 2012 to address any alleged inadequacies and to assess the current severity of her disabilities; however, she failed to report to the examination and has not provided good cause for failing to appear. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); see also Dingess/Hartman, 19 Vet. App. at 486. Analysis The Veteran claims her service-connected IBS, lumbar spine degenerative joint disease, and residuals of a right foot neuroma are more severe than currently rated. The Board attempted to obtain a more recent examination of the Veteran's disabilities; however, she failed to report for an examination scheduled for October 2012. Her failure to cooperate with VA made it impossible to obtain the more recent evidence that was the aim of the planned examination. If a Veteran fails to report for a VA examination scheduled in connection with an initial rating claim following the grant of service connection, which is classified as an original compensation claim under 38 C.F.R.3.655(b), the case shall be rated on the evidence of record. Fenderson v. West, 12 Vet. App. 119, 125 (1999); Turk v. Peake, 21 Vet. App. 565, 568-70 (2008). As that is the case here, the Veteran's initial ratings for her IBS, lumbar spine, and residuals of right foot neuroma with metatarsalgia of the second metatarsal head will be addressed based on the evidence of record. Id. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating 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 their residual conditions in civil occupations. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). A layperson is competent to report on the nature, onset, and severity of his or her current symptomatology. Competency is a legal concept in determining whether lay or medical evidence may be considered; in other words, whether the evidence is admissible. This is distinguished from credibility and weight, which are factual determinations going to the probative value of the evidence; that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). As it relates to this particular case, and the Veteran's statements describing the manifestations of her disabilities, the Board is mindful of the fact that the Veteran is a registered nurse practitioner. When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. IBS The Veteran's irritable bowel syndrome is currently rated as 10 percent disabling under 38 C.F.R. § 4.114, DC 7319. Under Diagnostic Code 7319, a 10 percent rating is assigned for moderate irritable colon syndrome with frequent episodes of bowel disturbances with abdominal distress. A 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114. Service treatment records show the Veteran reported having episodes of left lower quadrant pain and loose bowel movements. These symptoms were eventually diagnosed as irritable bowel syndrome. A VA examination report dated in August 2006 shows that the Veteran's only reported symptom associated with her IBS was recurring diarrhea. She denied any current treatment for her condition. On physical examination, her abdomen was flat. Bowel sounds were decreased and there were no masses or tenderness. The examiner's diagnosis was IBS. At an August 2008 VA examination the Veteran reported her IBS affected her general health because chronic diarrhea had caused ongoing stress and lifestyle issues. She reported having daily abdominal distress, mostly in the form of diarrhea and some constipation, but without nausea and vomiting; chronic constipation; or alternating diarrhea and constipation. She also noted occasional incontinence that was manageable. She reported experiencing gastroesophageal reflux disease with increasing frequency. She had abdominal pain that was localized generally and present more than two-thirds of the year. This pain was characterized with constant symptoms of distress, cramps and gas. Her current treatment was Omeprazole 40 mg per day, as this helped with the acid reflux. Antacid use was frequent. As for functional impairment, the Veteran reported that she had to leave work on days when her IBS was particularly bad and that she had to carefully plan when traveling in order to be able to attend to this condition. The IBS did not her affect body weight and she denied any hospitalization or surgery for this condition. At a hearing held in July 2012, the Veteran testified that IBS was disabling and debilitating because it is a "pretty significant disability" to have, as it required a lifestyle change. She further testified that she had accurately reported her symptoms to the August 2006 VA examiner. She noted, however, that the examiner did not record her statement that she was on Omeprazole. She further explained that she took Omeprazole and over-the-counter medications to limit the gas. Upon review of the August 2006 examination report at the hearing, the Veteran contended that the examiner did a poor job documenting what was discussed and her symptomatology. She stated that she had experienced constant abdominal distress at the time she left service and that she believed this was reported to the examiner in 2006. She also testified that this disability had not worsened since she left military service. Prior to the VA examination held on August 26, 2008, the overall objective evidence does not reflect severe IBS such that a 30 percent rating is warranted. 38 C.F.R. § 4.114. While the Veteran's service records reflect occasional complaints of abdominal pain and diarrhea, these symptoms were not shown to occur on a daily basis or shown to have been severe in nature. The August 2006 VA examination shows that the Veteran's only reported symptom associated with her IBS was recurring diarrhea, not reported as daily or severe. The Veteran also denied any treatment for her condition. The facts reported in the examination report are consistent with the facts that: there were no outpatient treatment records showing gastrointestinal complaints or complications secondary to IBS; and none of the treatment records reflected use of medication for IBS or gastrointestinal symptoms. The Board has considered the Veteran's assertion that the August 2006 VA examiner failed to conduct an adequate examination because she reported symptoms and treatment that were not noted in the examination report. The August 2006 examination was conducted by a VA staff clinician who completed a physical examination of the Veteran. While the examination findings appear to be very brief with respect to the IBS, the examiner noted that the Veteran reported her only symptom associated with IBS was recurring diarrhea, and that she denied any current treatment. As discussed above, the facts stated in the examination report are consistent with the other evidence of record and, for this reason, the Board finds that the Veteran's post-examination testimony is not credible to the extent that she asserts she had reported additional IBS symptoms and associated treatment to the August 2006 VA examiner. Furthermore, even considering the Veteran's testimony that she also had problems with gas and was on medication during this period, the overall evidence is not reflective of severe IBS. Rather, the findings more nearly approximate IBS of no more than moderate severity, which meets the criteria for a 10 percent rating. Based on the evidence of record prior to August 26, 2008, no more than a 10 percent rating was warranted as severe IBS symptoms were not shown. From August 26, 2008, the date of the last VA examination, the Veteran's IBS symptoms more nearly approximate the criteria for the next highest (and maximum) evaluation, which is 30 percent. In this respect, the August 2008 VA examination report shows IBS manifests with daily abdominal distress, mostly in the form of chronic diarrhea and some constipation, occasional incontinence, gas, cramping, and localized abdominal pain that is present at least two-thirds of the year. She also indicated that at times her symptoms are so bad that she must leave work. These findings more nearly approximate the rating criteria for severe IBS. Therefore, a 30 percent rating is warranted from the date that these symptoms of severe IBS were shown, which is August 26, 2008. The Board has considered rating the Veteran's service-connected disability under a different diagnostic code, but finds none that may be assigned on the facts of record or which would avail her of a higher disability rating. See Butts v. Brown, 5 Vet. App. at 538; see also Pernorio v. Derwinski, 2 Vet. App. at 629. There has been no objective medical evidence of ulcerative colitis (DC 7323), distomiasis (DC 7324), resection of the small intestine (DC 7328), resection of the large intestine (DC 7329), or fistula of the intestine (DC 7330). 38 C.F.R. § 4.114. Due consideration has been given to Hart v. Mansfield, 21 Vet. App. 505 (2007); however a higher evaluation is not warranted for any portion of the time period under consideration. The preponderance of the evidence is against the claim for an initial rating in excess of 10 percent prior to August 26, 2008; there is no doubt to be resolved; and a higher initial rating is not warranted for this period. However, a rating of 30 percent, and no higher, is warranted from August 26, 2008. Lumbar Spine Under the General Rating Formula for Diseases and Injuries of the Spine, the disability is evaluated 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. A 20 percent rating requires thoracolumbar spine forward flexion greater than 30 degrees but not greater than 60 degrees; or, 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. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less, or for favorable ankylosis of the entire thoracolumbar spine. Unfavorable ankylosis of the thoracolumbar spine warrants a 50 percent evaluation, and unfavorable ankylosis of the entire spine is rated 100 percent disabling. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormality is to be evaluated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, DC 5237, Note 1. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, normal extension is zero to 30 degrees, normal left and right lateral flexion is zero to 30 degrees, and normal left and right lateral rotation is zero to 30 degrees. 38 C.F.R. § 4.71a, DC 5237, Note 2. All measured ranges of motion should be rounded to the nearest five degrees. 38 C.F.R. § 4.71a, DC 5237, Note 4. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). According to the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes: A 20 percent rating requires evidence of incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating requires evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating requires evidence of incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. Note 1: For purposes of evaluations under DC 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. At an August 2006 VA spine examination, the Veteran described recurring lower back pain, without radiation. The pain was not debilitating, as the Veteran reported she was able to function, work, and perform activities of daily living. She used Motrin to treat the pain. She did not use a back brace. On physical examination, she had a normal gait. There was no tenderness to percussion of the spine and no postural abnormalities or fixed deformities were noted. Musculature was symmetrical with no spasm. Thoracolumbar spine range of motion included: forward flexion to 80 degrees, extension to 20 degrees, left and right lateral flexion to 20 degrees, and left and right lateral rotation to 50 degrees. No painful motion was noted. There were no additional functional limitations noted after repetitive motion, including pain, weakness, fatigability, decreased endurance or incoordination. No neurologic deficits were noted. X-rays revealed mild degenerative joint disease at L5-S1. The examiner's diagnosis was recurring lower back pain. At an August 2008 VA spine examination, the Veteran reported symptoms of pain, stiffness, and weakness associated with her lumbar spine degenerative joint disease. She denied numbness, bladder complaints, or bowel complaints due to the lumbar spine condition. She reported that her low back pain occurred twice a day for 3 hours at a time. The pain was said to travel to her entire back and shoot down the right leg. She described the pain as burning, aching, oppressing and sharp. The pain was elicited by physical activity, stress and sitting, computer work and relieved by rest, Motrin, Neurontin, and Tylenol. At the time of pain she can function with medication and stated that her back pain had not resulted in any incapacitation. Functionally, she reported that her pain affected her activities of daily living, mood, and activity. On physical examination, her posture was within normal limits. Head position was normal. There was symmetry of spinal motion with normal curves of the spine. The examination revealed no evidence of radiating pain on movement. Muscle spasm and tenderness were absent. Straight leg raising test was negative bilaterally. There was no ankylosis of the lumbar spine. Range of motion of the thoracolumbar spine included lumbar forward flexion from 0 to 90 degrees. Extension, left and right lateral flexion and left and right lateral rotation were all possible from 0 to 30 degrees. After repetitive use, joint function of the spine was additionally limited by pain, but not fatigue, weakness, lack of endurance or incoordination. The pain did not additionally limit the joint function. There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement. Peripheral nerve involvement was not evident during examination. Neurological examination of the lower extremities was normal. Motor and sensory function was within normal limits. The lower extremity reflexes revealed knee jerk was 1+ and ankle jerk was 1+ bilaterally. The examiner indicated that for the VA established diagnosis of lumbar spine degenerative joint disease, the diagnosis was changed to lumbar strain based on the Veteran's subjective history and the objective examination. At a hearing held in July 2012, the Veteran testified that her lifestyle had been altered due to the affects of chronic, constant pain stemming from her lumbar spine degenerative joint disease. She also testified that this disability had not worsened since she left military service. The Veteran's lumbar spine degenerative disc disease is currently rated at 10 percent pursuant to 38 C.F.R. § 4.71a, DC 5242. To merit a disability rating of 20 percent, the next highest possible rating, requires evidence of thoracolumbar spine forward flexion greater than 30 degrees but not greater than 60 degrees; or, a 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. The August 2006 and August 2008 VA examinations reflect that the Veteran had forward flexion to 80 and 90 degrees respectively, even with consideration of DeLuca. Further, the combined range of motion of the thoracolumbar spine at each examination was significantly greater than 120 degrees. There also was no evidence of muscle spasm or guarding, and no evidence of abnormal gait or spinal contour. For these reasons, the criteria for a rating higher than 10 percent are not met under the general formula. Alternately, a showing of IVDS with incapacitating episodes having a total duration of at least 2 weeks during the past 12 months warrants a 20 percent rating. There is no evidence of physician-prescribed bed rest for a period of at least 2 weeks at any time during the appeal period in question. Accordingly, a rating higher may not be assigned under DC 5243 on the basis of incapacitating episodes. The rating criteria provide for separate ratings for neurologic and orthopedic manifestations. See Note (1) of the General Rating Formula of Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. No neurological abnormalities associated with the service-connected lumbar spine degenerative joint disease have been shown by the evidence, thus separate ratings for neurologic manifestations are not warranted. Due consideration has been given to Hart v. Mansfield, 21 Vet. App. 505 (2007); however a higher evaluation is not warranted for any portion of the time period under consideration. The preponderance of the evidence is against the claim for a rating in excess of 10 percent; there is no doubt to be resolved; and a higher rating is not warranted. Right Foot Neuroma Service treatment records show the Veteran underwent treatment for chronic right foot pain that was determined to be related to a painful and chronic neuroma in the right foot, in the second and third interspace. She was initially treated with orthotics and injections, and ultimately underwent surgical removal of the neuroma in March 2006. Following the surgery, she continued to have pain in the right foot at the surgical site, in addition to numbness on the dorsum of the right foot in the second and third interspace, toe stiffness, swelling, and difficulty bending her toes. At a VA examination in August 2006, the Veteran reported having chronic pain. The pain was constant and present with walking and standing. She was unable to walk barefoot. She denied use of assistive ambulation devices or orthotics. She also noted she was not employed due, in part, to her right foot disability because of the pain. Flare-ups, along with increased pain and swelling, were reportedly present several times monthly. On physical examination, the examiner observed the Veteran to have an abnormal gait on her right foot, and specifically, an inverted gait. Pulses were palpable. There was a well-healed scar on the dorsum of her foot with pain on palpation between the second and third toe. There was decreased sharp/dull sensation on the contiguous sides of the second and third toes. No edema was noted. The Veteran had severe pain on palpation of the second interspace, as well as the second metatarsal plantarly. The diagnoses were residual pain, most likely stump neuroma, right foot and metatarsalgia, second metatarsal head, right foot. Private medical records dated from April 2007 to January 2008 reflect treatment for the right foot neuroma. Physical evaluations revealed dramatic tenderness beneath the second, and to a lesser degree, the third metatarsal phalangeal joint. Pulses were palpable, no edema was present, and varicosities were not observed. Touch, pin, vibratory, and proprioception sensation were normal. Inspection and palpation of the bones, joints, and muscles was unremarkable. Pre-dislocation syndrome was suspected based on the objective signs and symptoms, but an ultrasound in April 2007 did not confirm that suspicion, instead showing only mild inflammation. The Veteran underwent an osteotomy of the right second metatarsal with screw fixation in October 2007 and was progressing as expected postoperatively. X-rays of the right foot taken in August 2008 show no significant abnormality. At a VA examination in August 2008 the Veteran reported having constant localized pain in the right foot. The pain was described as burning, oppressive and sharp. The pain was elicited by physical activity, walking, and activities of daily living. The pain was relieved by rest and Motrin, though with limited effectiveness. The Veteran reported that she was capable of ambulation despite the pain. At rest she did not have any pain, weakness, stiffness, swelling, or fatigue; but when standing or walking she noted pain and stiffness without any weakness, swelling or fatigue. The Veteran also reported that she had little improvement following the osteotomy in 2007. With respect to functional impairment, the Veteran's ability to ambulate for extended periods was limited and her health status was reduced related to her inability to exercise to a level that provided cardio/endurance benefits. She noted that she sometimes required a cane for ambulation due to pain. On physical examination, posture was within normal limits, but her gait favored the left foot. Examination of the feet revealed evidence of abnormal weight bearing. There was tenderness of the right foot, plantar surface. There were no signs of unusual shoe wear pattern, callosities or breakdown. There was no painful motion, edema, disturbed circulation, weakness or atrophy of the musculature. There was active motion in the metatarsophalangeal joint of the right great toe. On neurological examination of the lower extremities motor and sensory function were within normal limits. The right foot (nonweight bearing) x-ray findings were within normal limits. The examiner noted that the Veteran had limitations with standing and walking. She could only stand for ten to fifteen minutes and then had to sit down. The examiner also noted that the Veteran required orthopedic shoes and shoe inserts, but no corrective shoes, arch supports, foot supports or build-up of the shoes. The symptoms and pain were relieved by the previously noted corrective shoe wear. The examiner concluded that, for the VA established diagnosis of right foot neuroma, the symptoms had resolved. At a hearing held in July 2012, the Veteran testified that she did not have paralysis of her entire foot. She explained that she had numbness and no range of movement of one digit on her foot. She also testified that this disability had not worsened since she left military service. The service-connected right foot neuroma with metatarsalgia of the second metatarsal head is currently rated 10 percent disabling under 38 C.F.R. § 4.124, DC 8525. Diagnostic code 8525 is used to rate paralysis of the posterior tibial nerve. Under this code, mild incomplete paralysis is rated 10 percent disabling. Moderate incomplete paralysis is rated 10 percent disabling; and severe incomplete paralysis is rated 20 percent disabling. Complete paralysis of the posterior tibial nerve is rated 30 percent disabling. 38 C.F.R. § 4.124a, DC 8525 (2012). In reviewing the Veteran's right foot symptoms, it is noted that they are both orthopedic and neurologic in nature. She has pain and stiffness with ambulation and prolonged standing, in addition to an abnormal gait and weightbearing. She is also status post osteotomy with screw fixation in the second right metatarsal. The 2006 VA examiner noted decreased sharp/dull sensation on the contiguous sides of the second and third toes, and the Veteran has testified to having numbness and loss of motion in one toe. It is clear from the record that the Veteran does not have complete paralysis of her right foot to warrant a 30 percent rating under DC 8525, or severe incomplete paralysis so as to warrant a 20 percent rating. The August 2006 VA examination showed decreased-but not absent- sharp and dull sensation along the contiguous sides of the second and third toes. The August 2008 VA examination showed normal motor and sensory function. The private treatment records show normal touch, pin, vibratory and proprioception sensation. Also, the Veteran indicated that her symptoms of numbness and inability to move only affected one toe. In light of the orthopedic and neurologic manifestations associated with the right foot neuroma and metatarsalgia of the second metatarsal head, the Board has considered whether there are any other diagnostic codes that may be used to award a higher rating other than diagnostic code 8525. See Butts v Brown, 5 Vet. App. 532, 538 (1993) (The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case."). Based on the Veteran's relevant medical history, her current diagnoses, and demonstrated symptomatology, DC 5284 (for rating foot injuries) appears to be more appropriate than DC 8525, which is primarily for rating neurologic impairment. Diagnostic Code 5284 provides for a 20 percent rating for a moderately severe foot injury and a 30 percent evaluation with a severe foot injury. Actual loss of use of the foot warrants a 40 percent evaluation. 38 C.F.R. § 4.71a, DC 5284 (2012). The Veteran's service-connected right foot neuroma with metatarsalgia of the second metatarsal head is primarily manifested by chronic pain and stiffness, along with some subjective numbness and loss of motion in one of her toe digits. The record also reflects that she has limitations of ambulation and standing, and requires use of shoe inserts, orthopedic shoes, and sometimes a cane. In the Board's estimation, and resolving doubt in favor of the Veteran, these symptoms are more nearly approximate to a severe foot injury, which warrants a 30 percent rating. In assigning this rating, the Board has considered the Veteran's competent and credible report of pain and functional impairment in keeping with 38 C.F.R. §§ 4.40 and 4.45 and DeLuca v. Brown, 8 Vet. App. 202 (1995). A higher rating of 40 percent is not warranted as there is no evidence that the Veteran has loss of use of her foot. Indeed, the record reflects that she is able to ambulate despite her subjective complaints of pain and even though a cane is needed at times. Thus, an initial disability rating in excess of 30 percent is not warranted. The Board has further considered whether the Veteran's service- connected right foot neuroma may be rated under any other diagnostic codes relating to the feet; however, they are simply not applicable to the service- connected disability. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The preponderance of the evidence is against the claim for a rating in excess of 30 percent; there is no doubt to be resolved; and a higher rating is not warranted. Finally, the Veteran is not entitled to an extraschedular evaluation. 38 C.F.R. § 3.321. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The rating criteria adequately contemplate the manifestations of the Veteran's IBS, lumbar spine degenerative joint disease, and residuals of right foot neuroma with metatarsalgia of the second metatarsal head. The IBS is manifested by recurring diarrhea, some constipation and abdominal distress. The lumbar spine disability is primarily productive of pain and limited motion. The right foot disability is productive of pain, stiffness, interference with prolonged ambulation and standing and no more than slight neurologic involvement. The respective manifestations are contemplated in the pertinent rating criteria and are adequate to evaluate the Veteran's disabilities. Therefore, referral for consideration of extraschedular ratings is not warranted. The Board also considered whether a claim of total disability based on individual unemployability was inferred in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran is in receipt of a combined disability rating of 100 percent, effective August 1, 2006 (i.e., the date of her separation from the military), rendering any TDIU claim moot. Thus, Rice is not applicable. ORDER Prior to August 26, 2008, entitlement to an initial rating in excess of 10 percent, for IBS is denied. From August 26, 2008, entitlement to a rating of 30 percent, and no more, for IBS is granted. Entitlement to an initial rating in excess of than 10 percent for lumbar spine, degenerative joint disease is denied. Entitlement to an initial rating of 30 percent, and no more, for residuals of right foot neuroma with metatarsalgia of the second metatarsal head is granted. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs